Prosthetic iris implantation for congenital, traumatic, or functional iris deficiencies.

PURPOSE: To determine the efficacy and safety of surgical implantation of prosthetic iris devices in patients with anatomic or functional iris deficiencies. SETTING: Cincinnati Eye Institute, Cincinnati, Ohio, USA. METHODS: Twenty-five patients were enrolled in an interventional prospective noncomparative case series. Twenty-eight eyes had prosthetic iris diaphragm implantation for traumatic iris defects, congenital aniridia or iris coloboma, herpetic iris atrophy, surgical iris loss, or ocular albinism. Prosthetic iris implantation was performed with phacoemulsification and intraocular lens (IOL) implantation in 20 eyes, secondary IOL implantation in 6 eyes, and IOL exchange in 1 eye. A single pseudophakic eye with disabling glare secondary to traumatic aniridia had secondary prosthetic iris implantation alone. The surgical ease of insertion, intraoperative and postoperative complications, postoperative anatomic results, visual acuity, and subjective glare reduction were evaluated. RESULTS: Patients were followed postoperatively for a mean of 10.2 months (range 1.4 to 25.7 months). All eyes achieved the desired anatomic result. Visual acuity was improved in 22 of 28 eyes (79%), unchanged in 5 eyes, and worsened by a single line in 1 eye. Patients were surveyed postoperatively to determine the change in glare disability. The severity of glare disability was subjectively improved in 23 of 24 patients (96%) who responded to the survey. Intraoperative complications included 3 fractured implants as well as an incomplete or torn capsulorhexis in 3 eyes. Postoperative complications included transient hypotony in 2 eyes, mild persistent inflammation in 1 eye, and macular edema followed by a retinal detachment in 1 eye with recent severe trauma. CONCLUSIONS: Implantation of prosthetic iris devices improved postoperative outcomes by reducing glare disability and, in selected cases, by correcting aphakia. Although operating on traumatized, congenitally aniridic, or uveitic eyes presents special challenges, implantation of prosthetic iris devices appears to be a safe and effective method for reducing the ubiquitous glare in patients with iris deficiency.

Indocyanine green-assisted peeling of the retinal internal limiting membrane during vitrectomy surgery for macular hole repair.

OBJECTIVE: To determine the efficacy and safety of indocyanine green (ICG)-assisted retinal internal limiting membrane (ILM) peeling during macular hole repair. DESIGN: Interventional, noncomparative, prospective case series. PARTICIPANTS: Twenty-four consecutive patients (24 eyes) with stage 3 or 4 macular holes. INTERVENTION: All eyes underwent a pars plana vitrectomy, including peeling of the posterior cortical hyaloid when necessary. Indocyanine green dye (0.5%) was instilled into the posterior vitreous cavity over the macula and left in place for 3 to 5 minutes. After removal of the ICG, the retinal ILM was peeled. Medium- to long-acting gas tamponade was used in all cases, and all patients were asked to position face down for 1 to 2 weeks. MAIN OUTCOME MEASURES: Intraoperative staining properties of ICG, technical ease of peeling of the retinal ILM, postoperative anatomic results, visual acuity, and complications were recorded. RESULTS: Indocyanine green stained the retinal ILM, but did not stain the underlying retina. Indocyanine green staining greatly facilitated the surgeons' ability to visualize and peel the ILM in each case. Peeled tissue was sent for both light and electron microscopic studies, which confirmed that the ICG-stained tissue was truly retinal ILM. Patients were observed after surgery for an average of 123 days (range, 23-195 days). Anatomic closure of the macular hole was achieved in 21 eyes (88%) with a single surgery. Visual acuity improved in 23 of 24 patients (96%) after surgery. There were no intra- or postoperative complications related to ICG use, and there was no clinical or fluorescein angiographic evidence of ICG toxicity. CONCLUSIONS: Indocyanine green stains the retinal ILM. This property facilitates ILM peeling by providing a stark contrast between the stained ILM and the unstained retina. Indocyanine green staining of the ILM appears to be a safe and useful adjunct in vitreous surgery for macular hole repair.

Indocyanine green-assisted peeling of the retinal internal limiting membrane.

OBJECTIVE: To determine whether indocyanine green (ICG) stains and facilitates peeling of the retinal internal limiting membrane (ILM). To investigate the different staining properties of the posterior cortical hyaloid, retinal ILM, and the retina after ILM removal. DESIGN: Autopsy eye study. MATERIALS: Eleven human cadaveric eyes. METHODS: Open sky vitrectomy including removal of the posterior cortical vitreous was performed. A 0.5% ICG solution was then injected into the posterior vitreous cavity over the macula. The dye was allowed to settle on the macula for 5 minutes and was then removed by mechanical aspiration. Peeling of the ILM was initiated with a bent needle and completed with intraocular forceps. Specimens were submitted for light and electron microscopy. MAIN OUTCOME MEASURES: Staining properties and ease of peeling of retinal ILM were evaluated. Retinal ILM removal was confirmed by histopathologic and electron microscopic examination. RESULTS: ICG contact with the retinal surface resulted in bright green staining of the ILM. This stain greatly facilitated ILM peeling by improving direct visualization of the membrane. The underlying retina did not stain, thus providing a clear distinction between the stained ILM and the unstained retina. Continuous circular peeling of the ILM was easily completed with this technique. Light microscopic and ultrastructural studies confirmed removal of the ILM. CONCLUSIONS: ICG solution distinctly stains the nearly invisible retinal ILM in human cadaveric eyes. ICG staining greatly facilitates ILM peeling by providing a stark contrast between the stained ILM and the unstained retina.

Cataract surgery combined with implantation of an artificial iris.

We describe 6 patients who presented with cataract or aphakia and absent or nonfunctional irides. The etiologies included congenital aniridia, traumatic iris loss, and chronic mydriasis secondary to recurrent herpetic uveitis. In 5 eyes, a prosthetic iris was successfully implanted in combination with small incision cataract surgery. In 2 eyes, a single-piece iris diaphragm and optical lens was implanted. Artificial irides offer a safe alternative for patients who previously had no viable options for iris reconstruction.

Management of uveitic glaucoma with Ahmed glaucoma valve implantation.

OBJECTIVE: To evaluate the safety and efficacy of Ahmed glaucoma valve implantation for the management of glaucoma associated with chronic uveitis. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Nineteen patients (21 eyes) with chronic uveitis underwent Ahmed glaucoma valve implantation for uncontrolled glaucoma between 1995 and 1998. INTERVENTION: All patients had their uveitis controlled before surgery via immunomodulatory therapy. Ahmed glaucoma valve implantation was performed. Immunosuppression was continued in the early postoperative period for strict control of inflammation. MAIN OUTCOME MEASURES: Control of intraocular pressure (IOP). A secondary outcome measure was the number of antiglaucoma medications required to achieve the desired IOP. Visual acuity and complications associated with the surgery were monitored. RESULTS: The postoperative follow-up averaged 24.5 months. At the most recent visit, all 21 eyes had IOPs between 5 and 18 mmHg. The average pressure reduction after Ahmed glaucoma valve implantation was 23.7 mmHg. The average number of antiglaucoma medicines required to achieve the desired IOP was reduced from 3.5 before surgery to 0.6 after surgery. No eye lost even a single line of Snellen acuity at the most recent postoperative visit. Two eyes developed hypotony in the course of follow-up. One resolved without specific intervention, and the other eye required two autologous blood injections and tube ligature to correct the hypotony. One eye underwent Ahmed glaucoma valve replacement for abrupt valve failure. Two eyes underwent penetrating keratoplasty for reasons believed to be unrelated to the glaucoma surgery. Kaplan-Meier life-table analysis showed a cumulative probability of success after Ahmed glaucoma valve implantation of 94% at 1 year. CONCLUSIONS: Ahmed glaucoma valve implantation can be an effective and safe method in the management of uveitic glaucoma. The authors hypothesize that control of the patients' uveitis, through preoperative and long-term postoperative immunomodulatory therapy, may have contributed to the success rate reported herein.

Expression of prostaglandin H synthase isoforms in human myometrium at parturition.

OBJECTIVE: The purpose of this study was to identify the isoforms and splicing patterns of prostaglandin H synthase present in pregnant human lower-segment myometrium and determine whether there is differential expression of the isoforms or splice variants with respect to gestational age or parturition. STUDY DESIGN: Lower-segment myometrium was collected at cesarean section at term (>37 weeks) or preterm (<37 weeks) from patients who were or were not in labor. Total messenger ribonucleic acid was isolated and reverse transcribed. Polymerase chain reaction for prostaglandin H synthase isoforms 1 and 2 and calponin were performed. Primers designed to characterize the splicing patterns of exon 9 of prostaglandin H synthase-1 were used. RESULTS: The predominant polymerase chain reaction product in all samples corresponds to prostaglandin H synthase-1 messenger ribonucleic acid spliced to include exon 9, but a less-abundant polymerase chain reaction product corresponding to prostaglandin H synthase-1 messenger ribonucleic acid spliced at the internal donor site of exon 9 was also detected. Prostaglandin H synthase-2 messenger ribonucleic acid was detected in human myometrium at a lower abundance than prostaglandin H synthase-1, and neither prostaglandin H synthase-1 or prostaglandin H synthase-2 messenger ribonucleic acid expression changed significantly with gestational age or labor. CONCLUSION: Both prostaglandin H synthase-1 and prostaglandin H synthase-2 isoforms are present in human myometrium. The prostaglandin H synthase-1 messenger ribonucleic acid that includes all of exon 9 encodes the predominant prostaglandin H synthase-1 isoform present in human myometrium. No significant alterations in the expression or splicing patterns for prostaglandin H synthase-1 were detected with respect to gestational age or the onset of labor; but prostaglandin H synthase-1 expression appeared higher at term in anticipation of labor. Although prostaglandin H synthase-2 is present in human myometrium, induction of prostaglandin H synthase-2 does not occur in lower-segment myometrium at parturition.

Analysis of the 5' end of the rat plasma membrane Ca(2+)-ATPase isoform 3 gene and identification of extensive trinucleotide repeat sequences in the 5' untranslated region.

We have characterized the 5' end of the rat gene encoding isoform 3 of the plasma membrane Ca(2+)-ATPase using S1 nuclease protection and DNA sequence analysis. The 5'-untranslated region consists of over 900 nucleotides and includes a 217-nucleotide sequence composed of alternating tracts of TCC and ACC trinucleotides. Analysis of genomic sequences 5' to the transcription initiation site revealed potential binding sites for transcription factors that are active in muscle and brain.

Molecular cloning and physical and genetic mapping of the human anion exchanger isoform 3 (SLC2C) gene to chromosome 2q36.

A human clone corresponding to the gene encoding anion exchanger isoform 3 (AE3) (approved gene symbol SLC2C) has been isolated and partially sequenced. Oligonucleotide primers based on this sequence were used in a polymerase chain reaction to specifically amplify a segment of the human gene from a panel of human-rodent somatic cell hybrids, allowing the assignment of AE3 to chromosome 2. To map AE3 more precisely to a cytogenetic band on chromosome 2, the AE3 cosmid was used as a probe in fluorescence in situ hybridization to human metaphase chromosomes. Fractional length measurements were made, and AE3 mapped at high resolution to the cytogenetic band 2q36. A polymorphic dinucleotide (GT/CA)n repeat marker was developed from sequences in the AE3 cosmid and typed on a subset of the CEPH families. Multipoint linkage analysis placed the AE3 gene between D2S128 and D2S126 on a genetic map of chromosome 2, corroborating the chromosomal localization of AE3 obtained by physical mapping methods.

Alternative splicing of exons encoding the calmodulin-binding domains and C termini of plasma membrane Ca(2+)-ATPase isoforms 1, 2, 3, and 4.

Rat plasma membrane Ca(2+)-ATPase (PMCA) mRNAs were examined by S1 nuclease protection (isoform 1) and polymerase chain reaction (isoforms 1, 2, 3, and 4) and the corresponding genes were analyzed to determine the tissue-specific splicing patterns involving exons encoding the calmodulin-binding domains and C termini. Splicing of PMCA1 involves a single 154-nucleotide exon that can be either included or excluded; when the exon is included four different splice donor sites, at positions 87, 114, 152, and 154, can be utilized. PMCA2 mRNAs are generated either by the inclusion of a 172-nucleotide exon, by the inclusion of both the 172-nucleotide exon and a 55-nucleotide exon, or by the exclusion of both exons. Four PMCA3 mRNAs arise by alternative splicing of a 154-nucleotide exon, in patterns that are analogous to those of PMCA1, and additional mRNAs are generated by the inclusion of a 68-nucleotide exon immediately before the 154-nucleotide exon. The simplest splicing pattern occurs in PMCA4, where a single 175-nucleotide exon is either included or excluded. The alternative mRNAs for each of the four genes are expressed in a tissue-specific manner and encode enzyme variants with different combinations of calmodulin-binding domains and C termini.

Structure of the rat plasma membrane Ca(2+)-ATPase isoform 3 gene and characterization of alternative splicing and transcription products. Skeletal muscle-specific splicing results in a plasma membrane Ca(2+)-ATPase with a novel calmodulin-binding domain.

We have isolated the rat gene encoding isoform 3 of the plasma membrane Ca(2+)-ATPase (PMCA3) and have determined its exon/intron organization. The PMCA3 gene contains 24 exons and spans approximately 70 kilobases. In addition, we have analyzed the splicing and polyadenylation patterns leading to the production of an alternative 4.5-kilobase (PMCA3) skeletal muscle mRNA that differs from the previously characterized 7.5-kilobase brain mRNA (Greeb, J., and Shull, G. E. (1989) J. Biol. Chem. 264, 18569-18576). cDNA cloning, Northern blot hybridization, and polymerase chain reaction analyses of the 4.5-kilobase mRNA demonstrate (i) the inclusion of a novel 68-nucleotide exon (exon 22) that is specific for skeletal muscle and significantly alters the calmodulin-binding domain and (ii) the utilization of an alternative polyadenylation site following exon 23 which eliminates the last coding exon (exon 24) and 3'-untranslated sequence of the 7.5-kilobase mRNA. We have also identified a 42-nucleotide exon (exon 8) that is included in the skeletal muscle PMCA3 mRNAs, but may be either included or excluded in the brain mRNAs. Exon 8 is inserted immediately before the sequence encoding a putative phospholipid binding domain and thus may alter regulatory interactions of the enzyme with acidic phospholipids.

Functional comparisons between isoforms of the sarcoplasmic or endoplasmic reticulum family of calcium pumps.

ATP-dependent calcium pumps that reside in intracellular organelles are encoded by a family of structurally related enzymes, termed the sarcoplasmic or endoplasmic reticulum Ca(2+)-ATPases (SERCA), which each have a distinct pattern of tissue-specific and developmentally regulated expression. A COS-1 cell expression system was used to examine the biochemical properties of the isoforms: SERCA1 (fast-twitch skeletal muscle). SERCA2a (cardiac/slow-twitch skeletal muscle), SERCA2b (ubiquitous smooth- and non-muscle), and SERCA3 (non-muscle). Each isoform was expressed efficiently and appeared to be targeted to the endoplasmic reticulum. All isoforms displayed qualitatively similar enzymatic properties and were activated by calcium in a cooperative manner with a Hill coefficient of 2. The quantitative properties of SERCA1 and SERCA2a (the muscle isoforms) were identical in all respects. SERCA2b, however, appeared to have a lower turnover rate for both calcium transport and ATP hydrolysis. SERCA3 displayed a reduced apparent affinity for calcium, an increased apparent affinity for vanadate, and an altered pH dependence when compared with the other isoforms. These properties are consistent with an enzyme in which the equilibrium between the E1 and E2 conformations is shifted toward the E2 state.

cDNA cloning, functional expression, and mRNA tissue distribution of a third organellar Ca2+ pump.

We describe the characterization of a rat kidney cDNA that encodes a novel Ca2+-transporting ATPase. The cDNA, termed RK 8-13, was isolated previously using an oligonucleotide hybridization probe corresponding to part of the ATP binding site of the sarcoplasmic reticulum Ca-ATPases (Gunteski-Hamblin, A.-M., Greeb, J., and Shull, G. E. (1988) J. Biol. Chem. 263, 15032-15040). The complete nucleotide sequence of the 4.5-kilobase cDNA has been determined, and the primary structure of the protein has been deduced. The enzyme consists of 999 amino acids, has an Mr of 109,223, and contains all of the conserved domains found in transport ATPases of the E1-E2 class. It exhibits 75-77% amino acid identity with the fast-twitch and slow-twitch/cardiac isoforms of the sarcoplasmic reticulum Ca-ATPase, and the hydropathy plots of the three enzymes are virtually identical. High levels of ATP-dependent Ca2+ uptake were demonstrated in microsomes of COS-1 cells that had been transfected with a construct consisting of the entire coding sequence of the cDNA in the expression vector p91023(B). Northern blot analyses of poly(A)+ RNA revealed that the mRNA for this protein is expressed in heart, skeletal muscle, uterus, brain, lung, liver, kidney, testes, small intestine, large intestine, and pancreas. These data show that the enzyme is a Ca2+-transporting ATPase and that its mRNA is expressed in a broad variety of both muscle and non-muscle tissues.