Cytomegalovirus and herpes simplex virus as causes of bilateral anterior uveitis in an immunocompetent patient.

We report a case with two distinct clinical manifestations of bilateral anterior uveitis caused by two different members of the herpes virus group. A 72-year-old immunocompetent man, who had a documented history of two episodes of Posner-Schlossman syndrome in the left eye, presented with multiple mutton-fat keratic precipitates and elevated intraocular pressure (IOP) in his right eye. Herpes simplex virus Type I DNA was detected by polymerase chain reaction in the aqueous humor of the right eye. One year later, the patient appeared with a few round and whitish keratic precipitates and elevated IOP in his left eye. Polymerase chain reaction analysis showed positive for cytomegalovirus in the aqueous humor of the left eye. During both episodes, the anterior uveitis subsided and IOP returned to normal after systemic and topical antiglaucomatous medication as well as topical steroid.

Relationship between central corneal thickness, refractive error, corneal curvature, anterior chamber depth and axial length.

BACKGROUND: To determine the relationship between central corneal thickness (CCT), refractive error, corneal curvature, anterior chamber depth and axial length in normal Taiwanese Chinese adults. METHODS: Five hundred normal Taiwanese Chinese patients aged 40-80 years were recruited for the study. Measurement procedures included CCT, refractive error, corneal curvature, anterior chamber depth and axial length. Exclusion criteria were previous ocular surgery, glaucoma, trauma history, external eye disease, and previous contact lens use. The relationships among parameters were tested using Pearson's correlation and linear regression analysis. RESULTS: The median CCT was 555 +/- 27 mum for males and 553 +/- 30 mum for females. Eyes with more myopic refractive error tended to have greater axial length (r = -0.645, p < 0.001). Eyes with axial elongation tended to have flatter cornea (r = -0.502, p < 0.001) and deeper anterior chamber (r = 0.651, p < 0.001). There were no significant correlations between the CCT and refractive error (r = -0.034, p = 0.445), corneal curvature (r = 0.013, p = 0.770), anterior chamber depth (r = 0.023, p = 0.614) and axial length (r = -0.053, p = 0.223). CONCLUSION: CCT was not associated with refractive error, corneal curvature, anterior chamber depth and axial length. CCT is an independent factor unrelated to other ocular parameters.

Diode laser transscleral cyclophotocoagulation in the treatment of refractory glaucoma with iris melanocytoma.

Iris melanocytoma is a rare melanocytic nevus with distinctive clinical and pathologic features. Secondary glaucoma may develop rapidly and respond poorly to glaucoma medication in some cases. However, few data are available in the literature with respect to the appropriate treatment for refractory glaucoma associated with iris melanocytoma. Herein, we present a 28-year-old man with blurred vision and an elevated intraocular pressure (IOP) of 40 mmHg in his right eye while on multiple glaucoma medications. A dark brown lobulated iris mass with surrounding small pigmented lesions was noted between the 4 and 5:30 o'clock positions. Sector iridectomy was performed and pathologic examination revealed an iris melanocytoma. After surgery, antiglaucomatous medications still failed to control IOP. The patient then underwent diode laser transscleral cyclophotocoagulation (TSCP). At the last follow-up of 15 months, IOP had returned to normal without the need for medication.

The long-term effect of Nd:YAG laser iridotomy on intraocular pressure in Taiwanese eyes with primary angle-closure glaucoma.

BACKGROUND: To investigate the long-term effect of Nd:YAG laser iridotomy on intraocular pressure (IOP) in Taiwanese eyes with primary angle-closure glaucoma (PACG). METHODS: The medical records of 81 patients (130 eyes) who were diagnosed with PACG and who had undergone Nd:YAG laser iridotomy between 1998 and 2002 were reviewed. According to the presence of symptomatic glaucoma attack, eyes were divided into an acute angle-closure glaucoma (AACG) group and chronic angle-closure glaucoma (CACG) group. In the AACG group, the acute episode was treated and resolved after Nd:YAG laser iridotomy. These eyes were diagnosed to have or developed glaucoma during the follow-up period. All patients were followed-up for at least 24 months. The presenting features, treatment and IOP during the follow-up period were analyzed. RESULTS: The mean follow-up period was 44.1 +/- 17.8 months (median, 36 months). There were 27 eyes (from 25 patients) in the AACG group. Only 2 eyes (7.4%) did not require any treatment after Nd:YAG laser iridotomy. Eleven eyes (40.7%) eventually underwent filtering surgery at a mean of 3.2 months (median, 3 months) after Nd:YAG laser iridotomy. There were 103 eyes (from 56 patients) in the CACG group. Eighty-five eyes (82.5%) required further medical treatment, of which 21 eyes (20.4%) eventually received filtering surgery at a mean of 9.8 months (median, 5 months) after Nd:YAG laser iridotomy. CONCLUSION: For most Taiwanese eyes with PACG after Nd:YAG laser iridotomy, additional medicine and surgery are required in the long term. Eyes in the AACG group needed more surgical intervention than those in the CACG group.

Comparison of the effects of latanoprost and bimatoprost on intraocular pressure in chronic angle-closure glaucoma.

PURPOSE: The aim of this study was to compare the intraocular pressure (IOP)-lowering effect of latanoprost and bimatoprost as primary therapy in patients with chronic angle-closure glaucoma (CACG) after peripheral iridotomy. METHODS: Eighty-two (82) consecutive CACG patients with an IOP greater than 19 mmHg after a peripheral iridotomy were recruited. CACG was defined as chronic elevated IOP, glaucomatous optic neuropathy, and a corresponding visual field defect in eyes with occludable angle and peripheral anterior synechiae on gonioscopy. Patients were randomly assigned to two groups based on daily treatment with either latanoprost 0.005% or bimatoprost 0.03% in the evening for 12 weeks. The IOP was measured at 9 AM and 4 PM on the same day at baseline and also at 4, 8, and 12 weeks. Between-group differences in mean diurnal IOP and IOP reduction were analyzed. RESULTS: After 12 weeks of treatment, mean IOP for both the latanoprost and bimatoprost groups was significantly reduced when compared to the baseline value (21.6 +/- 1.9 to 16.4 +/- 2.5 mmHg and 22.1 +/- 2.0 to 16.9 +/- 2.4 mmHg, respectively; P < 0.001 for both). There was no significant difference in IOP reduction between the two treatment groups (P = 0.40). At 4 and 8 weeks, the IOP changes from baseline were statistically significant at both times for both drugs (all P < 0.001). CONCLUSIONS: Both latanoprost and bimatoprost significantly reduced IOP in CACG patients who were inadequately treated by laser peripheral iridotomy.

Effects of bimatoprost 0.03% on ocular hemodynamics in normal tension glaucoma.

PURPOSE: The aim of this study was to investigate the effects of bimatoprost 0.03% on ocular hemodynamics in patients with normal tension glaucoma (NTG). METHODS: Twenty-two (22) patients with NTG were consecutively recruited. After basic eye examination and diurnal intraocular pressure (IOP) measurement, color Doppler imaging was used to measure the peak systolic and end diastolic velocities and resistive index of the central retinal, lateral posterior ciliary, and medial posterior ciliary arteries. Patients received bimatoprost 0.03% for 4 weeks, and these measurements were then repeated. The worse eye of each NTG patient was used in the statistical analysis. RESULTS: Bimatoprost 0.03% significantly reduced mean IOP from 15.1 +/- 3.8 mmHg at baseline to 12.0 +/- 2.9 mmHg after treatment in our sample of NTG patients (P < 0.001). No significant changes in blood velocities or resistance indices were observed in the retrobulbar vessels after the 4-week treatment. CONCLUSIONS: Topical bimatoprost 0.03% significantly reduced IOP in our NTG patients without causing significant hemodynamic changes in the retrobulbar vessels.

Comparison of the effects of latanoprost and travoprost on intraocular pressure in chronic angle-closure glaucoma.

PURPOSE: The aim of this study was to compare the intraocular pressure (IOP)-lowering effect of latanoprost and travoprost as primary therapy in patients with chronic angle-closure glaucoma (CACG) after peripheral iridotomy. METHODS: Seventy-three (73) CACG patients with IOP>19 mmHg after peripheral iridotomy and without previous antiglaucoma medication were consecutively recruited. CACG was defined as the presence of chronically elevated IOP, glaucomatous optic neuropathy, and a corresponding visual field defect in eyes with occludable angle and peripheral anterior synechiae on gonioscopy. Patients were randomly assigned to 2 groups, based on daily treatment with either latanoprost 0.005% or travoprost 0.004% in the evening for 12 weeks. The IOP was measured at 9 AM and 4 PM at baseline and at 4, 8, and 12 weeks. Between-group differences in mean diurnal IOP and IOP reduction were analyzed. RESULTS: After 12 weeks of treatment, mean IOP for both the latanoprost and travoprost groups was significantly reduced, when compared to the baseline IOP (from 21.3+/-1.8 mmHg to 16.0+/-2.3 mmHg and 21.7+/-1.7 to 16.7+/-2.2 mmHg; P<0.001 for both). There was no significant difference in IOP reduction between the 2 treatment groups (P=0.19). At 4 and 8 weeks, the IOP changes from the baseline were statistically significant at all time points for both drugs (all P<0.001). CONCLUSIONS: Both latanoprost and travoprost significantly reduced IOP in our sample of CACG patients after peripheral iridotomy.

Detection of varicella-zoster virus DNA in the iris of a zoster sine herpete patient.

A 55-year-old man presented with unilateral iridocyclitis and elevated intraocular pressure (IOP) in his right eye. Varicella-zoster virus (VZV) DNA was detected by polymerase chain reaction (PCR) in the iris of a patient of Zoster Sine Herpete. No symptoms or signs of herpes zoster like neuralgia or cutaneous eruptions on forehead were noted. His iridocyclitis was treated and responded well with systemic and topical acyclovior as well as topical steroid. However, the marked elevated IOP could not be controlled by maximal dosage of anti-glaucomatous medicine. The patient underwent trabeculectomy to control his IOP. Samples of aqueous humor and iris tissue were obtained and VZV was checked by PCR. VZV virus DNA was detected from samples of the aqueous humor and iris tissue patient of Zoster Sine Herpete by PCR analysis.

Refractory severe ocular hypertension after intravitreal triamcinolone acetonide injection.

PURPOSE: To report a serious complication following intravitreal triamcinolone acetonide injection. METHODS: Observational case report. RESULTS: In 2 patients, secondary intractable severe ocular hypertension occurred 2 months after a single 4-mg intravitreal injection of triamcinolone acetonide for macular edema. Both patients required trabeculectomy intervention to control intraocular pressure (IOP). CONCLUSION: We highlight the occurrence of intractable high IOP elevation as a serious complication 2 months after intravitreal triamcinolone acetonide. Cautious monitoring of IOP for several months after this therapy is recommended. The risks of this potentially devastating complication need to be weighed against the benefits of intravitreal triamcinolone in the individual patient.

Transplantation of the autologous submandibular gland to the lacrimal basin in rats.

PURPOSE: In this study, we designed an animal experiment in which we transferred a part of the autologous submandibular gland without performing a microvascular anastomosis. We studied histological changes and functional effects in the transfer glands. METHOD: Thirty male adult Sprague-Dawley rats were divided into three groups. In each animal of the three groups, the right eye was the control eye and the left eye the experimental eye. Surgical removal of the extraorbital lacrimal gland from the control eyes was performed to create a condition simulating keratoconjunctivitis sicca. In the experimental eyes of group 1, in addition to the removal of the extraorbital lacrimal gland, a part of the autologous submandibular gland was transferred to the orbit and fixed to the intraorbital lacrimal gland. In the experimental eyes of group 2, in addition to the removal of the extraorbital lacrimal gland, an aseptic silicon rubber was transferred to the orbit and fixed to the intraorbital lacrimal gland. In the experimental eyes of group 3, there was no removal of the extraorbital lacrimal gland but instead a sham operation was performed. The histological changes and innervation pattern in the transferred submandibular gland of group 1 were observed. Tear secretion of each group was measured to study the functional effect. RESULTS: Three months after the transplantation, the transferred submandibular glands were similar to the unoperated submandibular glands both in histology and innervation pattern. In group 1, the tear secretion in the experimental eyes was significantly greater than that of the control eyes at 2 and 3 months following transfer. In group 2, no significant difference was noted between the experimental eyes and control eyes. In group 3, the difference in tear secretion between the experimental eyes and control eyes was significant. CONCLUSION: The result of this study revealed that although the procedure did not involve vascular anastomosis, the transfer gland showed a normal histological appearance and good reinnervation, even 3 months after the transfer. These transferred submandibular glands continued to secrete tears. This secretion continued to increase up until the end of the experimental period.

Clinical experience in the management of neovascular glaucoma.

BACKGROUND: Neovascular glaucoma (NVG) is a devastating ocular disease with poor prognosis. The ideal surgical procedure has yet to be determined. In this study, the clinical course and visual outcome of NVG and their fellow eyes were investigated and the most appropriate management was also evaluated. METHODS: The study was conducted retrospectively consisting of NVG in-patients of Taipei Veterans General Hospital who were under the care of the same glaucoma specialist between January, 1998 and September, 2000. All patients had a minimal follow-up period of 6 months. RESULTS: The total number of patients enrolled was 35 (number of eyes enrolled was 35) with mean age of 66.4 +/- 12.3 years. The underlying cause was diabetes mellitus in 29 patients and central retinal vein occlusion in 6 patients. Twelve (34.3%) eyes had initial intraocular pressure (IOP) of over 60 mmHg. Only 1 (2.9%) eye had initial visual acuity better than 6/60. Four lesion eyes were able to receive panretinal photocoagulation whereas 31 eyes received panretinal cryotherapy. For IOP reducing procedures, 15 eyes received trabeculectomy, and 16 received Diode trans-scleral cyclophotocoagulation (TSCP). At the final visit, 20 eyes (trabeculectomy group: 11 and Diode TSCP group: 9) were able to maintain an IOP < or = 21 mmHg. Of these eyes, 15 (trabeculectomy group: 8 and Diode TSCP group: 7) were able to maintain or improve their vision. Of the remaining 4 eyes, 2 had cyclocryotherapy and 2 had trabeculectomy followed by Diode TSCP. IOP were controlled in these 4 eyes but none were able to maintain stable vision. Among the 34 fellow eyes with stable IOP, 32 were able to maintain stable vision. CONCLUSIONS: Trabeculectomy and Diode TSCP provided no statistically significant difference in IOP control (p = 0.32) and visual outcome (p = 0.59) in our patient group. More randomized, prospective trials are needed to define the most effective treatment for NVG.

Possible involvement of nitric oxide in the progression of diabetic retinopathy.

Abnormal nitric oxide (NO) synthesis has been implicated in the pathogenesis of diabetes mellitus. The aim of our study was to elucidate the relationship between the stages of diabetic retinopathy (DR) and the NO levels in aqueous humor and plasma. Using the chemiluminescence assay, we measured the concentrations of NO in aqueous humor and plasma samples obtained during intraocular surgery from 45 diabetic patients and 19 nondiabetic cataract patients. The patients with diabetes were classified into 4 groups: proliferative DR (PDR) with active neovascularization (active PDR; 9 cases), PDR with quiescent neovascularization (regressed PDR; 6 cases), background DR (BDR; 16 cases) and no DR (14 cases). We found that the aqueous NO levels (mean +/- SE) of the active PDR group (83.2 +/- 13.9 microM) were significantly higher than those of the BDR group (45.8 +/- 6.0 microM, p = 0.049) and the diabetics without DR (33.3 +/- 5.2 microM, p = 0.011), and, although not statistically significantly, they were also higher than those of the regressed PDR group (52.1 +/- 10.3 microM, p = 0.224). However, no significant differences were observed between any of the diabetic subgroups in the plasma NO levels (p = 0.345). We therefore concluded that NO present in the ocular tissues may play important roles in the progression of DR.

Elevated nitric oxide level in aqueous humor of AIDS patients with cytomegalovirus retinitis.

Human cytomegalovirus (HCMV) retinitis is the most common ocular opportunistic infection in AIDS. It often leads to blindness if left untreated. The questions as to how HCMV infection causes retinal immunopathogenesis and visual destruction in AIDS patients have not been completely established. Here we reported that the nitric oxide (NO) levels in aqueous humor samples in 10 AIDS patients with CMV retinitis (104.3 +/- 27.1 microM) were higher than the levels in 7 AIDS patients without CMV retinitis (36.1 +/- 10.4 micro M; p < 0.001). After ganciclovir treatment, the NO level in the vitreous body of 5 patients declined dramatically (53.4 +/- 11.8 micro M). By using immunohistochemistry assay, we found that the aggregates of macrophages infiltrated in the CMV-infected retina of 4 AIDS patients. Moreover, the expression of inducible-form NO synthase was detected in the infected retina of these patients. These results suggest that NO production in the eye may play a fundamental role in the immunopathogenesis of AIDS patients with CMV retinitis.

Significant variation of the elevated nitric oxide levels in aqueous humor from patients with different types of glaucoma.

Though several studies have shown that the biochemical function of nitric oxide (NO) in the eye might play an important role in the regulation of intraocular pressure (IOP), local control of ocular blood flow and loss of retinal ganglion cells by apoptosis, it is unclear whether the role of NO is similar in the pathogenesis of different kinds of glaucoma: primary open-angle glaucoma (POAG), chronic closed-angle glaucoma (CCAG) and neovascular glaucoma (NVG). To further explore this issue, we measured the concentrations of NO in aqueous humor and plasma samples from patients with POAG (n = 31), CCAG (n = 76), NVG (n = 8) and cataract (n = 30). All of the NVG patients suffered from severe proliferative diabetic retinopathy, while other patients were free of any other systemic disease. The NO levels in both aqueous humor and plasma samples were assessed by chemiluminescence assay. We found that the NO levels in aqueous humor samples were greatly varied in patients with POAG (36.2 +/- 3.3 microM), CCAG (47.7 +/- 3.4 microM) and NVG (65.8 +/- 5.4 microM), and all of them were significantly higher than in cataract patients (27.0 +/- 2.9 microM p < 0.05). Except NVG patients whose NO levels in plasma samples were highest (24.1 +/- 3.5 microM) among all groups, the plasma NO levels were not significantly different between the other glaucoma patients and the cataract patients. We therefore concluded that significant variation of the elevated NO levels in aqueous humor samples from the patients with different types of glaucoma may reflect their differences in the pathogenesis.

Nitric oxide levels in the aqueous humor in cataract patients.

PURPOSE: To determine the role of nitric oxide (NO) in the clinical manifestations of cataract in different age and etiological groups. SETTING: Multicenter study, Taipei, Taiwan, Republic of China. METHODS: Aqueous humor samples were obtained from 114 cataract patients in different etiological and age groups (eg, juvenile, traumatic, and age-related cataract). Using chemiluminescence assay, NO was detected through the light generated by ozone and NO interaction. The amount of NO production was calculated and compared among groups. The results were correlated with patient age. RESULTS: The NO levels in aqueous humor were highest in the 12 patients with traumatic cataract and lowest in the 15 patients with juvenile cataract (47.59 micromol/L +/- 12.81 [SD] and 7.66 +/- 2.62 micromol/L, respectively; P <.001). Aqueous humor NO levels were correlated with age and were highest in patients older than 80 years (mean 38.78 +/- 6.29 micromol/L) and in those with mature cataract (mean 40.15 +/- 6.15 micromol/L) (P <.05). CONCLUSIONS: The NO levels in the aqueous humor increased with age and traumatic events. The results suggest that NO could be a risk factor in cataract formation.

Apoptosis of human retina and retinal pigment cells induced by human cytomegalovirus infection.

Human cytomegalovirus (HCMV) retinitis is the most common ocular opportunistic infection in immunocompromised patients and AIDS. It often leads to blindness if left untreated. The question as to how HCMV infection causes retinal pathogenesis and visual destruction in AIDS patients remains unresolved. To answer the question, by using terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling assay, we detected the significant signals of apoptotic cells at the same sites in the HCMV-infected retina of AIDS patients as compared to AIDS patients without HCMV retinitis. In vitro study also revealed apoptosis induced by HCMV infection in human retinal pigment epithelium cells, mediated by activation of caspase 3 and poly(ADP-ribose) polymerase pathway. These results strongly suggest the fundamental role of HCMV-induced apoptosis in mediating cell death in infected human retina and retinal pigment epithelium cells to make severe visual impairment.