Twenty years of acanthamoeba diagnostics in Austria.

Acanthamoebae are the causative agents of an often seriously progressing keratitis (AK) occurring predominantly in contact lens wearers and can cause several disseminating infections potentially resulting in granulomatous amoebic encephalitis (GAE) in the immunocompromised host. Our institution is the Austrian reference laboratory for Acanthamoeba diagnostics and the aim of this study was to give an overview of proven cases of Acanthamoeba infections in Austria during the past 20 yr. All samples of patients with suspected AK or GAE were screened for Acanthamoeba spp. by culture and/or PCR and the detected amoebae were genotyped. Altogether, 154 cases of AK and three cases of GAE were diagnosed. Age of the AK patients ranged from 8 to 82 yr (mean 37.8) and 58% of the patients were female. Approximately 89% of the AK patients were contact lens wearers, almost all cases were unilateral and 19% of the patients required a keratoplasty. Age of the GAE patients ranged from 2 to 25 yr (mean 14.7), all were HIV-negative, but two were severely immunosuppressed at the time of diagnosis. The predominant genotype in the AK cases was T4, other genotypes found were T3, T5, T6, T10 and T11. The three GAE cases involved genotypes T2, T4 and T5.

Evaluation of ocular surface and tear film function following modified Hughes tarsoconjunctival flap procedure.

PURPOSE: To evaluate ocular surface characteristics and tear film function following modified Hughes flap for eyelid reconstruction. METHODS: This is an institutional study including 18 patients (6 male, 12 female) who underwent a tarsoconjunctival flap for reconstructing the lower eyelid's posterior lamella in one eye between 2005 and 2010. The median age of the patients was 72 (49-93) years at the time of surgery and 77 (51-97) years at the time of evaluation. The median follow-up time was 34 (9-69) months. All patients had large malignant or semi-malignant lid tumours. Data for subjective symptoms (OSDI questionnaire), lid margin morphology, tear break-up time (BUT), vital staining, Schirmer test, impression cytology, tear film osmolarity, lipid layer interference patterns, meibography and the size of the tumour and flap were recorded and compared with the contralateral side. RESULTS: Statistical analysis of the data revealed a significant difference between the surgically treated lid and the untreated side in meibomian gland loss, more lid margin abnormalities in the upper and lower eyelid (p<0.001) and increased fluorescein staining of the cornea (p=0.031). For the operated side, the median OSDI score was higher (17.2 versus 14.7), and the median BUT value was shorter (4.2 versus 5.6 seconds) compared with the median values of the contralateral side. CONCLUSION: Despite the favourable cosmetic and functional results of the Hughes tarsoconjunctival flap, our results indicate that this procedure does affect the ocular surface health in the treated eyes.

Influence of single-fraction Gamma-Knife radiosurgery on ocular surface and tear function in choroidal melanoma patients.

AIM: To evaluate ocular surface and tear function in patients with choroidal melanoma treated with single-fraction radiosurgery. METHODS: 36 patients (median age 62 years; range 26-84 years) were enrolled between 2001 and 2006 at a single institution. They were treated with the Leksell Gamma Knife in one fraction with a median dose of 30 Gy (range 25-35 Gy). In both eyes of all patients treated subjective symptom score (visual analogue scale) was evaluated, central corneal sensitivity testing, Schirmer test without local anaesthesia, and corneal and conjunctival staining were performed before therapy and 3, 6, 12, 24 and 36 months thereafter. The respective untreated fellow eye served as control. RESULTS: Three months after radiosurgery, the subjective dry eye symptom score and lissamine green staining score of the ocular surface were significantly higher in the treated eyes compared with the fellow eyes (p<0.001, p=0.028, respectively). After 12 months, a significant difference between the treated and the fellow eyes in corneal sensitivity (p=0.041) and corneal fluorescein staining (p=0.002) was found when compared with pretreatment values. After 24 months Schirmer test values without local anaesthesia were significantly reduced in the treated eyes vis-à-vis untreated fellow eyes and pretreatment values (p=0.004). The dose applied to the lacrimal gland was significantly correlated to ocular surface staining scores (p=0.001) and Schirmer test values (p=0.026) at 24 months after irradiation. CONCLUSIONS: Stereotactic single-fraction Gamma-Knife radiotherapy of choroidal melanoma with a median dose of 30 Gy significantly affected ocular surface and tear function and increased dry eye symptoms and signs.

Long-term follow-up of punctal and proximal canalicular stenoses after silicone punctal plug treatment in dry eye patients.

PURPOSE: To determine the clinical value and relevance of punctal and proximal canalicular stenoses after punctal plug therapy in moderate to severe dry eye syndrome. DESIGN: Retrospective, observational case series. METHODS: Seventeen eyes were determined to have punctum or proximal canalicular stenoses after spontaneous loss of a collared silicone punctal plug. After initial diagnosis all patients had 12 months or more of follow-up (mean, 39; range, 12 to 87 months). The clinical data collected included gender and age of patients, localization of the stenosis, plug size, duration of punctal occlusion, subjective symptoms, objective ocular surface disease parameters, and occurrence of complications. RESULTS: A statistically significant correlation between localization of the stenosis and plug size, and localization of the stenosis and duration of punctal occlusion could not be found. At follow-up, subjective symptoms (P < .01) and frequency of artificial tear application (P < .001) were significantly reduced compared to data before plug insertion. Schirmer I test results (P < .001), corneal fluorescein staining (P < .01), and rose bengal staining (P < .001) improved significantly, whereas tear break-up time (P < .2) and impression cytology scores of the conjunctival surface (P = .2) remained almost unchanged. Complications could not be found. CONCLUSION: Within the observation period of up to seven years, all stenoses remained asymptomatic. Additionally, subjective symptoms and most dry eye parameters in our study population improved.

Multiplex bead analysis of vitreous and serum concentrations of inflammatory and proangiogenic factors in diabetic patients.

PURPOSE: To investigate the role of inflammatory and angiogenic factors in the pathogenesis of diabetic retinopathy, we determined, in diabetic patients and controls, vitreous and serum concentrations of interferon-induced protein (IP)-10, monocyte chemoattractant protein (MCP)-1, macrophage inflammatory protein (MIP)-1alpha, MIP-1beta, regulated upon activation, normal T-expressed and secreted (RANTES), and vascular endothelial growth factor (VEGF). METHODS: We recruited 36 probands with type 2 diabetes mellitus (15 noninsulin-dependent and 21 insulin-dependent) and 69 normal controls. Using Cytometric Bead Array Technology, we measured vitreous and serum concentrations of IP-10, MCP-1, MIP-1alpha, MIP-1beta, RANTES, and VEGF. RESULTS: In diabetic patients the mean vitreous levels of IP-10, MCP-1 and VEGF were significantly higher compared normal controls. [IP-10 (pg/mL) 254.84 +/-311.67 versus 78.90 +/- 67.94 (p<0.001); MCP-1 (pg/mL) 1127.14 +/- 738.91 versus 700.80 +/-419.21 (p=0.002); VEGF (pg/mL) 954.98 +/- 2315.09 versus 37.90 +/- 28.51(p<0.001)]. Vitreous levels of VEGF correlated with vitreous levels of both IP-10 and MCP-1 (p<0.05). MIP-1beta, RANTES, and VEGF mean serum levels were significantly raised in diabetic probands while IP-10, MCP-1, and MIP-1alpha serum levels showed no significant elevation compared to controls [IP-10 (pg/mL) 346.20 +/- 287.36 versus 328.74 +/-352.35 (p=0.88); MCP-1(pg/mL) 133.10 +/- 89.10 versus 141.47 +/- 222.15 (p=0.50); MIP-1beta (pg/mL) 184.40 +/- 100.20 versus 139.56 +/- 151.38 (p=0.003); RANTES (pg/mL) 51336.23 +/- 19940.31 versus 33629.2 +/- 33301.0 (p=0.002); VEGF (pg/mL) 304.88 +/- 257.52 versus 154.45 +/- 114.78 (p<0.001)]. CONCLUSIONS: Our results suggest that in diabetics, there is an upregulation of IP-10, MCP-1, and VEGF in the vitreous and an upregulation of MIP-1beta, RANTES, and VEGF in the serum. These findings support the concept of an angiogenic and inflammatory element in the development of diabetic retinopathy.

Application of multiplex cytometric bead array technology for the measurement of angiogenic factors in the vitreous.

PURPOSE: This study was carried out to compare cytometric bead array (CBA) technology with conventional enzyme linked immunosorbent assay (ELISA) for the measurement of both vitreous and serum concentrations of interleukin-8 (IL-8), vascular endothelial growth factor (VEGF), and angiogenin (ANG) in diabetic and non-diabetic patients. METHODS: Measurement of vitreous and serum concentrations of IL-8, VEGF, and ANG using both ELISA and CBA was performed in 26 probands (13 diabetics and 13 non-diabetic control subjects). RESULTS: Vitreous and serum concentrations of IL-8, VEGF, and ANG determined by CBA showed a strong correlation with those measured by ELISA. Vitreous levels of IL-8, VEGF, and ANG were significantly higher in diabetics compared to non-diabetic control subjects. No significant correlation between vitreous and serum levels of any of the investigated parameters were found in either diabetics or control individuals. CONCLUSIONS: The present study is the first to utilize cytometric bead array technology for the measurement of angiogenic factors in the vitreous. Measurements obtained by ELISA and CBA technologies were highly correlated for IL-8, VEGF, and ANG in both vitreous and serum samples. Diabetic individuals showed significant elevation of IL-8, VEGF, and ANG in the vitreous but not in serum samples compared to control subjects. The most striking advantage of the CBA technology is the fact that numerous parameters can be measured in parallel using a comparatively small sample volume. It is therefore more rapid and cost effective than ELISA technology. CBA technology is a new, accurate method to measure IL-8, VEGF, and ANG in the vitreous.

Role of the CCL2/MCP-1 -2518A>G gene polymorphism in HLA-B27 associated uveitis.

PURPOSE: Acute anterior uveitis (AAU) is the most common form of uveitis. Up to 50% of patients with AAU are HLA-B27 positive. Since HLA B27 itself plays only a minor role in the overall genetic background, other genetic variants are likely to contribute to the susceptibility to AAU. The chemokine (C-C motif) ligand 2 (CCL2) gene, coding for monocyte chemoattractant protein-1 (MCP-1), a chemotactic cytokine, is involved in the induction of uveitis. A CCL2 gene polymorphism, which is characterized by an A>G substitution at nucleotide -2518 in the promoter region of CCL2 has been previously shown to affect MCP-1 synthesis. The purpose of the present study was to investigate a hypothesized association between this genetic variant and the presence of HLA-B27 associated AAU. METHODS: The study group comprised 114 patients with HLA-B27 associated AAU. One hundred and eleven healthy HLA-B27 positive individuals served as the HLA-B27 positive control group, whereas 81 healthy HLA-B27 negative individuals served as a HLA-B27 negative control group. Genotyping for the CCL2 -2518A>G polymorphism was performed by polymerase chain reaction. RESULTS: Carriers of a CCL2 -2518G allele were found significantly more often in patients with HLA-B27 associated AAU than among HLA-B27 positive controls (49.2% and 31.5%, respectively; odds ratio 2.1; 95% confidence interval 1.2-3.6; p=0.007). CONCLUSIONS: Our data suggest that the CCL2 -2518A>G polymorphism may play a role in HLA-B27 associated acute anterior uveitis.

Evaluation of the clinical course of dry eye syndrome.

OBJECTIVE: To assess subjective symptoms, tear function factors, and ocular surface morphology in the clinical course of patients with dry eye syndrome under treatment within an observation period of up to 8 years. METHODS: In 97 patients (78 women and 19 men) with ocular discomfort, a clinical diagnosis of dry eye syndrome was made based on typical symptoms and a reduced tear film breakup time of less than 10 seconds. Subsequent evaluations revealed a diagnosis of aqueous tear deficiency in 9 patients, meibomian gland dysfunction in 32 patients, and aqueous tear deficiency combined with meibomian gland dysfunction in 30 patients, aqueous tear deficiency associated with Sjögren syndrome in 12 patients, and aqueous tear deficiency and meibomian gland dysfunction associated with Sjögren syndrome in 14 patients. Follow-up assessments were performed 12 to 94 months (mean follow-up, 40 months) after the initial diagnosis. MAIN OUTCOME MEASURES: In different subgroups of dry eye tear film breakup time, Schirmer test without local anesthesia (Schirmer I), fluorescein and rose bengal staining, impression cytology, as well as subjective dry eye symptoms and frequency of tear substitute application were compared at baseline and after a follow-up of 1 to 8 years (mean, 3.3 years). RESULTS: At baseline, tear film function and ocular surface test results found more pathologic abnormalities and more severe subjective symptoms in patients with aqueous tear deficiency associated with Sjögren syndrome and aqueous tear deficiency and meibomian gland dysfunction associated with Sjögren syndrome compared with the other groups who had dry eye syndrome. No differences in frequency of tear substitute application were observed. At follow-up, tear breakup time, Schirmer I test results, and corneal fluorescein staining improved compared with baseline values, whereas rose bengal staining and impression cytology of the conjunctival surface remained almost unchanged. Subjective symptoms and frequency of artificial tear application were reduced. CONCLUSIONS: Within the observation period of up to 8 years, the dry eye syndrome improved or stabilized under appropriate treatment. Although no patient was completely cured, subjective reports as well as frequency of artificial tear application were reduced.

A conservative blepharoplasty may be a means of alleviating dry eye symptoms.

PURPOSE: Patients with dermatochalasis often complain of dry eye symptoms. In a prospective study, the influence of upper eyelid blepharoplasty on dry eye symptoms, tear film parameters and ocular surface morphology was evaluated. METHODS: Patients with upper eyelid dermatochalasis were studied before and 3 months after upper eyelid blepharoplasty. Changes in ocular symptoms and physical examinations such as tear film break-up time, Schirmer test without local anaesthesia, impression cytology of the bulbar conjunctiva and inflammatory reaction were recorded. RESULTS: Subjective dry eye symptoms were found in 11 patients (46%) preoperatively and in five patients (21%) postoperatively. Objective dry eye signs were present in eight patients (33%) before blepharoplasty and in nine patients (38%) 3 months postoperatively. Morphological findings did not change within the observation period. The inflammatory reaction shown by impression cytology decreased postoperatively. CONCLUSION: Blepharochalasis may be associated with dry eye. Blepharoplasty might be a means of alleviating dry eye symptoms. The reason for this subjective alleviation might be due to reduced inflammatory reaction, changes in blink mechanism or the fact that patients are more confident about their appearance.

Chlamydial conjunctivitis (in adults), uveitis, and reactive arthritis, including SARA. Sexually acquired reactive arthritis.

This chapter deals with Chlamydia -induced ocular and rheumatic diseases of the adult. All of these may follow a primary urogenital infection with Chlamydia trachomatis in genetically predisposed patients. Besides the infection with Chlamydia trachomatis, infections with Chlamydia pneumoniae and Chlamydia psittaci are also discussed as possible causative agents. Chlamydial conjunctivitis is frequently a secondary infection, and the organism is transferred from the urogenital tract to the eye by autoinoculation. Uveitis and reactive arthritis are believed to be triggered - among other infections - by a preceding urogenital infection. Both of them are closely associated with HLA-B27 positivity. The simultaneous occurrence of uveitis and reactive arthritis is termed Reiter's syndrome. We report on clinical characteristics, diagnosis and the role of Chlamydia in the pathogenesis of chlamydial conjunctivitis, uveitis and reactive arthritis as well as on the currently recommended treatment regimens.

Chlamydia pneumoniae seropositivity and the risk of nonarteritic ischemic optic neuropathy.

OBJECTIVE: To determine whether IgG antibodies to Chlamydia pneumoniae are associated with nonarteritic ischemic optic neuropathy (NAION). DESIGN: Retrospective case-control study. PARTICIPANTS: The study cohort consisted of 71 consecutive patients with NAION and 71 controls matched for age and gender. MAIN OUTCOME MEASURES: Serum immunoglobulin G (IgG) antibody titers to Chlamydia pneumoniae. RESULTS: Patients with NAION had significantly higher IgG antibody titers to C. pneumoniae compared with control subjects (IgG titer > or =1:128: 29 patients versus 15 controls, P = 0.017). The odds ratio for patients with an IgG titer > or =1:128 was 2.56 (95% confidence interval [CI], 1.2-5.5). Adjustment for arterial hypertension, diabetes mellitus, and myocardial infarction resulted in an odds ratio of 3.48 (95% CI, 1.3-9.6). CONCLUSIONS: Our results suggest that elevated titers of IgG antibodies to C. pneumoniae are associated with NAION.