[Black spots in the eye]. / Schwarzer Fleck am Auge.

Senile scleral plaques are characterized by a calcification located at the insertion of the horizontal rectus muscles. As a possible cause for their development a combination of solar tissue damage and continuous mechanical stress is discussed. We present a case of a 76-year-old male whose wife noticed expulsion of a calcified scleral plaque while applying antiglaucoma eyedrops. The local antiglaucoma therapy was stopped and acetacolamide was administered. Local therapy consisted of hyaluronic acid eyedrop and calcium pantothenate and retinol palmiate eye ointment. This treatment led to a rapid reepithelialization. The expulsion of calcified senile scleral plaques is a described complication which can necessitate surgical treatment.

[Cataract surgery. Effect on the posterior segment of the eye]. / Kataraktoperation. Effekt auf den hinteren Augenabschnitt.

Cataract surgery is a safe procedure with a high patient satisfaction rate. However, pseudophakia changes the physiology of the eye and immediate changes include release of inflammatory cytokines. Deformation of the globe and intraoperative fluctuations of intraocular pressure may induce microlesions and alterations of ocular perfusion. The barrier function between the anterior and the posterior segment is compromised after surgery and the geometry of the intraocular chambers changes. Especially the vitreous body is subject to increased destruction during the years after surgery. The occurrence of pseudophakic cystoid macular edema after cataract surgery is a well known complication. Several studies have described a progression of diabetic retinopathy, especially of diabetic macular edema after cataract surgery. In contrast cataract surgery does not seem to have a significant impact on the progression of age-related macular degeneration. However the risk for retinal detachment is significantly increased in pseudophakia for at least 10 years after surgery. Awareness of special risk factors can make cataract surgery, one of the most effective procedures in medicine, even safer.

[Ophthalmological findings as a hint for systemic disease]. / Ophthalmologische Befunde als Hinweis auf internistische Erkrankungen.

Many eye diseases are associated with systemic diseases. Moreover, ophthalmological findings can be first manifestations of systemic diseases. Therefore internists and ophthalmologists should be familiar with the signs, symptoms, and the management of eye diseases with a possible systemic association. Due to subspecialization in medicine an interdisciplinary approach is mandatory for optimal patient care. In this article examples of eye diseases with a possible association with systemic diseases are presented.

Efficacy and safety of lornoxicam compared with placebo and diclofenac in acute sciatica/lumbo-sciatica: an analysis from a randomised, double-blind, multicentre, parallel-group study.

AIM: The efficacy and safety of oral lornoxicam (LNX) as early treatment of acute sciatica/lumbo-sciatica was compared with placebo and diclofenac in a 5-day double-blind, randomised study. METHODS: Male or female patients (n = 171) aged 18-70 years with acute sciatica or lumbo-sciatica [acute sciatica defined as typical radiation of pain along the sciatic nerve (including radiating pain below the knee) and worsening of pain as defined by Lasegue's leg-raising test (< 60 degrees ) within 72 h and previous attack ceased > 3 months previously; lumbo-sciatica defined as symptoms of sciatica with concurrent lumbar pain and a predefined minimum pain score]. The dosage of study treatment was 8-24 mg/day LNX, 100-150 mg/day diclofenac or placebo. The primary end-point was the difference in pain intensity difference from baseline to 6 h (PID(0-6 h)) after the first dose of study treatment. Secondary end-points were pain relief, the cumulative sums of pain intensity difference and total pain relief on day 1 and on days 2-4. RESULTS: In total, 164 patients completed the study. Significant differences in PID between LNX and placebo were seen in the time interval 3-8 h after the first dose including PID(0-6 h) (p = 0.015). Secondary end-points favoured LNX vs. placebo, but in general were not significantly different. LNX and diclofenac had similar analgesic effect. Incidence and severity of adverse events were comparable for the three treatments; overall tolerability was rated as very good/good by 93% of the patients. CONCLUSION: These data indicate that the analgesic efficacy of LNX is superior to placebo and similar to diclofenac in acute sciatica/lumbo-sciatica.

[Surgical treatment of diabetic macular oedema]. / Chirurgische Therapie des diabetischen Makulaödems.

The therapy for diabetic macular oedema often remains unsatisfactory for both patient and treating physician. Therapeutic approaches comprise laser therapy as the evidence-based "basic therapy" and increasingly also intravitreal injections of drugs which, however, have only a limited effect. One argument for the use of vitrectomy in the treatment of diabetic macular oedema is its potentially permanent positive effect. On the one hand, removal of the adherent vitreous may facilitate the supply of the inner retina "per diffusionem" from the vitreous, on the other hand it may allow movement of harmful cytokines from the retina into the vitreous also by diffusion. Furthermore, from the pathophysiological standpoint, the vitreoretinal interface itself is modified by glycosylation processes and may thereby contribute to the occurrence of macular oedema. Pathological vitreofoveolar adhesions, which now can be visualised by use of ocular coherence tomography, may also add to the development of macular oedema in a mechanical-tractive manner. A critical analysis of the published clinical studies reveals that the macular retinal thickness is indeed reduced after vitrectomy, disappointingly however, this does not translate into better visual acuity in patients without detectable tractive components. But, in the case of eyes with tractive components of the diabetic macular oedema, there is good evidence for a surgical approach.

Elastosis perforans serpiginosa-like pseudoxanthoma elasticum in a child with severe Moya Moya disease.

A 2-year-old girl with Moya Moya disease who had relapsing cerebrovascular strokes presented with loose skin folds, 'chicken' skin appearance and perforating elastosis serpiginosa-like lesions in the genitocrural region. Histologically, calcified material perforating the epidermis and adjacent short curled and mineralized elastic fibres suggested a variant of pseudoxanthoma elasticum (PXE). As PXE is known to be caused by various mutations in the transmembrane transporter ABCC6 gene, we hypothesized that a novel ABCC6 mutation may underlie this unique combination of PXE and elastopathic vascular damage. Therefore, the complete ABCC6 coding region of the patient and her parents was screened for genetic alterations. No bona fide disease-causing mutation of ABCC6 could be found in the child and in her parents. However, two novel allelic amino acid substitutions (Arg1273Lys and Glu1293Lys; exon 27) were found in the girl and her father, localized in close proximity to the region that codes for the functionally critical second nucleotide-binding fold of ABCC6. Although a causal involvement of these amino acid substitutions could not be proven based on this study, both heterozygote substitutions may possibly have interacted with other undetected recessive maternal ABCC6 changes in the child. To the best of our knowledge, this is the first report of an association between early-onset PXE and severe Moya Moya syndrome possibly related to ABCC6 changes.

Mechanism of the Heck reaction using a phosphapalladacycle as the catalyst: classical versus palladium(IV) intermediates.

The mechanism of the (Mizoroki-)Heck vinylation of aryl bromides catalyzed by the phosphapalladacycle [[PdCH2C6H4P(o-Tol)2(OAc)]2] (1) was investigated in order to determine whether palladium(IV) intermediates play a significant role in the catalytic cycle. The phosphapalladacycle 1 was compared to the related palladium(0) catalyst [Pd[P(o-Tol)3]2] (2) and an intermediate of the classical catalytic cycle [[PdAr[P(o-Tol)3]Br]2] (3) obtained by oxidative addition of an aryl bromide to 2. Small, yet measurable deviations of the phosphapalladacycle 1 from the other catalysts 2 and 3 in the product distribution of styrene, in competition experiments of styrene and n-butyl acrylate, in the isotope effect on styrene, and the Hammett correlation on aryl bromides led to the conclusion that a different catalytic cycle is operative. Nevertheless, due to only small differences in these competition experiments a modified classical catalytic cycle with a novel, cyclometallated, anionic palladium(0) species 6 is proposed rather than palladium(IV) intermediates. Species 6 accounts for the observed high activity and stability of palladacycle catalysts in the Heck reaction. Palladium(IV) intermediates can be ruled out by taking into account the experiments performed here and recently published by others.

Terbinafine-associated hepatic injury.

We describe two cases of terbinafine-associated hepatic injury, in which a mixed cholestatic-hepatocellular type of hepatitis was present. In both cases extrahepatic cholestasis and viral hepatitis were excluded and involvement of other drugs was unlikely. In the first patient all abnormalities have disappeared, but in the second patient alkaline phosphatase, aminotransferase and gamma-glutamyl transferase levels have remained elevated (follow up 3 months after cessation of treatment with terbinafine). Most likely, the terbinafine-associated hepatic injury in these patients was caused by an idiosyncratic rather than a direct hepatotoxic reaction.

[Loss of taste sensation in terbinafine administration]. / Smaakverlies tijdens gebruik van terbinafine.

Terbinafine is a new antifungal agent for oral treatment of dermatomycosis. Seven patients are reported who developed taste loss after treatment with terbinafine. In four of them, taste loss was complete while one patient was still able to taste sweet products, and a second and third patient no longer tasted salty and sweet products, respectively. In all patients, the onset of the adverse reaction occurred 4-8 weeks after starting treatment. As far as known, taste loss is a transient effect which disappears within 3-6 weeks after discontinuation of terbinafine.

Circulating IgA-immune complexes in Henoch-Schönlein purpura. A longitudinal study of their relationship to disease activity and vascular deposition of IgA.

In Henoch-Schönlein purpura immune complexes in inflamed vessel walls characteristically contain immunoglobulin A(IgA). To determine whether IgA is also the predominant immunoglobulin in circulating immune complexes, we compared the results of three immune complex assays with specificities for different classes of immunoglobulins in a longitudinal study of 37 patients (30 children and seven adults) with Henoch-Schönlein purpura. Circulating IgA-containing immune complexes were detected by their reactivity with a low avidity anti-IgA antibody in 27 of the 37 patients. IgA was simultaneously present in cutaneous vessel walls in 95 percent of the patients with circulating IgA-containing immune complexes. High levels of IgA-containing immune complexes were found only during the initial phase of the disease. Immune complexes containing bound complement breakdown products were demonstrated by binding to conglutinin. IgA was found in these immune complexes in 17 patients, IgG in 17 and IgM in nine patients. There was no apparent relation with the class of immunoglobulin in the deposits. Conglutinin-binding immune complexes were present later in the course of the disease and after remission. C1q-binding immune complexes were only found in two patients. These findings suggest that immune complexes-containing IgA may initiate the vasculitis of Henoch-Schönlein purpura, whereas complement-reacted immune complexes containing immunoglobulins of the other classes appear in the circulation in a later phase.

Circulating and tissue-bound immune complexes in allergic vasculitis: relationship between immunoglobulin class and clinical features.

Sixty-two patients with allergic vasculitis and histological evidence of leukocytoclastic vasculitis were examined to determine whether clinical features, such as course and degree of systemic involvement, could be related to the class of the immunoglobulins in immune complexes (IC) in both the circulation and the vessel wall. Circulating IC were detected with the 125I-C1q-binding assay (C1q-BA), an anti-IgA inhibition binding assay (a-IgA-Inh BA) and the conglutinin-binding assay (Con-BA). Stabilized heat-aggregated IgG, IgA and IgM were used to determine the immunoglobulin class specificity of these assays. With the C1q-BA only aggregated IgG were detected, with the a-IgA-Inh Ba only aggregates containing IgA. With the Con-BA IgG, IgA or IgM in reactive aggregates were identified with class-specific antibodies. For patients with acute cutaneous vasculitis all assays were negative. The a-IgA-Inh BA was frequently positive in sera of patients with chronic cutaneous and acute systemic vasculitis; in the latter group conglutinin-binding IC of the IgG, IgA and IgM class were also detected. Levels in the C1q-BA were high for patients with chronic systemic vasculitis. Comparison of the results of the IC assays with the immunofluorescence studies of the cutaneous vessel walls of the same patients showed agreement between the results of the C1q-BA and deposition of IgG and the results of the a-IgA-Inh BA and IgA deposition. The class of immunoglobulin in conglutinin-binding IC did not correspond as well with the immunoglobulins in vessel walls. This study shows that certain clinical features of allergic vasculitis are related to the composition of the IC in the circulation and in the vessel wall.

Combined treatment of psoriasis with a new aromatic retinoid (Tigason) in low dosage orally and triamcinolone acetonide cream topically: a double-blind trial.

In a multicentre double-blind trial the effect of three therapy regimens was studied for 6 weeks in ninety psoriasis patients: (1) aromatic retinoid (Ro 10-9359) orally (0.50-0.66 mg/kg body weight) and placebo cream topically; (2) aromatic retinoid (Ro 10-9359) (same dosage) with 0.1% triamcinolone acetonide and 5% salicylic acid in lanette wax cream; (3) placebo capsules with 0.1% triamcinolone acetonide and 5% salicylic acid in lanette wax cream. Regimen 1 had virtually no effect and regimen 2 gave better results than regimen 3 for almost all parameters, although statistical significance was reached for only some of them. The 6 week double-blind period was followed by an open study in which all patients were treated according to regimen 2. The clinical result could be maintained up to the end of the study (18 weeks), when more than 60% of the patients showed good to excellant (80-100%) improvement. Most of the side-effects of retinoid were mild and relatively rare. It is concluded that the combination of the aromatic retinoid (Ro 10-9359) given in low dosage orally with corticosteroids topically is as effective as therapy with the retinoid in high dosage alone, but with markedly less side-effects.

Allergic vasculitis. A histological and immunofluorescent study of lesional and non-lesional skin in relation to circulating immune complexes.

This study concerns 57 patients who fulfilled histological criteria for the diagnosis allergic vasculitis. For 37 of these patients, biopsy specimen were available from lesional and adjacent non-lesional skin. Histological signs of vasculitis were found at both sites, but in clinically normal skin the perivascular infiltrate was less dense and neutrophils and eosinophils were sparse or absent. Fibrin was found in only ten patients and occurred less frequently in non-lesional skin. Deposits of immune complexes and/or complement were detected by immunofluorescence in 49 of the 57 patients. Hardly any differences between lesional and non-lesional skin were found with immunofluorescent microscopy. Circulating immune complexes were detected in 45 of the 56 available sera. A relationship was found between the class of immunoglobulin in immune complexes in the vessel wall and in the circulation. Moreover, the class of immunoglobulin seemed to be related to the course, the extracutaneous involvement, and the presence of associated diseases. No explanation was found for the histological differences observed between lesional and non-lesional skin.