Use of corticosteroid sparing systemic immunosuppression for treatment of corticosteroid dependent optic neuritis not associated with demyelinating disease.

AIM: To describe the authors' experience and that in the published literature regarding the use of corticosteroid sparing systemic immunosuppression for patients with corticosteroid dependent optic neuritis not associated with demyelinating disease. METHODS: The records of 10 patients from the authors' clinical database, and 38 patients from the published literature with corticosteroid dependent optic neuritis, were retrospectively reviewed to determine patient demographics, diagnosis, clinical course, and outcomes. These patients had recrudescence of symptoms, such as decreased vision and pain, with attempted taper of corticosteroid. Many of these patients also suffered side effects from systemic corticosteroid use such as weight gain and uncontrolled hyperglycaemia. Antimetabolites (for example, methotrexate and azathioprine), cyclosporine and/or alkylating agents (for example, cyclophosphamide and chlorambucil) were given to enable taper of corticosteroid while effectively controlling optic neuritis. RESULTS: The study included 43 women and 5 men: 17 patients with systemic lupus erythematosus, 12 patients with sarcoidosis, 3 with other systemic autoimmune diseases, and 16 with no clinically identifiable systemic association. 79% of all patients benefited from the use of systemic immunosuppression in that they had successful corticosteroid taper, control of inflammation, improvement in symptoms, and/or tolerance of adverse effects. Mild toxicity was common and 19% of patients, most often those taking cyclophosphamide, discontinued medication because of adverse effects. 24 of 28 (86%) patients on alkylators benefited clinically, while 20 of 29 (69%) patients on antimetabolites had clinical benefit. CONCLUSION: Systemic immunosuppression may be a safer and more effective treatment alternative to chronic oral corticosteroid use in cases of corticosteroid dependent optic neuritis not associated with demyelinating disease.

Iris nodules associated with infectious uveitis.

BACKGROUND/AIM: Iris nodules are an uncommon clinical sign in uveitis. The diseases most commonly associated with iris nodules and uveitis include sarcoidosis, Vogt-Koyanagi-Harada syndrome, multiple sclerosis, Fuchs' heterochromic iridocyclitis, and metastatic infection. While many of these diseases may be appropriately treated with immunosuppressive medication, the management of infectious uveitis is antimicrobial therapy. Inappropriate immunosuppressive therapy may result in a poor outcome for the patient with an infection. Consequently, cases of uveitis with iris nodules were reviewed to identify clinical features that may help differentiate infection from non-infectious inflammation. METHODS: The clinical database of 1353 consecutive patients evaluated at a tertiary care referral based North American uveitis clinic were retrospectively reviewed to identify cases of infectious uveitis with iris nodules. A Medline search was performed to identify additional cases. From these cases information regarding clinical presentation, diagnosis, treatment, and outcome were collected. RESULTS: Three cases (three eyes) were identified from the authors' own records of infectious uveitis with iris nodules. An additional 25 cases of infectious uveitis with iris nodules were identified in 22 published reports. Analysis of the authors' cases and these reports showed that infectious uveitis with iris nodules was specifically characterised by some or all of the following: (1) creamy, soft appearance to the nodule(s), (2) unilateral disease, (3) persistence or growth of the nodule(s) despite corticosteroid therapy, (4) marked inflammatory response in the anterior chamber and/or vitreous humour, and/or (5) history suggesting a potential source of septic emboli. CONCLUSION: Certain features of the clinical history and examination are useful in the diagnosis of metastatic infection in patients presenting with uveitis and iris nodules.

The future of lasers in dentistry.

In 1998, a laser-related trade journal printed an article on laser dermatology indicating that because of new applications, reduced prices, and instruments becoming more user-friendly, the dermatology laser market was becoming a billion dollar industry. If the same holds true in dentistry--keeping in mind that there are only approximately 7000 dermatologists in the United States--think of the potential for the dental laser market. It is huge, but to reach that potential, several criteria must be met: Market penetration must double in the next 4 to 5 years. Instrument sizes must diminish. Laser prices must decrease to an average of $10,000 for soft tissue lasers and $25,000 for hard tissue lasers over the next 10 years. Meeting these criteria would generate the necessary revenues for increased expenditures for research and development to improve existing delivery systems and develop new fiber types, continue development of a short-pulsed hard tissue laser to replace air turbines, and combine wavelengths into a single package, while looking into new wavelengths. If all of the above-mentioned become a reality in 10 to 15 years, the growth of the dental laser market could be limitless because of the hugeness of the worldwide dental marketplace. The last 20 years have witnessed many new developments in dental technologies, and the next 20 years promise to be even richer in technologic advancements. Lasers will be in the forefront of that growth.

Comparison of the effects of viscoelastic agents on clinical properties of the Unfolder lens injection system.

PURPOSE: To evaluate the effect of 7 viscoelastic materials on the physical properties of the Unfolder lens injection system. SETTING: John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, Utah, USA. METHODS: New sterile SI-40NB intraocular lenses (IOLs) were loaded into the Unfolder (AMO PhacoFlex II SofTip insertion system (Allergan) using 7 viscoelastic materials: sodium hyaluronate 1.0% (Healon, Provisc), sodium hyaluronate 1.4% (Healon GV), sodium hyaluronate 1.6% (Amvisc Plus), hydroxypropyl methylcellulose 2.0% (Occucoat), sodium chondroitin 4.0%--sodium hyaluronate 3.0% (Viscoat), and hyaluronate 3.0% (Vitrax). The IOLs were then injected after 10 or 120 seconds in the chamber (chamber dwell time) and 10, 60, or 180 seconds in the barrel of the Unfolder cartridge (barrel dwell time). Torque values (g/cm) required to extrude the lenses were measured with a torque gauge, and the cartridges and IOLs were inspected for damage. RESULTS: Longer chamber dwell times resulted in lower torque values to extrude the IOLs (P < .001). Conversely, longer barrel dwell times resulted in higher torque requirements for IOL extrusion (P < .001). Furthermore, rates of adverse events, such as nondelivery, IOL damage, or Unfolder cartridge damage, were higher with shorter chamber dwell times and longer barrel dwell times (P < .001). However, IOL damage was avoided when the manufacturer's recommended chamber and barrel times were used. CONCLUSION: Increasing chamber dwell time and decreasing barrel dwell time resulted in lower torque values to extrude IOLs from the Unfolder and increased successful use. Moreover, dispersive viscoelastic agents tended to be more forgiving of changing dwell times and therefore had lower torque values and adverse event rates overall.

Conservative soft tissue management with the low-powered pulsed Nd:YAG dental laser.

Lasers can be operated in a continuous or pulsed mode, either in contact or out of contact with the target tissue. This article discusses laser systems and their resultant effects, and presents histologic findings and clinical examples.

The pulsed Nd:YAG dental laser: review of clinical applications.

Since the first demonstration of a laser in 1960, numerous applications of this unique form of energy have been developed for the manufacturing, electronic, consumer and medical industries. Recent technological innovations have permitted development of lasers appropriate for use in the dental operatory. The carbon dioxide laser has been used for soft tissue surgery; the Nd:YAG laser has both soft and hard tissue applications. Advantages of laser treatment over conventional methods include minimal cellular destruction and tissue swelling, hemostasis, increased visualization of surgical sites and reduced post-operative pain. Additionally, it is possible to perform many procedures without needing anesthesia. Soft tissue clinical applications of the Nd:YAG laser include gingivectomies, gingivoplasties, operculectomies, biopsies, incising and draining procedures, frenectomies and treatment of aphthous ulcers; hard tissue clinical applications include vaporizing decay, etching enamel and dentin, desensitizing exposed root structure and creating temporary analgesia. As both clinical experiences and scientific investigations expand, possible future applications of the dental laser may well include development of new dental adhesives and composite systems, new methods for managing caries and new endodontic treatments. With its numerous benefits, the laser is having a positive impact on patients and the dental team.

The use of a laser for debridement of incipient caries.

The mode-locked YAG laser effectively removes debris and/or stains from incipient carious lesions in pits and fissures. Prior investigations inferred that the energy levels used in this study would not cause pulpal injury or remove sound intact enamel. This would be a desirable step in sealant therapy and could provide an improved method of debridement in treating precarious lesions.

Intraocular lens design for the neodymium:YAG laser.

Phacoemulsification was performed on both lenses of 24 rabbits. One eye received a lens implant with a convex-plano optic; the fellow eye received an implant with a convex-concave optic which separated the posterior surface of the implant from the posterior capsule by 0.2 mm, 0.3 mm, or 0.4 mm. A YAG laser capsulotomy was performed on all eyes immediately following surgery and an assessment of both microscopic and macroscopic YAG-induced lens damage was made. The meniscus optics with their capsule-implant separation showed significantly less YAG-induced damage than their convex-plano counterparts without this separation. Increasing the amount of capsule-implant separation beyond 0.2 mm did not enhance the degree of protection from YAG-induced damage.

Alteration of sarcoplasmic reticulum after denervation of chicken pectoralis muscle.

To determine the neural influence on the function of the sarcoplasmic reticulum (SR) of fast-twitch skeletal muscle, the superior pectoralis muscle of adult chicken was denervated, and the SR was isolated at 20 days post-denervation. The isolated SR was probably derived from the longitudinal SR and was relatively free of contaminants. The protein profile of the SR was quantitatively changed after denervation with an increase in the M55 and 30000-mol.wt. proteins relative to the Ca2+-ATPase. Ca2+-dependent ATPase activity and phosphoenzyme formation were lower in the denervated-muscle SR; however, the enzyme catalytic-centre activity was similar to the control value. The decrease in Ca2+-ATPase activity in denervated-muscle SR was accompanied by a lower Ca2+ accumulation so that the relationship between Ca2+ accumulation and Ca2+-dependent ATPase activity was well maintained in the SR from denervated muscle. The data imply that denervation may result in a diminution of functional Ca2+ pump sites. Evidence is presented, though, which suggests that denervation affects a single class of Ca2+-binding sites of the Ca2+-ATPase, resulting in a lower affinity for Ca2+.