Differences in retinal neovascular tissue and vitreous humour in patients with type 1 and type 2 diabetes.

AIMS: The aim of the study was to evaluate the histopathology of neovascular tufts and vitreous samples collected from patients with diabetes. METHODS: Vitreous samples and neovascular tufts were collected from patients with type 1 (n = 13) and (n = 17) type 2 diabetes with proliferative retinopathy, and from controls with a macular hole (n = 5). Neovessels were analysed using immunohistochemistry and vitreous samples with an enzyme-linked immunosorbent assay (ELISA). The main outcome measure was to examine differences in the levels of growth factors in patients with type 1 and type 2 diabetes with proliferative retinopathy. RESULTS: Vascular endothelial growth factor (VEGF)-A was most strongly present in the samples from patients with type 1 diabetes. In type 2 diabetes, VEGF-D was more abundantly present than in type 1 diabetes. Angiopoietin (ANG)-2 was also abundantly present. Macrophages and nuclear factor kappa B (NFkappaB) were found, indicating the presence of an inflammatory process in the neovascular tissues. CONCLUSIONS: VEGF-A and ANG-2 are equally important in the neovascular process in both type 1 and type 2 diabetes. VEGF-D is abundantly present in type 2 diabetes. In order to achieve better control of diabetic retinopathy, it might be beneficial to develop treatments that prevent the actions of ANG-2 and VEGF-D.

Retinal fixation of traumatic retinal detachment with metallic tacks: a case report with 10 years' follow-up.

BACKGROUND: Retinal rupture and detachment caused by traumatic ocular perforation has a poor prognosis without extensive repair procedures. The authors describe the phases of treatment of a complex injury in a 21-year-old man with a traumatic retinal rupture in whom metallic tacks were used for retinal fixation. The report does not include histopathology. METHODS: Observational case report and literature review. The outcome of a 10-year follow-up is evaluated at the latest visit by determining the visual acuity (VA) and by observing the state of retina and tacks. RESULTS: A traumatic retinal rupture with detachment was treated with titanium tacks for retinal fixation. By inserting a total of 13 metallic tacks for the repair of a temporal postequatorial retinal rupture and adjacent retinal detachment a successful outcome was achieved. Two additional operations were performed to reattach the retina of nasal hemisphere in the same eye. One dislodged tack was removed at the final operation. Ten years later, at the last intervention, VA was 12/20 in the injured eye. The retina was completely attached, and the remaining 12 tacks were in place, although six of them were partially pushed up by an encircling band. Proliferative vitreoretinopathy (PVR) was absent, and a relatively narrow circumferential zone of scar tissue adjacent to the row of tacks was visible. The patient occasionally experienced glare in the affected eye, but was otherwise symptom-free. CONCLUSION: Reports of long-term experiences with mechanical retinal refixation with metallic tacks are scarce. Especially in extended use, the tacks are claimed to cause several complications, including PVR. Although modern ophthalmic surgery offers a variety of methods for retinal reattachment, the complexity of the damage caused by trauma may lead to a dead end in refixation attempts. Nevertheless, retinal tacks may represent an adjunctive remedy in complex retinal detachment cases.

Hemorrhagic fever (Puumala virus infection) with ocular involvement.

BACKGROUND: Puumala virus infection (nephropathia epidemica) is a disease in the group of hemorrhagic fevers with renal syndrome causing ocular manifestations, e.g. transient myopia and changes in intraocular pressure. PATIENT AND METHODS: Comprehensive and repeated ophthalmic examinations of a previously healthy 35-year-old woman with acute Puumala virus infection were performed. Special attention was paid to ophthalmic A-scan ultrasound measurements and simultaneous blood chemistry tests. RESULTS: The ocular manifestations of this patient's illness included transient myopia, low intraocular pressure, conjunctival hemorrhages and changes of intraocular dimensions. There was forward movement of the anterior diaphragm and thickening of the crystalline lens, which occurred simultaneously with prominent fluctuations in the electrolyte balance, especially potassium. CONCLUSIONS: The observed changes in intraocular dimensions may have been caused by simultaneous fluctuations in electrolyte and osmotic balance, which could explain the myopic shift. The symmetry of the ocular measurements implied a systemic infection as the underlying reason for the ophthalmic symptoms and signs.

A comparison of dorzolamide and timolol in patients with pseudoexfoliation and glaucoma or ocular hypertension.

PURPOSE: The purpose of the study is to compare the efficacy and safety profile of 2.0% dorzolamide (three times daily) and 0.5% timolol (twice daily) for up to 6 months in patients with glaucoma or ocular hypertension associated with pseudoexfoliation. The additive effects of dorzolamide and timolol in patients requiring add-on therapy also was evaluated. METHODS: This was a double-masked, randomized, parallel comparison study at 15 Scandinavian sites. One hundred eighty-four patients with pseudoexfoliation and either glaucoma or ocular hypertension who were 21 to 85 years of age were studied. The treatment groups were 2.0% dorzolamide three times daily and 0.5% timolol maleate twice daily. RESULTS: At 6 months, the mean percent reduction in intraocular pressure of 2% dorzolamide and 0.5% timolol was 24% and 29%, respectively, at morning peak and 21% and 23%, respectively, at afternoon trough. The additional intraocular pressure-lowering effect of adding 2.0% dorzolamide twice daily to patients receiving timolol was 14% and 15%, at peak and trough, respectively. There were no differences between treatment groups in the incidence of clinical adverse experiences, and dorzolamide was not associated with the systemic adverse effects typically ascribed to the use of oral carbonic anhydrase inhibitors. CONCLUSION: Two percent dorzolamide (three times daily) was effective and well tolerated in patients with glaucoma or ocular hypertension associated with pseudoexfoliation over the course of 6 months; 0.5% timolol (twice daily) had a greater level of intraocular pressure-lowering activity than did dorzolamide, although the difference between the two treatments became less pronounced during the study period. Finally, 2.0% dorzolamide (twice daily) produced additional lowering of intraocular pressure when given with 0.5% timolol (twice daily).

Ocular characteristics in nephropathia epidemica or Puumala virus infection.

PURPOSE: We documented the largest series so far concerning the ocular characteristics of nephropathia epidemica. METHODS: A total of 37 consecutive nephropathia epidemica patients underwent a comprehensive ophthalmic examination during hospitalization for systemic infection, and a control examination after recovery. RESULTS: The most common ocular symptoms were: frontal headache or periocular pain (75.6%), blurred vision (54.1%) and photophobia (10.8%). The best corrected visual acuity of 7 patients (18.9%) was reduced during the acute phase as compared to the later control examination. Myopic shift was found in 15 patients (40.5%), three of whom (8.1%) developed real transient myopia. There were no attacks of angle closure glaucoma in this series. On the contrary, the intraocular pressure was decreased in 49 eyes (66.2%) during the acute stage of the disease. Lid edema was present in 28 eyes (37.8%), conjunctival injection in 20 eyes (27.0%), chemosis in 8 eyes (10.8%) and subconjuctival bleeding in 3 eyes (4.1%). Signs of acute anterior uveitis were found in 10 eyes (13.5%), however, this resolved without treatment. In one eye retinal edema with hemorrhages was detected. Ultrasonography revealed narrowing of the anterior chamber during the acute phase in 69 eyes (93.2%) and thickening of the crystalline lens in 64 eyes (86.5%). CONCLUSION: Ophthalmic findings in nephropathia epidemica are not uncommon. The symmetry of the clinical manifestations reflects the systemic nature of the underlying infection.

Intraocular pressure changes in nephropathia epidemica. A prospective study of 37 patients with acute systemic Puumala virus infection.

BACKGROUND: Nephropathia epidemica is a zoonose in the group of hemorrhagic fevers with renal syndrome and is caused by Puumala virus in Hantavirus genus. The purpose of this study is to find out how the intraocular pressure (IOP) is affected by the acute phase of this disease and how it relates to the previous case reports on angleclosure glaucoma attacks. PATIENTS AND METHODS: The prospective study documents IOP and anterior chamber depth measurements in 37 patients during the winter epidemic of nephropathia epidemica from 1992 to 1993. Ocular examinations were performed during the acute systemic infection and after clinical recovery. RESULTS: The IOP was lower and the anterior chamber shallower in the acute phase than after the clinical recovery of nephropathic epidemica. The mean differences in IOP were 1.8 mmHg in the right eye and 1.9 mmHg in the left (P < 0.001) and the mean differences in the anterior chamber depth were 0.22 mm in the right eye and 0.20 mm in the left (P < 0.001). No acute angle-closure attacks with highly elevated IOP were encountered in this study. The mean IOP did not rise higher than 14.3 mmHg in both eyes after the clinical recovery of systemic infection. CONCLUSION: In contradistinction to earlier assumptions, Puumala virus infection decreases the IOP. Shallowing of anterior chamber and narrowing of the anterior chamber angle in the acute phase of nephropathia epidemica did not lead to angle-closure attacks in this series.

Myopic shift and its mechanism in nephropathia epidemica or Puumala virus infection.

Nephropathia epidemica (NE) is a zoonose caused by Puumala virus. NE belongs to the group of haemorrhagic fevers with renal syndrome. Transient myopia has been described in the acute phase of the disease. This prospective study presents the changes of refraction and the results of ophthalmic A scan measurements of patients who were managed at Savonlinna Central Hospital for NE during an epidemic in the winter of 1992-3. This involved 37 patients and 74 eyes. The incidence of transient myopia was 8.1% and that of myopic shift 40.5%. A scan ultrasound measurements were performed in patients in the acute phase and after total recovery of their general illness. Statistical analysis revealed that there were significant differences in anterior chamber depth and lens thickness between the acute and control phases of the disease and between the patients who had myopic shift compared with those who did not have a significant myopic change in refraction. Based on these results it seems that the reason for transient myopic shift of NE is mainly a combination of two factors: forward movement of the anterior diaphragm and thickening of the crystalline lens. The term myopic shift should be used rather than transient myopia because it better describes the overall refractive change in NE.

Timolol-pilocarpine fixed-ratio combinations in the treatment of chronic open angle glaucoma. A controlled multicenter study of 48 weeks. Scandinavian Timpilo Study Group.

The effect of the fixed combination of 0.5% timolol maleate with 2% pilocarpine hydrochloride given twice a day and 0.5% timolol with 4% pilocarpine given twice a day was tested in a long-term, multicenter study. A total of 360 patients with open angle glaucoma were included; they were defined as those who had intraocular pressure greater than 21 mm Hg while receiving single, topical antiglaucoma therapy. Primarily, the purpose of the study was to investigate the efficacy of 0.5% timolol-2% pilocarpine, and second, to see to what extent an increase in concentration to 0.5% timolol-4% pilocarpine would further lower intraocular pressure in those patients with an intraocular pressure of greater than 21 mm Hg while taking 0.5% timolol-2% pilocarpine. The cohort of 228 patients went through the examinations for a total of 48 weeks. A mean decrease in intraocular pressure from 24.7 +/- 2.8 to 21.0 +/- 3.8 mm Hg was observed. During the trial, approximately 33% of the patients required an increase in concentration to 0.5% timolol-4% pilocarpine after the week 8 examination. At week 12, in those using 0.5% timolol-4% pilocarpine, an additional 2.2 mm Hg lowering of intraocular pressure was observed. Side effects were minor and temporary and did not necessitate withdrawal from the study.

Permanent blindness following retrobulbar hemorrhage after peribulbar anesthesia for cataract surgery.

We present a case in which a modified peribulbar anesthesia, administered with a 24-gauge (0.55 x 25 mm) sharp, disposable needle, induced an orbital hemorrhage, resulting in complete and permanent loss of vision. To our knowledge, this is the first report of severe complications following a peribulbar block.

Xanthogranuloma juvenile--a rare cause of orbital swelling in adulthood.

Juvenile xanthogranuloma, a non-Langerhans-type benign proliferation, in adulthood is a rare condition. This article reports the second known case in the western literature of solitary orbital involvement. The diagnosis was confirmed by orbital biopsy, and symptoms were dramatically relieved by corticoids, although a relapse occurred after their withdrawal. The importance of differentiating benign conditions from malignancies is discussed.

Retinal detachment during glaucoma therapy. Review. A case report of an occurrence of retinal detachment after using membranous pilocarpine delivery system [Pilokarpin lameller (Ocusert) 11 mg].

Miotic-induced retinal detachment (RD) is a condition that is not recognized as such by common consent. Clinically it has been shown that all miotic agents, whether strong or weak, can precipitate an RD, if there are additional contributing factors like high myopia, peripheral lattice degeneration of the retina, pathological vitreoretinal changes and previous history of an RD in the other eye, which all increase the basic risk of RD. Pilokarpin lameller 11 mg represents a form of miotic therapy having initially only a moderate accommodative and miotic effect, which further declines to a level of steady state during the next hours. Because the time interval after which a new Pilokarpin lameller unit is required lasts up to 1 week, the total amount of accommodation and miosis is much smaller than when applying daily 2% pilocarpine drops. However, it seems important, before the start of any kind of miotic therapy, to perform a careful examination and management of virtually all detachment-prone patients. This case report deals with an RD which occurred after 2 days of treatment with Pilokarpin lameller (Ocusert) 11 mg in a myopic patient who had a juvenile type of glaucoma and previous history of an RD in the other eye.

Practical problems in the use of Ocusert-pilocarpine delivery system.

The effects of the long-acting pilocarpine preparation, Ocusert, were studied by its application for one week into a total of 52 eyes of 42 earlier untreated glaucoma patients. From the diurnal pressure curves it was found to be equivalent to three daily administrations of 2 or 4% pilocarpine topically, the experiences were as follow: 8 of the preparations had to be removed before the end of the experiment due to insufficient effect and two were removed for other reasons; 19 fell out accidentally, 3 were displaced so as to be visible occasionally under the eyelid, but did not fall out; 2 patients succeeded in replacing the preparation after it had fallen out. In the 19 eyes (37%) of all patients still in the trial after the first day, the preparations stayed in place without any difficulty for the whole week. All patients experienced minor side-effects, but only one of them terminated the treatment due to these side-effects. Serious side-effects did not occur.