Follow-up study of human corneal endothelial cells, photographed in vivo before enucleation and 20 years later in grafts.

PURPOSE: To evaluate the long-term (20-year) survival of transplanted human corneal endothelial cells. METHODS: The donor endothelium had been photographed 20 years ago with a specular microscope both before enucleation in the melanomatous eye and in situ after keratoplasty. The same donor endothelial cells were now photographed again 20 years later with a modern specular microscope to ascertain the morphology and cell density of the grafts. RESULTS: In the earlier study the mean postoperative endothelial cell density was 1357+/-543 cells/mm2, the average cell loss 11 months postoperatively being 48.2%; 20.5 years postoperatively the cell loss was 62.9% of the preoperative cell count. In our well-documented patient population the endothelial cell loss during the last 19 years had been only 14.7%, which amounts to a cell loss of less than 1% per year. CONCLUSION: In transplanted corneas, the main endothelial cell loss seems to take place during the first 1-2 postoperative years.

Effects of experimental exposure to triethylamine on vision and the eye.

OBJECTIVES: To determine the effect of triethylamine (TEA) on the cornea and to evaluate the cause of blurred vision. To find the lowest observed effect concentration of exposure to TEA. METHODS: Four people were exposed to TEA for 4 hours at concentrations of 40.6, 6.5, and 3.0 mg/m3. Before and after every exposure, symptoms and ocular microscopy findings were recorded. Binocular visual acuity and contrast sensitivity at 2.5% contrast were also measured. Also, before and after the 40.6 mg/m3 exposure, corneal thickness was measured and ocular dimensions were recorded by ultrasonography, endothelial cells of the cornea were analysed, and serum and lacrimal specimens were collected for the analysis of TEA. RESULTS: After exposure to 40.6 mg/m3 TEA there was a marked oedema in the corneal epithelium and subepithelial microcysts. However, corneal thickness increased only minimally because of the epithelial oedema. The lacrimal concentrations of TEA were, on average (range) 41 (18-83) times higher than the serum TEA concentrations. The vision was blurred in all subjects and visual acuity and contrast sensitivity had decreased in three of the four subjects. After exposure to TEA at 6.5 mg/m3 two subjects experienced symptoms, and contrast sensitivity had decreased in three of the four subjects. There were no symptoms or decreases in contrast sensitivity after exposure to a TEA concentration of 3.0 mg/m3. CONCLUSIONS: TEA caused a marked oedema and microcysts in corneal epithelium but only minor increases in corneal thickness. The effects may be mediated by the lacrimal fluid owing to its high TEA concentration. Four hour exposure to a TEA concentration of 3.0 mg/m3 seemed to cause no effects, whereas exposure to 6.5 mg/m3 for the same period caused blurred vision and a decrease in contrast sensitivity.

Effects of long-term contact lens wear on the corneal endothelium.

PURPOSE: To analyze the long-term effects of soft and hard (PMMA) contact lenses (CL) on the human corneal endothelium. METHODS: One hundred and one contact lens wearers with > or =10 years' wearing time and 50 healthy control subjects were examined with specular microscope. RESULTS: The mean corneal endothelial cell densities of the CL wearers (2846 cells/mm2) and of the control eyes (2940 cells/mm2) differed by 94 cells/mm2 (p<0.05). The mean values for the coefficient of variation (CV) differed significantly (p<0.0001); for all CL wearers: mean CV=0.31, vs. for controls: 0.22. The mean endothelial cell density of the eyes exposed to CL wear for more than 25 years (30 eyes) was 2575 cells/mm2 (mean CV: 0.36). Rather low densities (<2000 cells/mm2) were observed in 16 eyes of the CL group (8%). Cell densities less than 2500 cells/mm2 were observed in a total of 41 eyes (20%) in the CL group, whereas in the control group (100 eyes) all of the subjects, except one, had cell densities of more than 2500 cells/mm2 in both eyes. CONCLUSION: A subgroup of PMMA as well as soft contact lens wearers react not only with high pleomorphism and polymegethism but also with a decrease in endothelial cell density.

Photoastigmatic keratectomy for correction of astigmatism in corneal grafts.

BACKGROUND: The efficacy and safety of excimer laser photoastigmatic refractive keratectomy (PARK) for treatment of astigmatism after penetrating keratoplasty (PKP) was evaluated in this study. METHODS: A VisX 20/20 excimer laser was used to correct the regular astigmatic component of the grafts. The epithelium was removed manually in seven cases and in three patients with the PTK mode of the laser. The results were analyzed for uncorrected visual acuity (UCVA), best corrected acuity (BCVA), haze, and changes in the cylinder and axis. The vectorial change in astigmatism was measured using Alpins' method. RESULTS: Preoperative astigmatism ranged from 3.50 to 11.25 D (mean, 5.98 +/- 2.28) and the mean attempted correction of astigmatism was 6.28 +/- 1.56 D (range, 3.50-9.00 D). The induced reduction of net corneal astigmatism was 48.1%. The vector-corrected astigmatism, which was 6.40 +/- 3.49 D at 1 month postoperatively, was reduced at 12 months to 4.28 +/- 2.42 D. The Alpin Success Index varied in the range 0.06 to 1.0. Although the UCVA improved by > or = 2 lines in 60% of the eyes, the BCVA decreased in 40% of the eyes and three patients required a reoperation. CONCLUSION: Although PARK is relatively safe and effective in reducing post-PKP cylinder and improves UCVA, the frequently and surprisingly late-developing corneal haze often impairs the BCVA.

Syphilitic interstitial keratitis with bilateral funnel-shaped iridocorneal adhesions. A case report.

We present the clinical and light microscopic ophthalmological findings in a 60-year-old woman with bilateral, symmetrical, paracentral anterior synechia formation and healed, old, inactive interstitial keratitis, probably secondary to congenital syphilis. The patient underwent ECCE and IOL implantation in the left eye and a triple procedure (corneal transplantation, ECCE and IOL) in the right eye. Gonioscopy, fluorescein angiography and light microscopy of a specimen from the triple procedure revealed a fibrovascular connection between the iris and cornea. The etiology of the funnel-shaped bilateral iridocorneal synechiae is discussed.

Systemic cyclosporin treatment for high-risk corneal transplantation.

The success rate for uncomplicated penetrating keratoplasty is very high. However, in high risk patients there is a significantly increased risk for immunologic graft failure and the success rate is relatively poor. Oral cyclosporin A treatment has dramatically decreased the rejection rate in solid organ transplantation. Its oral use in ophthalmology has so far been relatively limited and topical use restricted by poor penetration of the drug into ocular tissues. The favorable results of oral cyclosporin treatment to prevent corneal graft failure in high-risk patients is demonstrated in this study. High-risk corneal transplant patients were selected from the general population scheduled to undergo corneal transplantation. Twenty-two of 277 patients who were operated during a four-year period were regarded as high-risk keratoplasty patients. Systemic cyclosporin A treatment (5mg/kg/day) was given prophylactically to 14 of these patients who were considered to be at high-risk for keratoplasty rejection (CsA group). In addition the patients received a low dose of corticosteroids. Eight similar patients receiving high dose corticosteroids served as a control group (control group). In the CsA group graft survival was 78.6% compared with 37.5% in the control group at 1.5 years. The grafts of patients receiving CsA had a significantly better survival rate (p.o5) than those in control at one and 1.5 years. On the follow-up to four years graft survival in patients treated with CsA was, however, decreasing to 35.7%. The low graft survival in both high-risk groups is in great contrast to graft survival in all patients operated during the same period (93.1%). Systemic cyclosporin treatment when received at the time of the operation is effective in reducing failure from irreversible rejection in high-risk keratoplasty, but for maximal effect, a six-month period of treatment is too short. Subjective side effects were frequent but still acceptable. Blood tests did not reveal any pathological hepatic or renal laboratory values caused by system CsA administration. Careful and frequent follow-ups of the patients are however needed.

Comparison of etidocaine and bupivacaine + lidocaine in retrobulbar anaesthesia.

Etidocaine (15 mg/ml) was compared with bupivacaine (5 mg/ml) combined with lidocaine (10 mg/ml) in retrobulbar anaesthesia. One hundred and twelve patients were randomised into two groups. Supplemental anaesthesia was needed in 41% of cases of the etidocaine group and 32% of the bupivacaine-lidocaine group. Akinesia was evaluated by the surgeon both pre- and postoperatively and was found to be good or complete in more than 95% of both groups. Recovery from the motor and sensory block was investigated three times during the first 24 postoperative hours. The motor block of the orbicular muscle disappeared earlier than that of the globe. Akinesia lasted significantly longer in the etidocaine group than in the bupivacaine-lidocaine group: after 14 h 69% vs 100%, respectively, of the eyes showed normal movements. Sensation in the cornea was also regained more rapidly in patients treated with the mixture.

Early rehabilitation after small incision cataract surgery.

BACKGROUND: The use of smaller cataract incision is thought to induce less astigmatism, resulting in a more stable refraction and more stable wound. METHODS: We have analyzed the early astigmatic changes and rehabilitation in 20 eyes of 16 patients operated with advanced phacoemulsification techniques. The patients operated with small-incision surgery (incision 4.0 mm) were compared to those with large-incision surgery (incision 7.5 mm). Keratometric values and visual acuity data were evaluated up to 6 months postoperatively. RESULTS: Less initial induced astigmatism was demonstrated at day 7 postoperatively with a 4.0-millimeter incision (0.1 +/- 0.53 D) compared with a 7.5-millimeter incision (1.90 +/- 1.97). Similar but not statistically significant changes were seen at days 1 and 30 postoperatively. Visual rehabilitation was also faster in the small-incision group and 70% of the eyes gave uncorrected visual acuity of 20/40 or better in this group as early as the first postoperative day. Only 11% of the eyes showed that uncorrected visual acuity after large-incision surgery at first postoperative day. CONCLUSION: The low amount of induced cylinder, rapid stabilization of the wound, and faster visual rehabilitation confirms the advantage of small-incision cataract surgery to large-incision surgery.

Visual evoked potentials after retrobulbar or periocular anaesthesia.

The effect of the local anaesthetic agent, etidocaine, on the optic nerve function was examined at regional ophthalmic anaesthesia. Visual evoked potential (VEP) was recorded before and 15 minutes after injection of the anaesthetic agent in 19 patients scheduled for elective cataract surgery (seven retrobulbar and 12 periocular). Both the anaesthetised--that is, the eye to be operated on--and the fellow eye were examined. In the retrobulbar group, two patients displayed non-recordable VEPs while one had virtually non-detectable waves following the anaesthesia. In two retrobulbarly anaesthetised eyes, later peaks were unidentifiable while two other eyes had decreased amplitudes. In the periocular group, in nine patients, there was no clearcut effect on VEP resulting from the anaesthetic. In three patients of this group mild changes in the anaesthetised eyes were found. The differences in the effect of retrobulbarly or periocularly injected anaesthetics on VEP are probably due to the different concentration of the anaesthetic agent around the optic nerve.

Ptosis following periocular or general anaesthesia in cataract surgery.

The incidence and duration of postoperative ptosis was investigated in 64 patients undergoing cataract surgery. Thirty-two patients had a 2-point periocular regional anaesthesia while 32 others were given general anaesthesia. The palpebral aperture and the levator muscle function were measured preoperatively and then on the 1st, 2nd, 4th and 7th postoperative days or as long as ptosis persisted. On the 1st postoperative day, about half of the patients in both groups demonstrated ptosis. On the 2nd day, ptosis was more common in the general anaesthesia group. The ptosis persisted 1 week postoperatively in 2 patients, both belonging to the general anaesthesia group. It is concluded that postoperative ptosis is common both after local and general anaesthesia. In most cases it is shortlasting and may be related to the volume or myotoxicity of a local anaesthetic drug. The use of a superior rectus muscle bridle suture and/or lid speculum may be important in provoking ptosis of longer duration.

Comparison of retrobulbar and periocular injections of lignocaine by computerised tomography.

Ten patients undergoing cataract surgery were given a local anaesthetic with lignocaine solution which was mixed with iohexol contrast medium. The location of the needle and the substance injected was determined by computerised tomography following retrobulbar or periocular anaesthesia. The retrobulbarly inserted needles were within the muscle cone, directed towards the optic foramen. The periocular needles were outside the muscle cone, tangentially along the orbital floor or pointing slightly upwards. After the retrobulbar injection the contrast medium was seen within the cone immediately after the injection and outside the cone as early as 3 minutes after the injection. With the periocular technique, however, diffusion of the anaesthetic in the opposite direction (that is, into the muscle cone) was rapid. The contrast medium was identified inside the muscle cone 2 minutes after the injection. Compression with an intraocular pressure reduction device after both of these techniques prevented exophthalmos. It is concluded that retrobulbar-like anaesthesia can also be induced by an appropriate periocular technique.

Corneal endothelium in pigmentary glaucoma and pigment dispersion syndrome.

Corneal endothelial cell density was determined in 64 eyes (32 patients) with pigmentary glaucoma and in 18 eyes (9 persons) with pigment dispersion syndrome without glaucoma. Twenty-eight healthy eyes served as controls. The glaucomas were stabilized with topical treatment or following laser trabeculoplasty or filtration surgery. The mean duration of the glaucoma was 7.6 years (SD 6.1 years) subsequent to diagnosis. Neither in the glaucomatous, nor in the pigment dispersion syndrome eyes, could any statistically significant difference in cell density be noted compared to the control series. Within the glaucoma group pressure level, topical treatment, laser trabeculoplasty and trabeculectomy did not have any statistically significant effect on cell counts. Distinct pleomorphism and polymegatism of the endothelial cells were observed in the study groups. The endothelial cell density decreased linearly with age.

Effect of sodium hyaluronate on immediate postoperative intraocular pressure after extracapsular cataract extraction and IOL implantation.

We studied 129 eyes which were undergoing extracapsular cataract extraction with IOL-implantation. The amount of residual Healon had a clearcut effect on the IOP elevations postoperatively. In eyes operated on with the intercapsular techniques, pressure elevations and the mean values during the first 6 postoperative hours were significantly higher than in eyes operated on with the planned ECCE (can opener-technique) (P less than 0.01). The pressure elevation reached the maximal values 8-12 h postoperatively and had normalized already at 24 h in most cases, except in glaucomatous eyes which at that time had significantly higher mean IOP values than the non-glaucomatous eyes (P less than 0.01). When operations were done with an air bubble no clearcut postoperative pressure increases could be observed. Our study indicates that a comparatively small amount of Healon may cause a pressure elevation and the amount left in the eye has a greater effect upon the level of the pressure than the duration of the pressure elevation. The less we inject Healon into the eye and the more we avoid leaving it there, the less risk we have of the possibility of vision deteriorating high postoperative intraocular pressure.

Periocular anaesthesia: technique, effectiveness and complications with special reference to postoperative ptosis.

The effectiveness of periocular anaesthesia and its complications were examined in 100 successive cataract operations. The patients were divided into 3 groups according to the duration of ocular compression with an Autopressor device after administration of periocular anaesthesia. In the control group, no compression was used (C-O, n = 36 patients). In the other two groups, compression was used for 10 (C-10, n = 32) and for 20 (C-20, n = 32) min. No differences in globe or orbicular akinesia were found between the groups. At 10 min, immobilisation of the globe in different directions was attained in 60.1-84.5% of the patients. Compression for an additional 10 min did not significantly improve the akinesia. In contrast, the hitherto undescribed loss of light perception increased with time: 15 patients at 10 min and 22 at 20 min were unable to see light. Chemosis and haematomas in the upper eyelid occurred more often in C-0 than in the other 2 groups. One day postoperatively the average palpebral aperture was smaller in C-0 than in the other two groups. The frequent postoperative ptosis (74.3% on the 1st day) decreased rapidly, but on postoperative day 7, 9 patients still had ptosis. In only one patient was ptosis still recognizable at 6 weeks postoperatively. No serious complications occurred. This study demonstrates that periocular anaesthesia with ocular compression is a suitable method for cataract surgery.

Granular corneal dystrophy with early stromal manifestation. A clinical and electron microscopical study.

We describe a family tree from central Finland with 19 members of which 10 had typical granular corneal dystrophy (Bücklers 1938). This granular dystrophy seems to start from the subepithelial and anterior stromal region. In quite early ages the granules spread not only into the midstromal layers but also into the most posterior stroma between the stromal lamellae and Descemet's membrane. Corneal epithelial erosions were not noticed in this family. The central cornea was mostly affected and 2-3 mm of the corneal periphery was clear. No endothelial changes were found from the corneal midperiphery by specular microscopy. To date, two female patients have needed penetrating keratoplasty; one in her late thirties and the other in her early forties. Their corneal buttons were studied by electron microscopy and histochemically. Granular material was found between the stromal lamellae and also inside the stromal keratocytes. Bowman's membrane was disrupted and degenerated in the areas where the deposits were situated in the subepithelial region. Recurrence of the disease was observed in the corneal transplants of the two operated patients 3 years postoperatively, starting again in the subepithelial region and mostly in central areas of the transplant. This disease entity seems to be different from the granular dystrophy also reported from Finland by Forsius et al. (1983).

Long-term treatment of involuntary facial spasms using botulinum toxin.

Botulinum toxin, a powerful pre-synaptic neurotoxin produced by Clostridium botulinum, interferes with the release of acetylcholine from nerve terminals. Since September 1985, we have been using this toxin to treat altogether 62 patients with benign facial spasms. Most of the patients had been on drugs or psychotherapy, 2 had received alcohol injections, 2 had undergone surgery of the orbicular branch, and 2 electrocoagulation of the facial nerve. In essential blepharospasm the duration of the beneficial effect after each treatment with botulinum toxin was about 3 1/2 months. In patients with hemifacial spasm the response was clearly longer, nearly 5 months in most cases. The treatment gave the best and longest-lasting relief of symptoms in patients suffering from disturbing myokymia. Response was poorest in patients suffering from facial spasms who simultaneously had a severe psychiatric disease. The most frequent side effect was mild or moderate ptosis (22.6%). Some patients complained of dry eyes and a few cases displayed facial nerve paresis. Side effects caused by botulinum toxin injections are transient but so also, unfortunately, is the beneficial effect on facial spasms.

Effect of ocular compression (Autopressor) on intraocular pressure in periocular anaesthesia.

One hundred successive patients were operated on for cataract under periocular anaesthesia. The patients were divided into 3 groups to study the effect of extraocular compression on intraocular pressure. In the control group (C-O), no compression was used. In the other 2 groups, compression was applied immediately after local injection of the anaesthetic for either 10 (C-10) or 20 min (C-20). In the control group, a periocular local anaesthetic increased the IOP in 27 of 36 patients, the average increase being 3.8 mmHg (at 10 min). Postanaesthetic compression of the eye led to a decrease in intraocular pressure, which is beneficial for the operative procedure. During the first 10 min, the mean intraocular pressure decreased by 3.1 and 4.0 mmHg in groups C-10 and C-20, respectively. In the C-20 group, there was a further (1.3 mmHg) reduction in intraocular pressure between 10 and 20 min.