[Vitrectomy: in search of the ideal vitreous replacement]. / Vitrectomie: op zoek naar de ideale glasvochtvervanging.

Pars plana vitrectomy is a form of surgery to remove the vitreous body. It is performed with various eye diseases. Replacement of the vitreous body is necessitated by its removal. After more than 50 years the search for the ideal vitreous replacement has not yet ended. Different materials are used to replace the vitreous body. The advantages, disadvantages and applications of those materials are discussed. The lack of a material to successfully replace the vitreous body is a significant restriction in the treatment vitreoretinal pathologies.

[Internship abroad: should be mandatory for all medical students]. / Coschappen in het buitenland: Zouden voor elke coassistent verplicht moeten worden.

Medical students in the Netherlands have the opportunity to follow an internship abroad. In general, they view this as a unique experience. There are personal, scientific, political and humanitarian reasons to support making such an internship abroad obligatory for all medical students. Therefore the Dutch medical study programme, developed in 2001, needs to be reviewed.

Distinct cytokine patterns in the aqueous humor of children, adolescents and adults with uveitis.

PURPOSE: To determine the immune mediator profile in relation to age in the aqueous humor (AqH) of patients with uveitis. METHODS: AqH of children, adolescents, and adults with uveitis was analyzed for 16 immune mediators. RESULTS: No significant differences were found for IL-8, RANTES, and IP-10. The concentrations of the remaining 13 mediators were significant lower in adults compared with children and adolescents, except for IL-6, which was higher. CONCLUSIONS: Various immune mediators are present in higher concentrations in AqH of children and adolescents with different uveitis entities compared with that of adults, except IL-6, which was higher in adults.

Risk factors for the development of cataract requiring surgery in uveitis associated with juvenile idiopathic arthritis.

PURPOSE: To identify the possible risk factors for the development of cataract requiring surgery in children with juvenile idiopathic arthritis (JIA)-associated uveitis. DESIGN: Retrospective cohort study. METHODS: Data of 53 children with JIA-associated uveitis, of whom 27 had undergone cataract extraction (CE), were obtained. The main outcome measure, the interval between the onset of uveitis and the first CE (U-CE interval), was examined in relation to clinical and ophthalmologic characteristics and treatment strategies before CE. RESULTS: A shorter U-CE interval was found for children with posterior synechia vs those without posterior synechia (hazard ratio [HR], 3.57; 95% confidence interval [CI], 1.33 to 10.00). No significant difference was found for children in whom the uveitis was the first manifestation of JIA vs those in whom arthritis was the first manifestation of JIA (HR, 1.59; 95% CI, 0.63 to 4.00) and children treated with periocular corticosteroid injections vs those not treated with periocular corticosteroid injections (HR, 3.23; 95% CI, 0.95 to 11.11). Children treated with methotrexate (MTX) had a longer U-CE interval than children not treated with MTX (HR, 0.29; 95% CI, 0.10 to 0.87). CONCLUSIONS: The risk factor for development of early cataract requiring surgery in children with JIA-associated uveitis is the presence of posterior synechia at the time of diagnosis of uveitis. However, early treatment with MTX is associated with a mean delay in the development of cataract requiring surgery of 3.5 years.

Cytokines, chemokines and soluble adhesion molecules in aqueous humor of children with uveitis.

Uveitis in childhood is a visual threatening disease with a complication rate of more than 75%. Despite extensive research, the etiology of uveitis is still unclear although the general opinion is now that uveitis is a T-cell mediated disease. The purpose of this study was to investigate the profile of cytokines, chemotactic cytokines (chemokines) and soluble adhesion molecules in the aqueous humor (AqH) of children with uveitis in order to identify the factors that control the immune response in the eye. In this clinical laboratory investigation we analyzed, with a multiplex immunoassay, 16 immune mediators in the AqH of 25 children with uveitis and 6 children without uveitis. Increased levels of interleukin-2 (IL-2), IL-6, IL-10, IL-13, IL-18, interferon-gamma, tumor necrosis factor-alpha, soluble intercellular adhesion molecule-1, RANTES, IL-8 and interferon-inducible 10-kDa protein were found in the AqH of children with uveitis compared with controls. No significant differences were found for IL-1 beta, IL-4, IL-12 p-70, soluble vascular cell adhesion molecule 1 and Eotaxin. Lower levels of IL-10 and IL-8 were found in quiet stage uveitis (surgical) samples compared with active uveitis (diagnostic) samples and in samples of patients treated with methotrexate (MTX) compared with samples of patients not treated with MTX. Lower levels of IL-10 were as well found in samples taken during the first 3 months after the diagnosis of uveitis than samples taken later during the disease process. No significant differences were found between patients treated with or without topical or systemic (perioperative and long term) corticosteroids. In conclusion, in children with uveitis, multiple intraocular cytokines, chemokines and soluble adhesion molecules are increased in the AqH regardless of active or inactive inflammation. Whether the IL-8 and IL-10 levels in AqH of children with uveitis are correlated with uveitis activity, early or late phase of the course of the disease and systemic treatment with MTX needs further investigation in a bigger study population.

Prevalence of ocular diagnoses found on screening 1539 adults with intellectual disabilities.

OBJECTIVE: To study the prevalence of ocular disorders in adults with intellectual disabilities (IDs) in the Netherlands. DESIGN: Cross-sectional survey. SUBJECTS: A stratified random sample (for age more than 50 years and Down syndrome [DS]) of 1598 participants drawn from a base population of 9012 adult users of ID services with mild to profound intellectual disabilities in the Netherlands. METHODS: Participants underwent on-site visual screening on the basis of a protocol. Results were related to degree of ID, occurrence of DS, age, and a diagnosis of visual impairment or blindness. Referral to ophthalmologists followed when visual impairment was diagnosed. MAIN OUTCOME MEASURES: Diagnosis of ocular disorders and their prevalence. RESULTS: Refractive errors were most prevalent (60.6%), followed by strabismus (44.1%) and lens opacities (18.1%). Besides these, in participants diagnosed as visually impaired, cerebral visual impairment was the most common untreatable disorder (12.6%), followed by macular degeneration (5.4%). Compared with known figures from general populations, the prevalence of ocular diagnoses in adults with ID was significantly higher. The occurrence of refractive errors and strabismus was significantly related to DS (odds ratio [OR], 2.16; 95% confidence interval [CI], 1.56 to 3.00; and OR, 2.47; 95% CI, 1.93 to 3.17, respectively). Lens opacities had an independent relation with age more than 50 years (OR, 4.23; 95% CI, 3.04 to 5.88) and DS (OR, 8.27; 95% CI, 5.95 to 11.49). Keratoconus was independently related to DS (OR, 7.65; 95% CI, 3.91 to 14.96) and degree of ID (OR, 5.56; 95% CI, 2.79 to 11.06). Corneal opacities also were related to DS (OR, 2.70; 95% CI, 1.41 to 5.18) and degree of ID (OR, 5.53; 95% CI, 2.66 to 11.48). The risk of ocular hypertension was increased by age more than 50 years (OR, 2.54; 95% CI, 1.16 to 5.57) and severe or profound ID (OR, 4.86; 95% CI, 2.06 to 10.63); DS decreased the risk (OR, 0.21; 95% CI, 0.05 to 0.94). CONCLUSIONS: In 1539 adults with ID in the Netherlands, high prevalences of ocular disorders were found. Adults with ID in general have an increased risk of severe myopia, strabismus, and lens opacities; DS, older age, or severe ID further increase the risk of specific ocular disorders.

Refractive errors and visual impairment in 900 adults with intellectual disabilities in the Netherlands.

PURPOSE: To collect data on refractive errors and visual impairment in adults with an intellectual disability (ID) in the Netherlands. PATIENTS: A randomized sample of 2100 participants was drawn from a base population of 9000 adults with intellectual disabilities in the Netherlands. This article reports on the first 900 participants. METHODS: All participants underwent a protocol-based on-site ophthalmological assessment carried out by skilled investigators. RESULTS: Co-operation was classified according to the number of tests that could be carried out reliably and was good or excellent in 80% of subjects, average in 13% and poor in 7%. Refraction could be reliably assessed in 505/900 (56%) subjects. There was an increased risk of visual impairment in all subgroups compared to the general Dutch population. Visual acuity (VA) was related to the level of ID, but refractive errors were not. New spectacles were prescribed in 106 cases (12%). Of 374 people in whom both monocular VA and the refractive error of the right eye could be reliably assessed, 153 (41%) had a pretest prescription, 16 (10%) of which we found to be inadequate. Of the 221 participants without a pretest prescription, 41 (19%) benefited from correction. Only 38/84 (45%) subjects aged 50 years or older, who could benefit from correction for near vision, had near spectacles. New correction increased the mean distant VA significantly from 0.44 to 0.65 (p < 0.0005). CONCLUSIONS: With some adaptations, visual screening is feasible in a majority of adults with ID. Visual impairment and refractive errors are much more prevalent in adults with ID than in the normal population. Accurate spectacle correction resulted in significant improvement in distant VA.

Reactivations of ocular toxoplasmosis after cataract extraction.

PURPOSE: To determine the risk of reactivation of ocular toxoplasmosis following cataract extraction. DESIGN: Retrospective case-control study. PARTICIPANTS: Out of 154 patients with ocular toxoplasmosis, 14 patients (15 eyes) who had undergone a cataract extraction and 45 age- and sex- matched controls without cataract were selected. INTERVENTION: A review of the medical records of 14 patients with ocular toxoplasmosis and cataract and 45 control patients with ocular toxoplasmosis but without cataract. The clinical records of the controls and patients were assessed for an identical 4-month period following the date of the cataract extraction in the index patients. MAIN OUTCOME MEASURES: Development of a new active retinal lesion within 4 months after cataract surgery in patients and age -and sex matched-controls. The presence of risk factors such as sex, congenital or postnatal acquisition of ocular toxoplasmosis, age at first clinical manifestation of ocular toxoplasmosis, total number of attacks per affected eye, type of cataract, age at the time of cataract surgery and the intervals between surgery and first clinical manifestation of ocular toxoplasmosis and between surgery and the last recurrence of ocular toxoplasmosis, as well as the use of antiparasitic medication during surgery, type and complications of surgery and optimal visual acuity before and after cataract surgery. RESULTS: Reactivations of ocular toxoplasmosis following cataract extraction occurred in 5/14 patients (5/15 eyes), which was higher than the incidence of recurrences in age -and sex-matched controls (p < 0.001). No additional risk factors for the development of recurrences of ocular toxoplasmosis after cataract surgery were found. Incidence of recurrences preceding surgery did not differ between patients and controls. CONCLUSION: We identified an increased risk of reactivation of ocular toxoplasmosis following cataract extraction which implies that prophylactic treatment with antiparasitic drugs during and after the cataract surgery might be worthwhile for patients at risk of visual loss.

Rectus extraocular muscle paths and decompression surgery for Graves orbitopathy: mechanism of motility disturbances.

PURPOSE: To study possible causes of motility disturbances that may result from orbital decompression surgery in patients with Graves orbitopathy and especially the role of rectus extraocular muscle paths. METHODS: Sixteen patients with Graves orbitopathy were studied before and 3 to 6 months after translid (6 patients) and coronal (10 patients) orbital decompression surgery for disfiguring proptosis. Ocular motility changes were measured by comparing maximum ductions and severity of diplopia, and the positions and the displacements of the anterior rectus muscle paths were objectively measured using cine magnetic resonance imaging (MRI). RESULTS: Averaged preoperative rectus muscle path positions were not different from those in normal subjects. Averaged postoperative muscle path positions were generally the same as preoperative paths. The only significant exceptions were centrifugal (outward from the orbital axis) displacements of the inferior rectus (IR) muscle path after translid surgery, and of the medial rectus (MR) muscle path after coronal surgery. The amount of IR path displacement with translid surgery was directly correlated with range of depression and with severity of vertical diplopia. The amount of MR path displacement with coronal surgery was inversely correlated with range of abduction and directly correlated with severity of horizontal diplopia. CONCLUSIONS: The anterior orbital connective tissue seems to form a "functional skeleton" that is usually (except as noted for IR and MR) capable of keeping the rectus muscle paths aligned after decompression surgery and preserving the normal functions of rectus muscle pulleys. The centrifugal displacement of the IR and MR may increase the elastic component of the muscle force, leading to the specific patterns of motility disturbance that may occur in some patients after translid and coronal surgery. These findings suggest that standard surgical management of Graves orbitopathy should be supplemented.