Endometriosis, dysmenorrhoea and diet.

OBJECTIVE: To review the literature on the effects of diet on endometriosis and dysmenorrhoea. STUDY DESIGN: A systematic search for trials investigating a relationship between diet and endometriosis/dysmenorrhoea was undertaken, and 23 studies were included in this review. RESULTS: Data on the relationship between diet and endometriosis were limited to 12 trials, three of which were animal studies, resulting in a total of 74,708 women. One large study (n=70,709) found a relatively strong association between endometriosis and trans-fatty acid consumption, and a lower risk of endometriosis with increased consumption of long-chain omega-3 fatty acids. The latter finding was also supported by smaller studies. No further dietary recommendations for reducing the risk of endometriosis were possible, and results for intake of vegetable, fibre and fruit were equivocal. The relationship between diet and dysmenorrhoea was investigated in 11 trials with different designs, including a total of 1433 women. Intake of fish oil seemed to reduce dysmenorrhoea. CONCLUSION: The literature on endometriosis and dysmenorrhoea in relation to diet is sparse, yielding equivocal results on specific elements. Overall, however, the literature suggests that specific types of dietary fats are associated with endometriosis and/or dysmenorrhoea, thereby indicating that there may be modifiable risk factors. Further research is recommended on both subjects.

Challenges to deliver therapies.

Medical science and pharmaceutical technology have progressed in enormous leaps. The professions have access to knowledge of improved therapies that cover a large selection of diagnoses. This state of affairs is a successful result of the long and purposeful co-operation between science and technology, theory and practice. The therapies have changed but their delivery to the patient remains the same. During the recent international recession and the continuous cost containment programmes the question of availability has risen to the fore. Availability is a question of means. That is usually interpreted as equal to saving and cost cutting. At times of affluence it could mean allowance but that seems far in the past. Availability also concerns the physical distribution of the therapies such as pharmaceuticals. So far, advances in the science have not affected either the distribution or availability of pharmaceutical products. With the rise in patient awareness, pressure is rising to make full use of the research results. This is a natural, albeit unmet, demand and represents an opportunity for the pharmacy institutions with their well trained personnel, modern outlets and the unique as well as traditional position in direct contact with the patients. This role could gain added weight through the progress of the technologies that allow ambulatory therapies instead of cost consuming institutionalisation. It would appear quite natural that the providers of such services would seek the pharmacy outlet networks as their proper points of delivery. There is no doubt that this choice would be taken as a convenient solution by the consumers of the services. This would offer considerable savings to society and efficiency to the patients.

Progressive constriction of the anterior capsular opening following intact capsulorhexis.

The continuous curvilinear capsulorhexis has rapidly increased in popularity as the procedure of choice when using phacoemulsification for cataract extraction. Only recently, however, have complications of this technique been reported. We review the complications of a continuous curvilinear capsulorhexis and present three cases involving progressive constriction of the postoperative anterior capsular opening. One patient had a history of myotonic muscular dystrophy, another had pars planitis, and the third had high myopia. A review of ocular findings in myotonic dystrophy and pars planitis is also presented, and the possible pathophysiology of this progressive constriction is explored.

Noninvasive repositioning of a posterior chamber intraocular lens following pupillary capture.

A case of pupillary capture of a posterior chamber intraocular lens (IOL) is presented. A nonsurgical approach that may help reposition an IOL optic entrapped in a pupillary capture when chemical mydriasis fails is described. Suggestions for a logical progression of nonsurgical procedures to help release optic capture are presented. Possible causes and preventative measures to decrease the incidence of pupillary capture of a posterior chamber IOL are discussed.

Risk of bilateral testicular germ cell cancer in Denmark: 1960-1984.

The incidence of a second primary testicular germ cell cancer among 2850 (96.6% of eligible) men with a histologically verified first primary germ cell cancer diagnosed in the period 1960-1979 in Denmark was established. Of these 2850 men, 73 (2.6%) developed a contralateral testicular cancer. In five of these patients (0.18%), the tumors were synchronous. The cumulative risk of developing a contralateral cancer 25 years after diagnosis of the first testicular germ cell cancer was 5.2% according to a Kaplan-Meier estimate. It was higher among men with a nonseminoma as the first tumor (8.4%) than among men with a seminoma as the first tumor (3.6%). Of the second tumors, 12% were stage II and 17% were stage III at the time of diagnosis. Based on 24,588 person-years at risk and 68 nonsimultaneously occurring bilateral testicular germ cell cancers, the overall relative risk (RR) of developing a second primary cancer in the contralateral testicle following a first germ cell cancer was found to be 24.8 (95% confidence interval = 19-38). Among men with a nonseminoma, the risk was higher (RR = 27.1) than among men with a seminoma (RR = 22.5). The excess risk was not affected by age at diagnosis, calendar period, or time since diagnosis. Close surveillance by screening for and treatment of carcinoma in situ of the remaining testicle in testicular cancer patients are advised.

The distribution of cadmium within the human prostate.

Five normal prostates from autopsies of humans aged 61-76 yr were divided into 2 x 24 topographically well-defined pairs of slices that were analyzed for cadmium (Cd) and examined histologically. The corresponding kidney cortex concentrations were also determined. The concentrations in ng Cd/g wet wt were in the range of 50-500 in the prostates and 8,000-39,000 in the kidneys with good mutual correlation. Large variations in Cd concentrations within the prostates were found. The concentrations were highest at the base (near the bladder) and lowest at the apex of the gland. Furthermore, large variations within horizontal layers were found, and this variation was not correlated to the histological amount of stroma or glands.

Amelanotic malignant melanoma of the conjunctiva with local metastasis to the eyelid.

Conjunctival melanomas are uncommon. The amelanotic variety is extremely rare. We describe a patient with an amelanotic melanoma of the superior conjunctiva that was primarily excised, followed by extensive conjunctival resection and liquid nitrogen cryotherapy applied to the tumour bed. Eight months later a local metastatic lesion was noted in the lower eyelid. Eyelid metastasis in conjunctival melanoma is uncommon but may occur owing to the rich lymphatic vasculature within the conjunctiva.

Irradiated homologous tarsal plate banking: a new alternative in eyelid reconstruction. Part I. Technique and animal research.

Reconstruction of full thickness eyelid defects requires the correction of both posterior lamella (tarsus, conjunctiva) and anterior lamella (skin, muscle). Tarsal substitutes including banked sclera, nasal cartilage, ear cartilage, and periosteum can be beneficial for posterior lamellar repair, while anterior lamellar replacement, including skin grafts, pedicle flaps, advancement flaps, etc., is important to cover the posterior reconstructed portion. At times, due to extensive tissue loss, the eyelid reconstruction can be particularly challenging. We have found an alternative posterior lamellar reconstructive technique utilizing irradiated homologous tarsal plate that can be particularly useful in selected cases of severe tissue loss. The experimental surgical procedure in monkeys and the histological fate of the implanted tarsus is described in Part I, and followed in Part II by our experience with this tissue in six human patients.

Irradiated homologous tarsal plate banking: a new alternative in eyelid reconstruction. Part II. Human data.

Reconstruction of full thickness eyelid defects requires the correction of both posterior lamella (tarsus, conjunctiva) and anterior lamella (skin, muscle). Irradiated homologous tarsal plate provides a structured framework for the lid reconstruction, and is incorporated nicely into the normal lid anatomy.

Protective effect of the anterior lens capsule during extracapsular cataract extraction. Part I. Experimental animal study.

In an experimental study using albino Rex rabbits, the intercapsular cataract extraction (ICCE) technique was performed in 20 eyes with a small anterior capsulotomy. A large, can opener capsulotomy was performed in another 20 eyes, and 10 unoperated eyes served as controls. Endothelial cell loss was determined by vital staining with Trypan blue and Alizarin red S stains. Average endothelial cell loss with the ICCE technique was 1.2%; with the can opener technique, the average cell loss was 6.6%. This difference was statistically significant (P less than 0.01). The percentage of endothelial cell loss in the control eyes was 0.5. A positive correlation between endothelial cell loss related to phacoemulsification time and/or the amount of irrigating fluid used existed for the can opener group only (P less than 0.01). These results demonstrate that the presence of an almost intact anterior lens capsule during removal of lens substance is protective to the corneal endothelium.

Protective effect of the anterior lens capsule during extracapsular cataract extraction. Part II. Preliminary results of clinical study.

In a clinical study, 61 patients underwent phacoemulsification with subsequent intraocular lens (IOL) implantation. An intercapsular capsulotomy with phacoemulsification was performed on 23 patients and a can opener capsulotomy with phacoemulsification on 38 patients. Wide-field specular microscopy was performed preoperatively and postoperatively on all of the eyes in the study. The cell counts were not divulged to the surgeon before or at the time of surgery. Average endothelial cell loss for the intercapsular technique was 3.9%; with the can opener technique, the average cell loss was 10.1%. This difference was statistically significant (P less than 0.01). Positive correlations between endothelial cell loss relating to ultrasound time and/or the hardness of the cataract existed for the can opener group only (P less than 0.01). These results demonstrate that a protective effect is provided by the presence of the anterior lens capsule during lens substance removal.

A method to study the interaction between intraocular lens loops and anterior segment vasculature.

Gold-coated plastic casts of the anterior segment ocular microcirculation of the rabbit eye were studied by scanning electron microscopy to define the interaction between ciliary sulcus fixated intraocular lenses and the anterior segment vasculature. A detailed description of the technique is given. Interactions such as loop deformation by the tissue and loop erosion into the vascular tissue are shown. Possible clinical applications of this experimental model are discussed.

Posterior capsular opacification and intraocular lens decentration. Part I: Comparison of various posterior chamber lens designs implanted in the rabbit model.

Experimental phacoemulsification procedures were performed in 54 Rex rabbits. In 96 eyes, posterior chamber intraocular lenses (IOLs) were implanted in the capsular sac, and 12 eyes served as controls with no lens implantation. The IOLs were divided into eight groups consisting of both one-piece and three-piece styles with various optic designs. Each lens was evaluated for the relative effect on posterior capsular opacification (PCO) and optic decentration, two of the most common complications of modern cataract surgery and IOL implantation. Optics with a convex-anterior, plano-posterior design (the type of IOL optic most frequently implanted today) had the highest incidence of PCO. With capsular fixated IOLs, the features that have a statistically significant impact on reducing PCO include (1) one-piece, all-polymethylmethacrylate (PMMA) IOL styles, (2) a biconvex or posterior convex optic design, and (3) angulated loops. Lens decentration was not affected by the optic design, but statistical analysis showed that one-piece, all-PMMA IOL construction provided the most consistent centration.

Posterior capsular opacification and intraocular lens decentration. Part II: Experimental findings on a prototype circular intraocular lens design.

In a prospective randomized study, 25 New Zealand white rabbit eyes were implanted with four intraocular lens (IOL) designs. These included a one-piece modified J-loop IOL, a three-piece modified J-loop IOL, a rigid disc IOL, and an experimental compressible disc (CD) IOL. The CD IOL revealed the lowest mean posterior capsular opacification (PCO) of all IOLs tested (P less than .01). With all lenses tested, a positive correlation between PCO and decentration was found (R = 0.55, P less than .05). These results suggest that because of its design features (i.e., one-piece construction, biconvex optic, posterior angulation of the fixation element), the CD lens produces a mechanical barrier against lens epithelial cell migration and reduces the incidence of PCO.

Decentration of flexible loop posterior chamber intraocular lenses in a series of 222 postmortem eyes.

Two hundred twenty-two postmortem eyes containing posterior chamber intraocular lenses (IOLs) were analyzed for optic decentration in relationship to lens style, implant duration, and loop fixation site. Decentration values were not affected significantly by either lens style or implant duration. In 33.3% of specimens, both loops were situated within the lens capsular sac, 18.0% had both loops fixated in the ciliary sulcus, and in 48.7% one loop was fixated in the lens capsular sac and the opposite loop in the ciliary sulcus or zonular region. There was a statistically significant difference in the amount of decentration in the three fixation groups studied. Capsular fixation provides the best and most consistent centration compared with fixation of both loops in the ciliary sulcus or asymmetrical fixation with only one loop in the capsular sac.

Comparative histopathologic study of various lens biomaterials in primates after Nd:YAG laser treatment.

A Nd:YAG laser was used to perform posterior capsulotomies on primates in whom one-piece silicone or three-piece polymethylmethacrylate intraocular lenses were in place for more than one year. The eyes were followed for eight weeks after treatment before enucleation. Histologically, no toxic effects caused by the dispersion of any of the biomaterial within the eyes and no significant inflammatory reactions were seen. The silicone lenses used in this study compared favorably with traditional polymethylmethacrylate lenses when posterior capsulotomies with a Nd:YAG laser were performed.

Anterior chamber lenses. Part I: Complications and pathology and a review of designs.

Clinicopathologic data to assist ophthalmologists in choosing a safe and efficacious anterior chamber intraocular lens (IOL) are rapidly becoming available. Two important factors that have led to an increased success rate with some anterior chamber IOL styles are (1) attention to lens design and (2) attention to modern manufacturing and lens finishing techniques. We now know much more about how to achieve appropriate lens flexibility, which decreases the need for perfect sizing. Increased attention has been given to the anterior-posterior vaulting characteristics of IOLs. This has reduced the incidence of various complications such as the intermittent touch syndrome and the uveal chafing syndrome. We recognize several design flaws in some lens styles. For example, there is now a considerable decrease in the number of small-diameter, round-looped anterior chamber IOLs being implanted, particularly those with a closed-loop configuration. Several problems have been and continue to be caused by some poorly manufactured anterior chamber lenses with sharp optic and haptic edges. Technology to assure smooth lens finishing and polishing is available and readily accessible to all manufacturers. Defective lenses should soon be a thing of the past.

Anterior chamber lenses. Part II: A laboratory study.

An analysis of 606 surgically removed anterior chamber intraocular lens (IOL) specimens revealed that 351 or 58% of these were small-diameter, round loop, closed-loop styles. Because of the extremely high percentage of IOLs with this design received in our laboratory and the correlation of clinical histories with our histopathologic findings, we have concluded that such IOLs do not provide the safety and efficacy achieved by other anterior chamber lens designs. The finely polished, one-piece, all-PMMA styles fared well in our study. Although these one-piece styles comprise well over 50% of the American market share of anterior chamber IOLs, they comprise only 14% of all anterior chamber IOLs accessioned in our laboratory, compared to 58% for closed-loop designs. We believe that implantation of anterior chamber lenses with small-diameter, round, closed loops is no longer warranted. Patients in whom these IOLs have already been implanted should be carefully followed. It is our opinion that the FDA should recall or closely monitor all IOLs of this design and that implantation of closed-loop lenses should be discontinued in the United States. Furthermore, we believe that an IOL deemed to be not medically sound or worthy of implantation in the United States should not be marketed or donated outside of this country.

Incidence of bilateral testicular germ cell cancer in Denmark, 1960-84: preliminary findings.

The incidence of a second primary testicular germ cell cancer in the contralateral testicle among 2338 men with a first primary testicular germ cell cancer diagnosed in the years 1960-79 in Denmark was established in this preliminary report. The material represents 83% of the total cohort followed until 31 December 1984. The relative risk for a patient with testicular cancer to get yet another testicular cancer was studied, taking into account the histology of the first primary testicular germ cell cancer. Based on fifty-eight nonsimultaneous contralateral testicular cancer cases and 19,995 'person-years at risk', the overall relative risk of invasive germ cell cancer in the contralateral testicle following a first germ cell testicular cancer was found to be 23.3 (95% confidence interval: 18-30). Among men with nonseminoma the risk was higher (relative risk = 27.5) than among men with seminomas (relative risk = 20.1). Overall, sixty-two (2.7%) patients developed a second cancer. In four of these patients bilateral tumours occurred simultaneously.