Aqueous humor flow in unilateral carotid stenosis.

Our purpose was to study the relationship between carotid artery occlusive disease and aqueous flow in human subjects. Aqueous humor flow was measured by fluorophotometry in seven patients with unilateral carotid artery disease documented by oculoplethysmography. The mean (+/- SD) flow was 2.03 +/- 0.38 microliter/min in the affected eyes, 2.44 +/- 0.66 microliter/min in the unaffected contralateral eyes, and 2.56 +/- 0.61 microliter/min in a group of 14 age-matched controls. A statistically significant difference (p < 0.05) in the aqueous flow rate was seen between the affected and unaffected eyes and between the affected and control eyes. Aqueous flow in the unaffected and control eyes was not statistically different. The anterior chamber volumes and intraocular pressures were also not significantly different among groups. Severe carotid artery disease may reduce aqueous humor formation by lowering ciliary body blood flow to a point beyond which the eye cannot compensate.

Combined phacoemulsification, intraocular lens implantation, and trabeculectomy with a modified scleral tunnel and single-stitch closure.

In most combined phacoemulsification and filtration surgery, the standard tunnel incision is altered to create a scleral flap, usually a limbal-based scleral flap with radial suture closure. We describe a new technique that has the advantages of both scleral tunnel architecture and horizontal suture closure. It creates a scleral groove tangential to the limbus and a standard scleral tunnel. Phacoemulsification and intraocular lens implantation are performed under the scleral tunnel. A 10-0 nylon horizontal suture is positioned for scleral tunnel closure and looped aside. A central "T" relaxing incision is made at the midpoint of the scleral tunnel up to the posterior insertion of conjunctiva. A punch sclerectomy is performed. The 10-0 nylon horizontal suture is tied. The conjunctiva is closed and bleb elevation is confirmed via deepening through a corneal paracentesis incision. The results in an initial series of 24 consecutive eyes followed for a mean of seven months are presented: Mean visual acuity improved from 20/70 to 20/30 and mean intraocular pressure reduction was 5.0 +/- 2.4 mm Hg (standard deviation). By preserving standard scleral tunnel architecture and single horizontal suture closure, this technique permits rapid visual recovery and accelerated return to full activity. It also permits postoperative titration of aqueous outflow by laser suture lysis, if indicated. Against-the-rule astigmatic drift associated with limbal-based scleral flaps and antimetabolite therapy may be minimized.

Biochemical quantification of triamcinolone in subconjunctival depots.

OBJECTIVE: To biochemically quantify the amount of active triamcinolone acetonide remaining after subconjunctival administration and to assess the effectiveness of surgical management for glaucoma induced by triamcinolone. DESIGN: Case series. PARTICIPANTS: Seven eyes of seven patients whose ages ranged from 47 to 84 years underwent excision of depot triamcinolone. Six of seven eyes required surgical intervention for medically unresponsive intraocular pressure (IOP) elevation. RESULTS: Pharmacologically active triamcinolone was identified up to 13 months following injection (range, 3 to 13 months). The mean amount in the excised sample was 5.4 mg (range, 2.0 to 8.8 mg), and the mean percentage of the original sample remaining was 20% (range, 4.2% to 44%). Glaucoma was diagnosed a mean of 3 months after injection (range, 1 to 6 months). Mean IOP was 37 mm Hg before excision and 16 mm Hg after removal. Surgical excision of visible triamcinolone normalized IOP in six of seven patients without need for glaucoma medications. CONCLUSIONS: Periocular injection of triamcinolone necessitates careful monitoring of IOP. Medically unresponsive IOP elevation may occur as late as 6 months following periocular triamcinolone injection. Surgical excision of remaining triamcinolone depot is an effective therapy for IOP elevation. Guidelines for safely using triamcinolone are discussed.

Transcorneal erbium laser sclerostomy: towards a guarded laser sclerostomy technique.

PURPOSE: To attempt transcorneal laser sclerostomy with the erbium laser and to control the flow of aqueous through this sclerostomy with a suture ligature. METHODS: A contact erbium laser was used to create sclerostomies through small corneal incisions in both eyes of eight rabbits. Prior to surgery, a Merocel sponge soaked in mitomycin-C (0. 4 mg/cc) was applied to the conjunctiva at the operative site in one eye of each rabbit for 5 min. In the perfused human autopsy eye, following the creation of transcorneal erbium laser sclerostomy, a ligature suture was placed at the limbus around the sclerostomy opening to limit fluid flow. RESULTS: Using the erbium laser probe and the transcorneal approach, patent sclerostomies were created in all eyes. Intraocular pressures were significantly lower in mitomycin-C-treated eyes up to four months postoperatively (p = 0. 05). Eyes not treated with mitomycin-C demonstrated failure of filtering blebs by 1 month postoperatively (mean bleb survival = 9. 3 days). All mitomycin-C-treated eyes showed evidence of bleb formation up to 4 months postoperatively. Histologic examination of transcorneal sclerostomies in rabbit eyes showed patent sclerostomies at 1 day postoperatively with minimal adjacent thermal damage. In perfused human autopsy eyes, intraocular pressure was maintained near preoperative levels following placement of a ligature suture around the sclerostomy and decreased with release of the suture. CONCLUSIONS: These results demonstrate that functional filtering blebs can be created via small transcorneal incisions using the erbium laser. Transconjunctival mitomycin-C produces lower postoperative intraocular pressures and prolongs bleb survival. Aqueous flow through the sclerostomy was controlled with a suture ligature.

Diagnostic value and limitations of orbital biopsy in Wegener's granulomatosis.

Patients with Wegener's granulomatosis may present with ophthalmic involvement in either the classic or limited forms. Although the overall clinical picture and serologic testing for antineutrophil cytoplasmic antibody (ANCA) are important, biopsy is often necessary for a definitive diagnosis. Accurate interpretation of these orbital biopsies is essential. The authors reviewed the histopathologic features of 13 orbital biopsies in patients with well-documented Wegener's granulomatosis. The classic triad of vasculitis, tissue necrosis, and granulomatous inflammation was seen in 7 of 13 biopsies (54%). Vasculitis in combination with other microscopic findings was seen in 4 of 13 (31%) biopsies. Giant cells were seldom seen. Two biopsies showed only perivascular infiltrates. Based on this study, it appears that a spectrum of histopathologic features can be seen in orbital biopsies in Wegener's granulomatosis. This study underscores the importance of clinical correlation, the application of the ANCA test, and comparison with extraorbital biopsies, if available, when interpreting orbital biopsies in the diagnosis of Wegener's granulomatosis.

Isolated neurofibromas of the conjunctiva.

We studied four histologically verified cases of isolated neurofibromas of the conjunctiva. The histologic pattern was diffuse in two patients, plexiform in one patient, and solitary in one patient. Simple excision was curative in all cases. We emphasize the importance of distinguishing neuromas (which may be associated with multiple endocrine neoplasia) from neurofibromas.

Aspergillus terreus endophthalmitis in a patient with chronic lymphocytic leukemia.

A 65-year-old woman with a 7-year history of chronic lymphocytic leukemia presented with acute visual loss, pain, and redness in her right eye. Results of stains and cultures of anterior chamber fluid were negative. Neurologic problems, bronchopulmonary pneumonia, recurrent skin lesions, and a low-grade fever developed. Progressive respiratory distress ensued, and the patient died 1 month after presentation. Cultures from antemortem sputum and skin samples were positive for Aspergillus terreus. Postmortem histologic results showed extensive A terreus invasion of the posterior vitreous, retina, choroid, and anterior optic nerve. This organism was also found in histologic sections from the right adrenal gland, left kidney, thyroid, urinary bladder, right lung, skin, esophagus, sputum, vessels of the myocardium, and brain. To our knowledge, A terreus endophthalmitis has not been reported previously.

Marrow embolus to posterior ciliary vessel.

A 69-year-old man with respiratory disease sustained multiple rib fractures during resuscitation for respiratory arrest. Death occurred after the second attempt. Autopsy findings included carcinoma of the lung with widespread metastases, multiple pulmonary marrow emboli, and a marrow embolus to the posterior ciliary vessel.

Role of testing for anticytoplasmic autoantibodies in the differential diagnosis of scleritis and orbital pseudotumor.

Wegener's granulomatosis is a multisystem disease often with protean manifestations. Eye signs and symptoms can be prominent and may be the patient's initial complaint. For a definitive diagnosis of Wegener's granulomatosis, a tissue biopsy specimen must show vasculitis and necrotizing granuloma. The presence of anticytoplasmic autoantibodies in the serum of patients has been found to be highly specific for Wegener's granulomatosis and can considerably facilitate early diagnosis and be used to monitor disease activity. In two illustrative cases, the utility of this laboratory test in the differential diagnosis of scleritis and orbital pseudotumor is demonstrated.

Neovascularization of the disc in pars planitis.

Neovascularization of the disc (NVD) was present in 9 of 163 patients with pars planitis. In all cases, NVD was unilateral and observed in eyes with recent exacerbation of the inflammatory process. To reduce intraocular inflammation, all nine eyes were treated with varying combinations of topical, periocular, and systemic corticosteroids. In addition to corticosteroids, one eye received Argon laser photocoagulation, two eyes underwent peripheral cryotherapy, and one eye was treated with both Argon laser photocoagulation and peripheral cryotherapy. With decrease or disappearance of intraocular inflammation, NVD resolved in all cases without recurrence during follow-up study, which ranged from 6 to 189 (mean, 81) months. Rhegmatogenous retinal detachments developed in two eyes treated with peripheral cryotherapy. Both detachments were successfully repaired with surgery. Control of intraocular inflammation appears to be the key factor for regression of NVD in pars planitis. If NVD does not regress or vitreous hemorrhage occur, photocoagulation and peripheral cryotherapy may be beneficial.

6-amino-2-benzothiazole-sulfonamide. The effect of a topical carbonic anhydrase inhibitor on aqueous humor formation in the normal human eye.

The carbonic anhydrase inhibitor, 6-amino-2-benzothiazolesulfonamide, formulated as a 3% suspension in a gel vehicle was instilled in one eye of 21 human subjects in a single dose study to determine its effect on aqueous dynamics. A small but statistically significant effect on aqueous humor flow was observed 2 to 7 hours after application. By 8 hours, the effect had disappeared, and intraocular pressure (IOP) measured 8 hours after application of a single dose was unchanged in these normal volunteers. The drug and its vehicle caused local side effects including irritation, hyperemia, and blurred vision. The authors wondered if multiple doses would produce a greater effect. Four subjects received up to four doses of the drug over 2 days and were restudied. Marked bulbar injection and follicular conjunctivitis, attributable to either the drug or the vehicle, developed in two of the subjects, both contact lens wearers. A milder form of bulbar injection and follicular conjunctivitis developed in a third subject, who received three doses of the drug and was not a contact lens wearer. These side effects precluded additional multiple-dose testing of this formulation of the drug, and no conclusions about the effect of the drug on aqueous flow can be drawn from this portion of the study.