[Penetrating keratoplasty in high-risk children: prevention of graft rejection].

PURPOSE: To evaluate the efficacy of prolonged courses of systemically administered subtherapeutic Metipred and cyclosporine in prevention of graft rejection in high-risk children. MATERIAL AND METHODS: The study included 27 children at high risk of graft rejection due to re-keratoplasty (n = 8), limbo-keratoplasty for corneal staphyloma (n = 4), or transplantation into vascularized corneal bed (n = 15). All patients were divided into two groups--the study group (n =11) and the control group (n = 16). In order to evaluate the efficacy of two different prevention schemes, the occurrence of graft rejection, rejection crises, and crisis-associated clouding of the transplant was analyzed. RESULTS: The occurrence of transplant opacity was two times lower in the Metipred-cyclosporine group than in the conventional prevention group. Kaplan-Meier one-year survival of the transplant was 53% in the study group and 27% in the control group. Two-year survival rate difference appeared even more significant--53% and 18% correspondingly. CONCLUSION: It is clinically shown that subtherapeutic use of Metipred and cyclosporine decreases the occurrence of rejection crises and transplant failure almost by half in high-risk patients as compared with topical corticosteroids; at the same time the side effects of systemic immunosuppression are not substantial. Thus, the suggested prevention scheme allows to perform keratoplasty and expect a clear transplant in children who previously were considered inoperable, i.e. with total vascularized corneal opacity, giant staphylomas, and corneal burns.

[Congenital glaucoma and thymomegaly: clinical and immunological characteristics].

A comprehensive examination of children with thymomegaly and congenital glaucoma revealed systemic and local humoral immunological disorders mainly as immunodeficiency, a family history of the disease, susceptibility to infections and allergic diseases, the presence of malformations, severe glaucoma, and a complicated postoperative period, which are suggestive of the defective state of the immune system, which should be kept in mind while making a surgical treatment and using an immunomodulator therapy, by exercising a great caution. Such children require observations by a pediatrician, an oculist, and an immunologist and consultations given by other specialists.

[Possibilities for prevention and treatment of blindness and impaired vision in children caused by congenital eye diseases].

Blindness, disability, and impaired vision present important medicosocial problems. According to the WHO, there are 1.5 million blind children in the world. The prevalence of child blindness in Russia is 1.6, and that of impaired vision is 3.5 per 10000 children. It is considered that child blindness can be prevented in 40 to 50% of children. According to data collected during ophthalmological examinations in specialized school, blindness in 88 to 92% of cases is caused by. Presently, significant achievements have been made in treatment of congenital eye diseases. Application of modem surgical techniques in patients with cataract, aphakia, or amblyopia makes it possible to increase visual acuity to 0.3 or higher in 35% of children, and to 0.005 to 0.25 in 45% of children. Modem pathogenetically directed surgery together with timely treatment allows for the normalization of intraocular pressure and visual stabilization in 76.4 to 86.4% of children with congenital glaucoma. In this connection, the achievements of scientific research should be introduced into practice. Realization of the 1999 WHO program on liquidation of eliminable blindness include three key directions: treatment and prevention of blindness; consolidation of the infrastructure and technology of ophthalmological aid; training of specialists.

[Combined laser instrumental extraction of congenital cataracts in children].

The authors have developed a new method for removal of congenital cataract in children, by taking into account its clinical forms, namely, combined laser instrumental extraction including YAG-laser anterior capsular rhexis, followed by removal of lens debris by the aspiration-irrigation technique. A differential technology of YAG-laser anterior capsular rhexis has been developed, by taking into account of age-specific features of the lens and eyes in children. The optimum energy modes and techniques have been defined for different clinical forms of congenital forms of congenital cataracts. An analysis of the outcomes and complications of extraction of congenital cataracts has indicated that the authors' combined laser instrumental extract procedure (75 operations) assures the better quality of anterior capsular excision, improves optical and functional effects, and reduces the frequency of some complications as compared to the routine instrumental procedure (107 operations) (p < 0.05-0.001). Clinicofunctional and immunological studies have provided evidence for that the YAG-laser technique has no significant effect on the child's eye. Combined laser instrumental extraction is indicated for the treatment of any forms of congenital cataracts in children.

[Polypeptide bioregulators in the treatment of different-type abiotrophy of the retina].

The efficiency of retinalamin was studied in 33 patients, aged 4 to 7, with 5 types of retinal abiotrophy. The experimental group comprised children with retinal abiotrophy of Franceschetti type (36%) and mixed type (39%). The pathological process was stabilized during 18 months in all cases of developed disease. The visual acuity improved in 82% of patients after treatment by retinalamin; visual fields enlarged and central scotomas reduced in 54% of cases. Parameters of elctroretinography improved in 37% of cases.

[Problems and outlooks for the preventive treatment of retinopathy in prematures].

The immediate and remote (up to 7 years) results of preventive cryo- and/or lasercoagulation of avascular retinal zones made in 390 children with active progressing retinopathy of prematures (RP) were analyzed. The efficiency of cryocoagulation in processes localized in zones 2-3 of the eye bottom made 92%, and that of the combined technique (laser- and cryocoagulation) with lesions in zones 1-2 and with plus-diseases was up to 80%. The preventive treatment is indicated for the 3d threshold (ordinary clinical course) and before-threshold (with plus-disease and localization zone 1) stages. Such treatment is not justified when undertaken early and in developed retinal detachment. Further research of the disease pathogenesis is needed to enhance the efficiency of the RP treatment, i.e. research of growth factors of endothelial vessels, autoimmune reaction to S-antigen of the retina and of dosed oxygentherapy etc.

[Experience in penetrating keratoplasty in children: graft survival, functional results and risk factors]. / Opyt skvoznoi keratoplastiki u detei: vyzhivaemost' transplantata, funktsional'nye rezul'taty, faktory riska.

Penetrating keratoplasty in children is related with a labor-consuming process of follow-up and care as well as with a high risk of graft rejection and a moderate vision improvement. Nonetheless, keratoplasty has been and still remains a surgery of choice due to a lack of an alternative procedure; its technique and results have been gradually promoted in practice. The authors analyzed 112 keratoplasties in childhood-age corneal opacifications of different types. The graft survival amounted to 71%, 61% and to around 55% after 1, 2 and 5 postoperative years, respectively. Neovascularization, glaucoma, repeated keratoplasty, an original vitreous pathology, an expanded surgical scope (reconstructions) etc. were attributed to risk factors. The visual acuity improved by more than 0.02 in 54% of cases; it remained unchanged or worsened in 22% of cases and it could not be assessed in 24% of cases. The best results were achieved in a group of patients with acquired corneal opacifications of the nontraumatic nature; the worst results were observed in congenital anomalies of the anterior eye segment. Finally, the success of penetrating keratoplasty in children was ensured through a careful selection of patients, an accurate surgical technique and through a fast treatment of postoperative complications.

[Diagnosis and importance of the opportunistic herpes-virus infection in etiology and pathogenesis of different eye diseases]. / Gerpesvirusnaia infektsiia v étiopatogeneze razlichnykh zabolevanii glaz.

A total of 439 patients (adults--184, children--255) with herpetic keratitis as well as with uveitis and choriorenitis of different geneses and localizations were examined. An aggravation of HSV-infection was determined by detecting, in the blood), anti-bodies to the unstructured early viral antigens by using the immune enzyme analysis (IEA). The efficiency of the test was demonstrated during the examination of patients with different ophthalmic pathologies. An active infection was detected in 16-39% of patients with various ocular diseases of non-herpetic etiology. The pathogenetic value of reactivated HSV infection is diverse: it can function as an etiological or trigger factor and it can aggravate the main disease through causing, postoperatively, complications.

[Complications of trabeculectomy in congenital glaucoma in children]. / Oslozhneniia trabekuléktomii pri vrozhdennoi glaukome u detei.

Presently, trabeculectomy is being widely used for congenital glaucoma in children. The authors established, after examining 92 children, that the efficacy of surgical treatment was on the average affirmed in 98.7% of cases during the early observation period, and in 89.8% of cases during the late observation period (1-5 years). Complications occurred in 12% of eyes during the early and late postoperative periods. The complications observed during the early postoperative period were not the cause for relapses of elevated intraocular pressure. Excessive cicatrization in the surgical intervention zone was the most prevalent cause for the instability of the achieved treatment results in the late period.

[Clinical informative value of new methods of ultrasonic examination in the differential diagnosis of various forms of congenital diseases of the eyes in children]. / Klinicheskaia informativnost' novykh metodov ul'trazvukovogo issledovaniia v differentsial'noi diagnostike razlichnykh form vrozhdennoi patologii glaz u detei.

Clinical informative value of computer echography for the differential diagnosis of severe intrauterine uveitis (68 children, 96 eyes), retinopathy neonatorum (37 children, 74 eyes), Coats' retinitis (35 children, 35 eyes), and retinoblastoma (17 children, 26 eyes) was studied in a group of 157 children (231 eyes) with opaque refracting media. Ultrasonic diagnostic equipment with a high level of computer support essentially improved the resolving capacity of echography and detected accessory acoustic signs of some congenital ocular diseases.

[Postoperative complications of penetrating subtotal keratoplasty in children]. / Posleoperatsionnye oslozhneniia skvoznoi subtotal'noi keratoplastiki u detei.

Accordingly to experience of corneal transplantations during 1981-2001 in the children's clinic of the Helmholz Moscow Research Institute of Ocular Diseases the authors present the clinical picture, rate, prognostic value and modes of correction of postoperative complications after keratoplasty. A retrospective study analyzed the incidence of complications after 94 penetrating keratoplasties performed in 82 children aged from 10 months to 14 years in 89 eyes for congenital corneal opacity (n = 22) or corneal opacity caused by trauma (n = 40) or inflammation (n = 20). 60 (73%) within 1 year after operation developed different reactions and complications due to transplant failure in 41 (44%) cases. Among them there were graft rejection episodes (34%), anterior synechiae and retrocorneal membrane formation (17%), donor corneal neovascularization (11%), elevated intraocular pressure (11%). There were a few cases with shallow anterior chamber, hyphema/hemophthalmos, retinal detachment, primary graft failure, corneal ulcer, suture infiltrates and abscesses. Subatrophy of the eye was an outcome in 3 cases. The development of complications after penetrating keratoplasty is determined mainly by the physiology of children, age, severity of underlying and concomitant pathology of the eye. Nevertheless, the odds of donor tissue for transparent graft survival increase if such complications are detected and removed.

[Features of retinopathy of prematurity, progressing as "plus-disease"]. / Osobennosti retinopatii nedonoshennykh, protekaiushchei kak "plius-bolezn'".

"Plus-disease" is a particular grave form of retinopathy of premature babies found in 7% of extremely premature and somatically loaded children. The following criteria are indicative of "plus-disease": location of pathological changes in the central zone of eye fundus (zone 1-2), marked vascular activity and hemorrhages in the center and on the periphery of the retina, pupil regidity, iris vasodilatation and fulminant (3 days-3 weeks) progression of the process from initial signs up to signs of extraretinal growth or exudative amotio retinae without forming premature stages typical for retinopathy (torus lines). Upon revealing the first signs of "plus-disease" ophthalmological examinations should be carried out with the interval of 2-3 days. To increase efficiency of preventive treatment it is recommended to use the combined procedure of cryo- and laser coagulation of avascular zones and a zone of vascular amostosis in appearance of extraretinal vascular growth, which makes it possible to arrest disease progression in 75% of cases.

[Clinical variants and immunologic features of rheumatoid uveitis in children of different age]. / Klinicheskie varianty i immunologicheskie osobennosti revmatoidnykh uveitov u detei raznogo vozrasta.

Variability of clinical manifestations of rheumatoid uveitis, possibility of an atypical course (peripheral or panuveitis), and greater severity and specific features of the disease in case of its early (before the age of 3 years) manifestation are demonstrated on the basis of observations of 79 patients with rheumatoid uveitis. Despite systemic therapy with corticosteroids and cytostatics, no manifest post-steroid immunodeficiency was observed. Moderately expressed gammapathies were detected in 60% cases; hypoimmune states predominated, which were more often detected in children aged under 6 years. No cases of pronounced suppression of functional activity of lymphocytes were observed. Humoral and cellular response to persistent ophthalmotropic infections were observed more rarely than in children with uveitis of other etiology. Positive rheumatoid factor was detected in 9% cases, antinuclear antibodies in 60%. Antibodies to DNA were detected in the sera of 10% examinees, to native and denatured DNA in the lacrimal fluid of 21.2 and 16.7%, respectively. The causes of absence of obvious post-steroid immunodeficiency and relatively low rate of interorgan autosensitization in children with juvenile rheumatoid arthritis and uveitis are discussed. Further investigation of clinical and immunological correlations are needed for improving the prediction of the course of rheumatoid uveitis and development of treatment strategy.

[Prevalence and clinical significance of active cytomegalovirus infection in patients with inflammatory ophthalmopathy]. / Rasprostranennost' i klinicheskoe znachenie aktivnoi tsitomegalovirusnoi infektsii u bol'nykh s oftal'mopatologiei vospalitel'nogo kharaktera.

A total of 374 patients with different inflammatory diseases of the eyes were examined (227 children and 147 adults). For detecting active cytomegalovirus (CMV) infection, sera were tested for antibodies to nonstructural intact CMV proteins. Antibodies were detected in 26 of 147 adults (17.7%) and 15 of 227 children (6.6%). Difference in the frequency of detection of active CMV infection in adults and children is statistically significant (p < 0.01). Three groups of patients with active CMV were distinguished: children with congenital diseases, immunocompromised patients, and the most numerous group of patients with isolated ocular diseases without manifest signs of immunodepression. In this latter group active CMV was detected in patients with different clinical diagnoses, including ophthalmic herpes. Russian commercial enzyme immunoassay kit CMV-Control proved to be a highly sensitive, simple, and cheap test for the diagnosis of exacerbations of chronic CMV infection.

[Cytomegalovirus infection in children with endogenous uveitis]. / Tsitomegalovirusnaia infektsiia u detei s éndogennymi uveitami.

A total of 405 children aged 3 months to 15 years with uveitis of different origin and localization and 50 mothers of children with intrauterine uveitis were tested for cytomegaloviruses (CMV). Chronic CMV infection was detected in 79% children and 88% mothers. Active CMV infection was diagnosed in 7.1% children with various clinical forms of uveitis; it was somewhat more frequent in cases with grave posterior uveitis and panuveitis complicated by detachment of the retina and vitreous fibrosis. Anti-CMV IgG antibodies indicate an infection, but their detection is insufficient for identifying the etiology of uveitis. Active CMV infection can be a cause of uveitis or aggravate uveitis of another etiology and favor the development of postoperative complications. In many cases active CMV infection was detected in children during remission without clinical signs of uveitis activity. Individual analysis of clinical laboratory data is needed for each patient in order to evaluate the etiological and pathogenetic role of active CMV infection.

[Results of optic reconstructive interventions in children with ocular injuries]. / Rezul'taty optiko-rekonstruktivnykh vmeshatel'stv pri travmakh glaza u detei.

Optic reconstructive interventions were carried out in 36 children with ocular injuries aged 3-14 years. Perforating keratoplasty was combined with measures aimed at repair of the normal anatomic status of the eye and the transparency of its optic media. Microsurgical interventions were performed for penetrating corneal wounds in 27 cases, for penetrating corneoscleral injuries in 8, and for eye contusion in 1 case. The patients were followed up for 1 year after surgery. Taking in of donor cornea, time course of visual acuity, intra- and postoperative complications, and the risk factors of the graft failure were evaluated. Transparent healing of donor cornea was observed after 1 month in 94% cases and after 1 year in 60%. In the immediate postoperative period, vision improved in 32 patients, deteriorated in 1, and did not change in 3 patients. In 56% children visual acuity with correction of 0.05 diopters and higher was attained, while before the intervention the predominant (in 80% children) variant was pr. certae. Among the complications, the most incident were graft rejection crises and secondary glaucoma liable to conservative therapy. Vitreoretinal injury is one of the unfavorable factors fraught with the graft failure. Hence, perforating keratoplasty is an effective and obligatory surgical procedure ensuring sufficient visual rehabilitation in the majority of children with severe ocular injuries.

[Enteroviral persistence in eye infections in monkeys (postuveitis syndrome)]. / Enterovirusnaia persistentnaia infektsiia glaza u obez'ian (postuveitnyi sindrom).

Follow-up (5.5 years) of monkeys with a history of acute enterovirus uveitis (AEU) after intraocular infection with ophthalmotropic ECHO 11 and ECHO 19 strains showed progressive changes in the infected eye; destruction of the iris, formation of films in the anterior chamber of the eye, deformation of the pupil, and signs of cataract and glaucoma. A short (1-30 days) stage of active reproduction of infective virus (up to 10(10) TCD50/g tissue in the first days postinfection) was followed by the second very long stage of limited specific multiplication of virus in ocular tissues. The virus was not detected during the second stage, but its components (virusspecific antigen and crystalloid accumulations of virions) were found in ophthalmic and conjunctival tissues; moreover, high levels of neutralizing antibodies were detected in the blood. The results indicate AEU transformed into a stubborn persistent infection of the eye in monkeys. The findings of this follow-up and published reports about many-year follow-up of children with AEU permit us to classify a post-uveitis disease as a special nosological form of a persistent enterovirus infection and denote it as enterovirus post-uveitis syndrome. The main signs of this syndrome are a history of AEU, progressive destructive changes in the anterior segment of the eye, presence of virus components in ocular tissues in remote periods after infection, and high antibody level in the blood.