Recurrent alpha-fetoprotein secreting Sertoli-Leydig cell tumor of ovary with an unusual presentation.

Alpha-fetoprotein secreting (AFP) Sertoli-Leydig cell tumors of ovary (SLCT) are now identified as a distinct entity among the uncommon group of sex cord tumors of ovary. We report an unusual case of recurrent AFP secreting ovarian tumors and as ileocecal mesenteric cyst in a 25-year-old patient resulting in difficulty in initial diagnosis of AFP producing SLCT. Although six recurrent cases were described out of the 25 reported cases of AFP secreting SLCTs, this patient with an unusual presentation of recurrence is the second case in the literature to the best of our knowledge.

Transpupillary thermotherapy for subfoveal occult choroidal neovascularization: effect on ocular perfusion.

PURPOSE: To perform a descriptive analysis of the effects on ocular blood flow of transpupillary thermotherapy (TTT) for occult subfoveal choroidal neovascular membranes (CNVMs) in age-related macular degeneration (AMD). METHODS: Eleven subjects with occult subfoveal CNVM due to AMD were assessed in a masked fashion by color Doppler imaging (CDI) within 24 hours before, 24 hours after, and 1 month after undergoing TTT. RESULTS: In the posterior ciliary arteries (PCAs), there were no statistically significant changes observed in the peak systolic velocity (PSV), end diastolic velocity (EDV), or resistive index (RI) at 24 hours. At 1 month, the mean EDV decreased 36% (P = 0.0105) and the mean RI increased 3.8% (P = 0.0305) in the nasal PCA. Although there was a similar trend in the temporal PCA, the differences did not reach statistical significance. In the central retinal artery (CRA), the mean PSV decreased 16% (P = 0.0137), and the mean EDV decreased 21% (P = 0.0222) at 24 hours after treatment. There were no statistically significant differences in the CRA blood flow indices at 1 month after treatment. In the ophthalmic artery, there were no statistically significant differences observed in the mean PSV, EDV, or RI at 24 hours or 1 month after treatment. CONCLUSIONS: TTT is associated with transiently decreased volumetric blood flow in the retinal circulation 24 hours after treatment. In the posterior ciliary arteries that supply the choroid, there were no changes observed at 24 hours, but at 1 month, there was a decrease in the mean EDV and an increase in the RI in the nasal and temporal PCAs, reaching statistical significance in the nasal PCA only. This study suggests that TTT could lead to alterations in choroidal blood flow, as assessed by CDI. Further study is warranted.

Multifocal electroretinography in multifocal choroiditis and the multiple evanescent white dot syndrome.

PURPOSE: To study and compare the findings on multifocal electroretinography (MERG) between multifocal choroiditis (MFC) and the multiple evanescent white dot syndrome (MEWDS). SUBJECT AND METHODS: Patients were recruited prospectively from the Department of Ophthalmology & Visual Sciences at the University of Iowa Hospitals & Clinics. They were evaluated using Goldmann visual fields (GVF) and MERG. Patients were diagnosed as having either MFC or MEWDS based on their clinical findings before MERG testing. RESULTS: Nineteen patients (23 eyes) were included in the study. Eleven patients were diagnosed with MFC and eight patients with MEWDS. Fourteen eyes with MFC and seven eyes with MEWDS were tested with MERG during the acute phase of their respective conditions. Fourteen patients (8 MFC and 6 MEWDS) were followed serially with MERG. Patients with MEWDS demonstrated focal depression corresponding to GVF defects with subsequent near total recovery of the MERG to baseline. Patients with MFC typically demonstrated diffuse loss of function over the entire test field. Focal scotomata, in addition to the diffuse depression, could be identified in 7 of 14 patients. Patients with MFC demonstrated only partial or no recovery of MERG following acute episodes, which was significantly different from the course followed by patients with MEWDS (P < 0.001, Fisher's exact test). CONCLUSION: Multifocal electroretinography differentiates MFC from MEWDS. Patients with MFC have permanent damage to the retina with diffuse depression of MERG. Patients with MEWDS, however, typically demonstrate greater focal loss initially on MERG followed by nearly full recovery of first order retinal function.

Evaluation of patients with visual field defects following macular hole surgery using multifocal electroretinography.

PURPOSE: To investigate patients with visual field defects following macular hole surgery to determine the cause of such defects, specifically with reference to ischemic damage versus mechanical trauma. METHODS: Five patients with known visual field defects following macular hole surgery were studied with Goldmann perimetry, Humphrey automated perimetry, and multifocal electroretinography (MERG). Three patients returned at a later date for nerve fiber layer analysis. RESULTS: None of the five patients demonstrated evidence of a- or b-wave loss on MERG in the regions corresponding to the visual field defects. Two of three patients studied with the nerve fiber layer analyzer demonstrated significant loss of nerve fiber layer thickness in the quadrant corresponding to the field defect. CONCLUSION: The normal MERG results indicate that the possibility of an arteriolar occlusion as the principal cause for the defects is unlikely in most cases. Data suggest that the site of damage is in the nerve fiber layer, although the specific cause of this damage remains to be determined.

Perfluoro-N-octane (PFO) in the repair of complicated retinal detachments due to severe proliferative diabetic retinopathy.

PURPOSE: To report our experience with perfluoro-N-octane (PFO) in the surgical management of complicated retinal detachments due to proliferative diabetic retinopathy. METHODS: Retrospective review of 18 consecutive eyes of 18 patients with tractional or combined tractional and rhegmatogenous retinal detachments due to severe proliferative diabetic retinopathy managed by pars plana vitrectomy and the intraoperative use of PFO. Preoperative characteristics, intraoperative findings and procedures and postoperative results were recorded. RESULTS: The mean preoperative acuity was 2/200 (range, 20/25 to light perception). The mean final visual acuity was 4/200 (range, 20/20 to no light perception). With a mean follow-up of 6 months, there was an 89% anatomic reattachment rate at the last visit and visual acuity was stable or improved in 72% of eyes. CONCLUSIONS: In our experience, PFO is a helpful surgical adjunct in the anatomic reattachment of tractional or combined tractional and rhegmatogenous diabetic retinal detachments. Visual acuity was stabilized or improved in the majority of eyes.

Hepatocellular carcinoma metastatic to the orbit.

We report a rare case of orbital metastasis from hepatocellular carcinoma and review previously documented cases of this condition. The clinical, histopathological, and immunohistochemical characteristics of hepatocellular carcinoma metastatic to the orbit are described. Results from histopathological examination and histochemical findings of the orbital mass established the diagnosis. A review of 10 cases of metastatic hepatocellular carcinoma to the eye and orbit disclosed painful proptosis as the most common clinical sign of hepatocellular carcinoma metastatic to the orbit. In 5 (56%) of the 9 cases that had orbital metastasis (including the present case), the diagnosis was made after the patient first was examined with symptoms from the orbital mass. Metastatic hepatocellular carcinoma should be considered as a rare cause of painful proptosis. While patients usually are seen with signs and symptoms of widespread metastatic carcinoma, patients with hepatocellular carcinoma with orbital involvement may be first examined by the ophthalmologist because of the clinical manifestations of the disease, proptosis and pain. Other orbital lesions associated with painful proptosis are discussed briefly.

Optimal imaging protocol after intraocular silicone oil tamponade.

PURPOSE: Our purpose was to define the optimal protocol for imaging of the orbits after vitreous humor replacement with silicone oil. METHODS: Eleven eyes in 10 patients with tractional and/or rhegmatogenous retinal detachment were studied. Five CT scans and 18 high-field (1.5 T) MR images were obtained. Standard T1-weighted, T1-weighted with fat and silicone saturation, fast spin density-weighted, and T2-weighted orbital MR sequences were performed. Unique pulse sequences included fast spin density-weighted and T2-weighted imaging with and without fat saturation or silicone saturation, gradient-echo imaging, and short-tau inversion recovery imaging. RESULTS: The T1-weighted MR and CT studies were comparable in displaying the silicone. However, the fat- or silicone-saturated fast T2-weighted sequences always showed the fibrous bands and subretinal fluid to best advantage. In one case, the eye also contained inadvertently retained perfluorocarbon liquid, which blended with silicone oil on both saturated images, requiring companion T1-weighted sequences without saturation to demonstrate its presence. CONCLUSION: Simple, commonly available fat-saturated fast T2-weighted MR images supplemented by standard T1-weighted images are all that are needed to evaluate the eye efficiently after vitrectomy and tamponade.

Computerized videokeratography and keratometry in determining intraocular lens calculations.

PURPOSE: To compare the accuracy of standard keratometry and computerized videokeratography (CVK) in determining intraocular lens (IOL) power calculations. METHODS: Using the EyeSys Corneal Analysis System, we prospectively obtained CVK maps on 75 eyes of 69 patients scheduled to have phacoemulsification with implantation of a posterior chamber intraocular lens. Using manifest refraction obtained at 6 weeks postoperatively, we optimized the calculations for the Hoffer Q, Holladay, and SRK/T formulas for standard keratometric and the following six CVK values: average curvatures at the 1 mm, 2 mm, and 3 mm zones, the keratometric equivalent at the 3 mm zone, and the Stiles-Crawford weighted averages over the 3 mm and 6 mm zones. The accuracy of these parameters was determined by calculating the mean absolute error and percentage of patients with accuracy within < or = 0.5 diopter (D), < or = 1.0 D, and < or = 2.0 D. RESULTS: Keratometrically derived data were slightly more accurate than the CVK-derived values. The average difference in mean absolute error between the keratometric and CVK values was 0.13 D for the Hoffer Q formula, 0.11 D for the Holladay, and 0.08 D for the SRK/T. CONCLUSIONS: In this population of patients, we found the CVK-derived corneal curvature values to be slightly less accurate than standard keratometry in predicting IOL power. However, CVK provides important corneal curvature data for IOL calculations in patients with abnormal or surgically altered corneal surfaces.

Ultrastructural features and prevalence of tubuloreticular structures in the ocular vasculature of patients with AIDS: a study of 23 cases.

BACKGROUND: Tubuloreticular structures (TRS) are subcellular inclusions that are most commonly found in endothelial cells and lymphocytes of patients with autoimmune or collagen vascular disorders. In AIDS, TRS have been described in various tissues throughout the body including the lung, kidney, liver, muscle, and skin. METHODS: Ocular tissues from 23 patients with AIDS were examined by electron microscopy. These included 17 postmortem eyes in addition to three chorioretinal and three conjunctival biopsy specimens. RESULTS: The overall prevalence of TRS in the ocular and conjunctival endothelial cells was found to be 83% (19/23). CONCLUSIONS: This is the first documented study of the prevalence of these structures in the ocular structures of patients with AIDS. Given the high frequency of their occurrence in AIDS, it is recommended that the presence of TRS in ocular or conjunctival tissues be an indication for obtaining an HIV antibody titre. Additionally, a rheumatological examination for HIV seronegative patients is suggested.

MR imaging of the eyelids: normal and pathologic findings.

MR imaging is commonly used to evaluate orbital and facial soft-tissue disease. Although the eyelids are visible on these images, the radiographic appearance and the detailed anatomy of these structures has received little attention in the literature [1-4]. Anatomic correlation with MR images may be extremely helpful in the accurate interpretation and staging of eyelid malignancies and infections.

A pathogenic autoimmune process targeted at a surrogate epitope.

Immunization with the retinal interphotoreceptor retinoid-binding protein (IRBP) induces in a variety of animals an inflammatory eye disease, experimental autoimmune uveoretinitis (EAU). We have previously shown that sequence 1181-1191 of bovine IRBP (BOV 1181-1191) is immunodominant and highly uveitogenic and immunogenic in Lewis rats. Sequence 1181-1191 of the rat IRBP (RAT 1181-1191) differs from BOV 1181-1191 by two residues, at positions 1188 and 1190, that are pivotal for the immunological activity of the bovine epitope. Here we show that, unlike its bovine homologue, RAT 1181-1191 did not induce EAU or an immune response in Lewis rats. The immunological inactivity of RAT 1181-1191 in Lewis rats is due at least in part to its poor affinity toward the antigen-presenting cells of these rats, as shown by its failure to compete with binding of BOV 1181-1191 to Lewis adherent spleen cells. Moreover, unlike all other known autologous homologues of immunopathogenic epitopes, RAT 1181-1191 was not recognized by lymphocytes sensitized against BOV 1181-1191 and failed to stimulate proliferation, uveitogenic capacity or signal transduction in these cells. These findings thus suggest that RAT 1181-1191 is not a likely target for lymphocytes sensitized against BOV 1181-1191 in the process in which these cells recognize IRBP in the rat eye and trigger the inflammatory reaction of EAU. Our data further suggest that the target for the disease-inducing lymphocytes is sequence 273-283 of the rat IRBP: (a) sequence 273-283 is highly conserved and is identical in the bovine and rat proteins; (b) determinant 273-283 is a "repeat" of 1181-1191 in the fourfold structure of IRBP and shares seven residues with BOV 1181-1191; (c) rat peptide 273-283 is recognized by lymphocytes sensitized against BOV 1181-1191 and stimulates them for proliferation and for acquisition of uveitogenicity; and (d) moreover, sequence 273-283 is superior to BOV 1181-1191 in its capacity to generate uveitogenicity in lymphocytes sensitized against this bovine peptide. The present study thus describes for the first time a system in which an autologous homologue of an immunopathogenic epitope is inactive and a "surrogate" determinant apparently serves as the target for lymphocytes sensitized against the immunopathogenic peptide.

Non-cytochrome mediated mitochondrial ATP production in bloodstream form Trypanosoma brucei brucei.

The life cycle of Trypanosoma brucei brucei involves a series of differentiation steps characterized by marked changes in mitochondrial development and function. The bloodstream forms of this parasite completely lack cytochromes and have not been considered to have any Krebs cycle function. It has been suggested that glycolysis is the sole source of ATP in all bloodstream forms. However, earlier results indicated that in the mitochondria of the transitional intermediate/short stumpy bloodstream forms, the biochemical pathways are present that could allow intra-mitochondrial production of ATP. Using a high mannitol buffer to enhance permeability, we confirm previous observations showing that transitional forms maintain motility and respiratory activity with 2-oxoglutarate as the sole substrate. Using a luminometer to measure intracellular ATP levels via the luciferin/luciferase chemiluminescence assay, we show that these same transitional forms, but not long slender forms, maintain high levels of intracellular ATP in the presence of 2-oxoglutarate. Further, in the presence of bongkrekic acid, an inhibitor of the mitochondrial adenine nucleotide translocase, ATP levels are reduced with subsequent death and lysis of the cells when 2-oxoglutarate, but not glucose, is used as sole substrate. These data are direct evidence of ATP production by transitional bloodstream form mitochondria.

[Postoperative anus stricture and leukoplakia lesions]. / Estrechez anal postoperatoria y lesiones leucoplásicas.

We present 35 cases postoperative anal stenosis of patients operated at the Sanatorio y Maternidad del Sur, Bahía Blanca, Argentina, in the last 9 years (1978-1986). In 9 cases (25.7% the pathologist reported leukoplasic lesions from the anus and anal channel. We remark the value of the pathology in these cases and we suggest to send to the pathologist all the tissues from anal surgery, because we believe this is the way to make the best prophylaxis of anal cancer.

Estrechez anal postoperatoria y lesiones leucoplásicas. / [Postoperative anus stricture and leukoplakia lesions]

We present 35 cases postoperative anal stenosis of patients operated at the Sanatorio y Maternidad del Sur, Bahía Blanca, Argentina, in the last 9 years (1978-1986). In 9 cases (25.7

the pathologist reported leukoplasic lesions from the anus and anal channel. We remark the value of the pathology in these cases and we suggest to send to the pathologist all the tissues from anal surgery, because we believe this is the way to make the best prophylaxis of anal cancer.

Plans support energy management.

A look at how three local Blue Cross and Blue Shield Plans have developed energy management programs illustrates certain similarities and differences based on the local environment.

Assessment of drug intervention on the ischemic myocardium: serial imaging and measurement with computerized tomography.

Computerized tomography was evaluated as a technique for imaging and measuring the effect of an intervention on acutely ischemic myocardium. Because cell edema occurs with acute myocardial ischemia and decreases the X-ray attenuation coefficients (tissue density) of myocardium, computerized tomographic images were used to quantitate the effect of hyperosmotic mannitol on ischemia-induced edema. Canine hearts were arrested and scanned after (1) temporary occlusion of the proximal circumflex artery followed by reflow of blood, or (2) continued occlusion of the distal left anterior descending coronary artery. X-ray attenuation values (Hounsfield units) were linearly related to tissue wet/dry weight ratios (r = 0.87, P less than 0.001). After 2 hours of occlusion of the left anterior descending coronary artery the hearts that received mannitol manifested a significant reduction (P less than 0.05) in the volume of left ventricular wall involved with edema. Although the area of edema measured with computerized tomography tended to be smaller in the hearts treated with mannitol than in untreated hearts subjected to a 6 hour occlusion of the left anterior descending coronary artery, the size of the lesion was variable and did not differ significantly from that in untreated hearts. With either short periods of circumflex arterial occlusion followed by blood reflow or with 2 or 6 hours of prolonged occlusion of the left anterior descending coronary artery, the difference in mean attenuation coefficients between the ischemic and nonischemic areas of myocardium in mannitol-treated and untreated hearts was significantly less. These results indicate that computerized tomography in the arrested heart can detect and quantitate the lesion of early acute myocardial ischemia and can quantitate the effect of drug intervention.

Right and left ventricular volumes and wall measurements: determination by computed tomography in arrested canine hearts.

Computed tomographic (CT) images of in vitro hearts filled with iodinated contrast medium have delineated right and left ventricular cavities, papillary muscles, major trabeculae, pulmonary artery, and the aorta. Because of relatively good structural definition, this study was undertaken to determine the potential use of CT in the measurement of cardiac dimensions and cavity volumes. Ten isolated arrested canine hearts were filled with an iodinated oil-paraffin mixture and scanned transversely from base to apex. Measurements of the thickness of the interventricular septum and of the left ventricular posterior wall (indexes of cardiac hypertrophy) had a high degree of correlation to similar measurements of corresponding heart specimens. Using serial tomographic images, the cavity volumes of individual tomographic scans were totaled. The volume of each scan of given thickness was obtained either by the use of planimetry or from a numerical computer printout. Both the planimetric and computer methods gave right and left ventricular volumes which correlated well (P less than .05) with the volumes of paraffin casts. Unlike other techniques widely used for ventricular volume measurement, the method described does not depend on an assumption that the chamber resembles a specific geometric model. This method of volume measurement is applicable to both the left ventricle, regardless of its shape, and to the concave irregularly shaped right ventricle.

Computerized tomography of ischemic myocardium: quantitation of extent and severity of edema in an in vitro canine model.

The capacity of computerized tomography to assess myocardial edema resulting from acute coronary occlusion was investigated in 19 arrested and 2 beating canine hearts. Edematous myocardium was consistently detected as areas of decreased attenuation values. The magnitude of the decrease in attenuation value was linearly related to the severity of the edema. The anatomic definition and tomographic information in the arrested hearts provided the capability for localization and quantitation of the extent of the lesion. The results of these in vitro investigations indicate that CT scanning is a technique which will contribute important pathophysiologic information about the evolution of myocardial ischemia.