A multicentre randomized placebo-controlled double-blind study on the efficacy of Ketotifen in infants with chronic cough or wheeze.

The efficacy of Ketotifen was examined in the treatment of 113 infants between 6 and 36 months of age presenting with a history of cough and/or wheeze in a multicentre randomized placebo-controlled double-blind study. A 4 week no-medication baseline phase preceded the 16 week treatment phase in which infants took 2.5 mL twice daily of either placebo or Ketotifen (0.5 mg) syrup; this was followed by a 4 week wash-out phase. Diary card evaluation was performed by the parent or guardian for the duration of the study and recorded wheeze and cough twice daily as well as medication used. The percentage of symptom-free days decreased significantly in both groups (P < 0.005) with placebo-treated infants experiencing significantly more symptom-free days compared with the Ketotifen group (P < 0.01), although this difference was never more than 10% in any 4 week treatment period. Symptom severity scores and use of beta-agonist medication were also less in the placebo-treated infants but did not reach statistical significance. This study was unable to show a therapeutic advantage of Ketotifen over placebo in this group of infants with chronic cough and/or wheeze and the apparent statistical advantage of placebo is not a clinically relevant finding.

Survival of corneal endothelium in McCarey-Kaufman (M-K) medium subjected to agitation.

Studies were made comparing the corneal endothelium of bisected human corneas; one half of each was mechanically agitated in McCarey-Kaufman (M-K) medium, while the other half remained static in M-K medium for an equal period of time. Scanning electron microscopic (SEM) analysis of the corneal endothelium suggested that the endothelium of the corneas undergoing agitation does not show deterioration in morphology when compared with the non-agitated group. This finding is significant as donor corneas are now being transported in greater numbers.

Progressive corneal endothelial cell changes in anterior segment disease.

We have demonstrated marked changes in the corneal endothelium in some groups of patients with ocular anterior segment disease including chronic cyclitis, both heterochromic and classical, pseudoexfoliation of the lens capsule, and anterior segment pigment dispersal syndrome. The most striking changes occurred in heterochromic cyclitis with reduced endothelial cell counts (p less than 0.01) and altered cellular morphology. In almost all eyes with cyclitis endothelial belbs were seen. In eyes with unilateral pseudoexfoliation of the lens capsule there was a lower endothelial cell count with pleomorphism and polymegathism, the changes being somewhat more marked with raised intraocular pressure (p less than 0.01). In anterior segment pigment dispersal syndrome there was an even smaller reduction in count (p less than 0.05) with mild changes in morphology. Factors producing endothelial cell changes included hypoperfusion of the iris with microneovascularization of the iris stroma, intercellular bleb formation with oedema of the corneal endothelium, and raised intraocular pressure. A normal iris circulation is important to the integrity of the corneal endothelium.

Deep corneal stromal opacities with contact lenses.

Two patients with deep corneal stromal opacities occurring after prolonged contact lens wear are described. The opacities were associated with folds or striae in Descemet's membrane which they overlay. Development of the opacities was associated with ocular discomfort, photophobia, reduced vision and a history of prolonged daily wearing times. Although the corneal endothelial cell counts were within the normal range, the count was reduced in the affected eye in the patient with the unilateral deep stromal opacity and there was mild polymegathism of the endothelial cells. It is possible that the long-term effects of subtle endothelial cell changes may cause a keratopathy with later scarring and opacification. Poor oxygen transmissibility, carbon dioxide build-up, or suction effects by the lens may all be aetiological factors. Early recognition and treatment, particularly with a better fitting lens of high oxygen transmissibility is important, as once developed the opacities regress only slowly and may result in permanent visual impairment.

Interstitial keratitis in untreated latent (late) syphilis.

Untreated latent syphilis with interstitial keratitis is not uncommon in the older age group who may present with refractive problems. It is important to investigate these patients with a full range of serological tests for syphilis to determine whether they have been treated adequately in the past. If there is evidence of untreated latent syphilis, examination of the cerebrospinal fluid is important to exclude asymptomatic neurosyphilis for which intensive systemic therapy in hospital is indicated. If there is no evidence of central nervous system involvement a course of penicillin is still indicated, but may be given on an outpatient basis. This is illustrated by the histories of six patients who presented to The Royal Victorian Eye and Ear Hospital between 1962 and 1979.

Keratoplasty for pseudophakic keratopathy.

Penetrating corneal grafts were performed on 15 eyes with keratopathy due to implantation of iris-supported intraocular lenses, on one eye with keratopathy due to an anterior chamber lens, and one eye with keratopathy due to a posterior chamber lens. A systematic meticulous surgical technique, with a softened eye, the use of a Flieringa ring, anterior vitrectomy and sodium hyaluronate (Healon) have resulted in clear grafts in all except in four eyes. Although most grafts have remained clear, the visual results are poor mainly due to glaucoma and/or maculopathy. Every effort was made to retain the implants and some were repositioned and sutured to the iris. Long-term postoperative follow-up, with good patient compliance and the judicious use of topical corticosteroids and timolol, is essential to maintain clear grafts.

Clinical use of the wide field specular microscope.

The Pocklington (Keeler-Konan) wide field specular microscope has been in use for 18 months at the Corneal Diseases Unit, The Royal Victorian Eye and Ear Hospital, Melbourne. In this study, the microscope has been applied clinically to assess the state of the corneal endothelium and to evaluate comparative endothelial cell density and morphology in certain anterior segment microsurgical procedures. The clinical conditions studied are primary posterior chamber intraocular lens implantation, secondary intraocular lens implantation, intraocular lens exchange, and penetrating keratoplasty.

The granulomatous reaction in herpetic stromal keratitis: immunohistological and ultrastructural findings.

A granulomatous reaction was identified in six corneal buttons obtained from patients with herpetic stromal keratitis. The inflammation, characterized by lymphocytes, plasma cells, macrophages and multinucleate giant cells, was associated with Descemet's membrane in five cases and with a break in Bowman's membrane in one case. The ultrastructural changes were documented by scanning electron microscopy in all cases. Transmission electron microscopy, performed in four cases, failed to disclose the presence of viral inclusions. Immunoperoxidase stains utilizing antibodies to the herpes simplex virus were done on all cases. Positivity (the presence of herpes simplex virus antigen or herpes simplex-like antigen) was detected within epithelium (three cases), within stroma (three cases), and within some inflammatory cells of the granulomatous reaction at Bowman's membrane. Positive staining was not detected in cells of the granulomatous reaction at Descemet's membrane. These results suggest that the reaction at Descemet's membrane, which has been found in a variety of corneal conditions, may be due to a poorly understood alteration in the antigenicity of Descemet's membrane.

Relocation of posterior corneal rings in clinical wide field specular microscopy.

A clinical study of posterior corneal rings in human eyes was undertaken using the Pocklington (Keeler-Konan) contact wide field specular microscope designed by Sherrard. The method used to reproduce identical posterior corneal rings in the same human cornea, in vivo, using the contact wide field specular microscope camera, without the aid of a contact lens, is described. The technique enables the clinician to relocate and evaluate a selected area of human endothelial cells in the same eye.

Clinical specular microscopy: the Australian experience.

It is almost one year since the Corneal Diseases Unit of The Royal Victorian Eye and Ear Hospital began preliminary evaluation of the Pocklington Keeler-Konan Wide-Field Specular Microscope. With this instrument, approximately one square millimetre of living human corneal endothelial cells can be observed and photographed. This relatively large area gives a far more valid assessment of endothelial cell morphology and numbers than was possible with narrow field instruments. Reproducible lines enable the relocalization of the same area of endothelium. Observations of endothelial cells have been made in health and disease, including eyes with corneal dystrophy, following cataract surgery with and without intraocular lens implantation, corneal grafting, and after the use of Healon in the anterior chamber.

Ocular rigidity and intraocular pressure in keratoconus.

Eighty-five patients with keratoconus and 20 normal controls were studied. Ocular rigidity, calculated using the Friedenwald nomogram, correlated with corneal thinning (p less than 0.001) and area of cone (p = 0.05). Schiøtz pressures with increasing weights fell more than normal in Grades 0 to 3 keratoconus, but returned to normal following corneal grafting, as did ocular rigidity. Goldmann applanation pressures were low over the apex of the cone, varying most in eyes with lowest ocular rigidity and with greatest corneal thinning, but also in large sagging cones which had only minimal corneal thinning. Pressures by Mackay-Marg tonometry were normal in keratoconus. The axial length of eyes with keratoconus even after corneal grafting was longer than normal and correlated with myopia. It is concluded that abnormalities of ocular rigidity, Schiøtz and Goldmann pressures in keratoconus are determined by abnormal corneal rigidity. If corneal rigidity is low or corneal thinning is present, Goldmann applanation pressures are falsely low and Mackay-Marg tonometry more closely approximates the true intraocular pressure. The cone develops by stretching with limited loss of tissue and the lower rigidity and reduced apical stress decrease the likelihood of rupture.

Retrospective study of alkali burns of the eye.

This report examines the epidemiology, management and morbidity of 159 cases of alkali burns of the eye admitted to The Royal Victorian Eye and Ear Hospital from 1972 to 1981. It was intended to use this as a basis for future accurate assessment and management of this problem. Grading of burns on information provided within the histories was according to Hughes' classification as modified by Ballen. Aspects examined were type of alkali, nature of accident, treatment, complications and follow-up. Results showed that the majority of burns were grade 1 or 2; only a few grade 1 and slightly more grade 2 burn patients suffered any complications, and none of these resulted in loss of vision. All patients with grade 3 and 4 burns suffered severe complications. It would appear that grade 3 and 4 burns need a more specific and energetic plan of treatment. Lime was the most common agent, and the largest group involved comprised male workers who suffered injuries at work. On the basis of the findings of the study the following points are raised: (i) a protocol for future study is suggested; (ii) there is a need for a more discriminate use of EDTA; (iii) do grade 1 burns require hospital admission?; (iv) treatment of grade 3 and 4 burns is still unsatisfactory; (v) the public must be made aware of the existing dangers of alkali burns and their prevention.

Adeno-viral kerato conjunctivitis.

In summer, 1976 an epidemic of Kerato Conjunctivitis commenced in Melbourne, Australia. A total of 422 patients was studied in the adeno-viral clinic at the Royal Victorian Eye and Ear Hospital, Melbourne, from 1976 to 1979. Most patients were referred from the Casualty Department of the hospital, but others came from private practice. A total of 72 cases were adeno-viral with positive cultures. Types 8 and 19 predominated, but sporadic cases of types 1, 3, 4 and 7 were also isolated. Herpes Simplex type 1 was positive in 13 patients. The hospital staff were involved in spread of adeno-virus type 8. Six patients contracted Kerato-Conjunctivitis following removal of corneal foreign bodies from the casualty ward, and several patients contracted epidemic Kerato-Conjunctivitis after beta-irradiation post-pterygium surgery. These latter two methods of infection have not been reported before. Treatment and prevention is discussed.