Failure to obtain follow-up testing for gestational diabetic patients in a rural population.

OBJECTIVE: To determine physician and patient compliance rates for diabetes testing in patients with previous gestational diabetes. METHODS: Questionnaires regarding follow-up testing and personal health history were sent to 66 patients with previous gestational diabetes who did not have diabetes when they participated in a follow-up study conducted 5 years earlier. A 2-hour glucose tolerance test (GTT) was offered to those whose last test was done more than 1 year previously. RESULTS: All 66 individuals returned the questionnaire and 20 (30.3%) reported having received a yearly 2-hour GTT. Of the remaining 46, 19 had been tested at least once in the previous 5 years, but 27 had not been tested. Of the patients who had been tested at least once in the 5-year period, their physicians initiated testing 61.5% of the time and the patients initiated the remainder. There were no significant differences between physician specialty and rate or appropriateness of the testing. Of 39 individuals who had been tested at least once in the 5-year period, eight had diabetes and four were glucose intolerant. Of 12 individuals who had not been tested in the past year and agreed to be tested in 1995, four had diabetes and two had glucose intolerance. CONCLUSION: Although physicians and their gestational diabetic patients knew the risks of diabetes development, compliance with follow-up testing was poor and the risk of developing diabetes high.

A method for performing full-thickness, orthotopic, penetrating keratoplasty in the mouse.

In an attempt to overcome the lack of well characterized, inbred, and congenic strains, as well as a paucity of immunological reagents, in rabbit and rat models, we have developed a procedure for performing full-thickness, penetrating keratoplasty in the mouse. One hundred percent of isografts (BALB/c onto BALB/c) were successful, while 83.3% of allografts (C3H onto BALB/c) failed. The use of a mouse model to study corneal graft failure will allow a critical evaluation of the role of a variety of immunological mediators in causing graft failure.

Intracameral injection of allogeneic lymphocytes enhances corneal graft survival.

Failure of corneal grafts is thought to involve the development and activation of specifically sensitized T-cells. One method which might be used to circumvent the development of such cells is the phenomenon of anterior chamber-associated immune deviation (ACAID). Injection of antigen into the anterior chamber of the eye leads to an immune response characterized by normal antibody response coupled with depressed T-cell reactivity especially as measured by delayed-type hypersensitivity. To determine if this phenomenon could be used to alter the course of graft failure, potential recipients (Lewis rats) were injected intracamerally (IC) with allogeneic lymphoid cells (Wistar-Furth). Orthotopic, full-thickness, penetrating keratoplasty was done 0-30 days later, and the recipients were observed for at least 60 days. Approximately 75% of Wistar-Furth corneal grafts placed on uninjected Lewis rats failed as evidenced by continued opacity, edema, and infiltration of mononuclear cells into the grafts. The IC injection of Wistar-Furth lymphocytes decreased this failure rate to 25% and 50% when grafting was done 14 and 7 days after injection, respectively. Grafts of cornea from a third strain onto IC injected animals failed at an intermediate rate which demonstrated some immunologic protection. The results of these studies indicate that IC injection of allogeneic lymphocytes results in prolonged acceptance of corneal grafts syngeneic with the injected lymphocytes.

Vogt-Koyanagi-Harada syndrome and pregnancy.

Two black women had bilateral anterior and posterior uveitis, nonrhegmatogenous retinal detachments, pleocytosis, headaches, dysacousis, and alopecia. These patients with Vogt-Koyanagi-Harada (VKH) syndrome improved clinically while they were pregnant after the discontinuation of corticosteroid treatment. They developed recurrent symptoms and findings after termination of their pregnancies. We speculate that changes in immunity and humoral constituents during pregnancy account for their remissions. It is important to assess the menstrual history and to avoid pregnancy before initiating steroid treatment for VKH syndrome.

Retinochoroidal coloboma: varieties of clinical presentations.

Several presentation and associated clinical problems can be seen with retinochoroidal colobomas. We review five cases of retinochoroidal coloboma with no specific clinical problems and present five cases with clinical visual impairment. The five symptomatic cases include: one with extensive bilateral involvement; one with associated rhegmatogenous detachment and peripheral tears; one with retinal detachment and apparent holes in the intercalary membrane; one with subretinal neovascularization; and a case with diabetic retinopathy, optic nerve coloboma, and peripheral retinochoroidal coloboma in one eye and a total coloboma in the other eye.

Pseudotumor cerebri and macular disease.

The most common indications for treatment of patients with pseudotumor cerebri are the presence of severe intractable headaches and evidence of optic neuropathy. The role of the ophthalmologist in following patients with pseudotumor cerebri has been to document optic nerve dysfunction in terms of visual field abnormalities or loss of visual acuity. Macular changes have been described in association with papilledema. A case of pseudotumor cerebri and associated macular disease is reviewed to call attention to the need for the ophthalmologist to differentiate between visual loss secondary to optic neuropathy from that of macular disease. The case illustrates how quickly macular disease can develop. The management of patients with pseudotumor cerebri is discussed.

Laser treatment of toxoplasmosis.

Medical treatment of toxoplasmosis may not be effective always, or toxicities may preclude further use of medications. In this situation, laser photocoagulation may be considered. Three cases of toxoplasmosis were treated with krypton/argon laser photocoagulation. One case required retreatment. All remained quiescent after treatment.

Endolaser photocoagulation of toxoplasmosis.

Traditional medical treatment regimens for toxoplasmosis using such agents as sulfadiazine, clindamycin, pyrimethamine, and prednisone may not be effective always. Alternative methods of treatment such as diathermy and cryotherapy have been advocated. Photocoagulation has been used with some effect. In advanced cases vitreous opacification may preclude external photocoagulation technique. Two cases are presented in which vitrectomy and endolaser photocoagulation techniques were used. Endolaser treatment may be done in situations where vitreous opacification may preclude other methods.

Sarcoidosis and peripheral neovascularization.

Twenty-eight patients with sarcoidosis were examined. Four of the patients had a history of uveitis. Retinal periphlebitis was noted in one case, and peripheral retinal neovascularization was found in two non-sickle cell black patients. Vitreous hemorrhage developed in one of the patients with neovascularization, prior to laser treatment and this patient eventually required vitreous surgery. The other patient was treated with prophylactic laser. Peripheral retinal neovascularization may be a noteworthy finding that will be found in larger numbers with attention to the retinal periphery in cases of sarcoidosis.

Diffuse malignant change in a ciliochoroidal melanocytoma in a patient of mixed racial background.

A 69-year-old man of mixed racial background was discovered to have a large, deeply pigmented mass in his left eye with a history of rapid growth during the previous 6 months. The eye was enucleated, and histopathological examination revealed an epithelioid malignant melanoma arising from a melanocytoma.

Toxicity of intravitreal injection of fluconazole in the rabbit.

Fluconazole is a new bis-triazole derivative proven highly effective against Candida in various animal models. To determine its potential use in exogenous fungal endophthalmitis, 13 New Zealand white rabbits were given intravitreal injections of up to 100 micrograms/0.1 mL of the antifungal. All eyes underwent biomicroscopy, ophthalmoscopy and electroretinography before and after the procedure. No evidence of toxic intraocular effects was detected with these techniques or on light microscopy, performed 8 days after injection. The results suggest that fluconazole has potential application in the treatment of exogenous fungal endophthalmitis.

Laser treatment of a subretinal neovascular membrane associated with retinochoroidal coloboma.

Subretinal neovascularization associated with retinochoroidal coloboma is a rare finding. Only two other cases have been reported in the literature, neither of which were treated with photocoagulation. Here, the author reports a case of subretinal neovascular net associated with a retinochoroidal coloboma, which was treated with laser photocoagulation. The patient's vision improved from 20/200 to 20/30-1 following two argon green laser treatments, with a 33-month follow-up since the initial treatment.

An unusual case of retinoschisis and retinal detachment.

An unusual case of retinoschisis and associated retinal detachment in a 61-year-old man is reported. The case involved a retinoschisis area with 22 outer-layer retinal holes and two inner-layer retinal holes in the superior nasal quadrant of the left eye. The retinal detachment extended posteriorly beyond the schisis area. The patient's condition was managed with a combination of cryotherapy and a scleral buckle. Postoperatively, the did well despite the presence of a choroidal detachment that resolved in one month. Cases previously reported have not precisely listed the number of retinal holes. This case is unusual in that there are an unusually large number of retinal holes.

Ophthalmomyiasis.

Ophthalmomyiasis refers to the invasion of the eye by the larval form of the Diptera order fly. The cases reported to date have often displayed rather typical subretinal migratory tracks that are hypopigmented but show hyperfluorescence with angiography. A 37-year-old soldier had been entirely asymptomatic but displayed unilateral subretinal migratory tracks with areas of pigment clumping in the periphery.

Keratoconus following contact lens wear.

While it can be stated that cases such as ours are examples of simultaneous development of keratoconus are otherwise predisposed individual rather than direct results of contact lens wear, it is still a disturbing development. Although inheritance patterns are vague if existent in keratoconus patients, it might fall on the ophthalmologist to prove that lens wear was not associated with the problem in a legal forum. With increasing attention to medicolegal problems, the burden of careful and reasonably close follow-up cannot be ignored in contact lens patients.

Congenital anophthalmos. Problems in management.

The management of congenital anophthalmos is difficult under the best of circumstances. Therapy is directed towards enlargement of the sorbet by expansion and/or surgical techniques. Early expansion therapy within the first year of life appears to be warranted in view of the differential orbital growth rates.

Corneal foreign bodies of coconut origin.

Corneal foreign bodies of varied nature have been reported, however, vegetable foreign bodies in the cornea have seldom been described. A case is reported of a male from the Marshall Islands in the Pacific who retained a number of deep corneal foreign bodies after being struck in the eye by a piece of a coconut shell. The foreign bodies caused considerable inflammation which ceased after they were exposed and removed by means of a centrally based lamellar corneal flap. The patient's eye has remained quiet for 4 months following removal of the foreign bodies.