Macular translocation--what our patients need to know.

Age-related macular degeneration is the most common cause of rapid and irreversible central vision loss among persons older than 60 years in the United States. Vision loss occurs as a result of choroidal neovascularization in which abnormal blood vessels in the choroid bleed and scar beneath the fovea. If this is caught early, a new approach called macular translocation surgery can be considered. In this procedure, the surgeon moves (translocates) the macula to a healthy area of the retina where it may recover and maintain its function. Moving the fovea allows the surgeon to use laser to destroy the abnormal blood vessels and spare the fovea. As with any procedure, it is important for the patient to have a positive perioperative experience, to be able to report and prevent postoperative complications, arrange follow-up care and transportation, and have realistic expectations of visual outcomes. To this end, a patient education brochure has been developed to ensure a more informed, involved, and satisfied patient. Our topics include: (1) a brief description of macular degeneration, (b) perioperative examinations and procedures, (3) the procedure itself, surgical risks, and postoperative care, (4) appointments for follow-up and laser procedures a few days after surgery, and (5) possible improvements in visual outcomes. Our objectives are to describe macular translocation surgery as it pertains to the management of choroidal neovascularization in age-related macular degeneration and to identify the essential perioperative elements that patients need to know about macular translocation surgery.

Surgical management of subfoveal neovascularization in children.

OBJECTIVE: To report the authors' clinical experience with submacular surgery for subfoveal membranes in children and to evaluate the histopathologic findings of membranes in children with various etiologies of choroidal neovascularization. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Twelve eyes of 12 consecutive children with subfoveal choroidal neovascularization treated by vitrectomy and excision of the choroidal neovascular complex. INTERVENTION: Vitrectomy, excision of the choroidal neovascular complex, and air-fluid exchange. MAIN OUTCOME MEASURES: Visual acuity and recurrence of choroidal neovascular membrane. RESULTS: Preoperative visual acuities ranged from 20/60 to 20/800 (median, 20/300). Postoperative visual acuities ranged from 20/25 to 20/400 (median, 20/80) after an average follow-up of 20 months (range, 7-62 months). Ten of 12 eyes improved from immediate preoperative visual acuity, and four eyes developed recurrence of neovascular membranes over a mean follow-up of 18 months. Histopathologic examination of six excised membranes showed that the most common components of the membranes were retinal pigment epithelium, fibrocytes, vascular endothelium, and collagen. CONCLUSION: Selected eyes of children with subfoveal neovascular membranes and no evidence of membrane regression may benefit from submacular surgery. The histopathologic findings were similar to adult choroidal neovascularization not associated with age-related macular degeneration.

Human diabetic neovascular membranes contain high levels of urokinase and metalloproteinase enzymes.

PURPOSE: Retinal neovascularization is one of the leading causes of blindness. A crucial event in this process is the remodeling and penetration of the capillary basement membrane by migrating endothelial cells. This process requires proteolysis of basement membrane components by a variety of proteinases. The objective of the present study was to determine the expression of proteinases in human retinal tissues showing active neovascularization. METHODS: Epiretinal neovascular membranes surgically removed from patients with proliferative diabetic retinopathy were analyzed by zymography, and the types and amounts of proteinases present in the tissues were determined. Retinas from nondiabetic donor eyes served as control specimens. RESULTS: Both the high- (54 kDa) and low- (33 kDa) molecular-weight forms of urokinase were present at significantly higher levels in neovascular membranes than in normal retinas. The pro forms of the matrix metalloproteinases (MMP) MMP-2 and MMP-9 were significantly elevated in the neovascular membranes in comparison with levels in normal retinas. In addition, the active forms of these enzymes were present in the membranes, whereas there was no detectable level of the active forms in normal retinas. CONCLUSIONS: Human diabetic neovascular membranes contain high levels of urokinase and MMP. The increased activity of proteinases in the final common pathway of retinal neovascularization indicates that inhibition of these enzymes may be a useful therapeutic target as an alternative approach in the management of proliferative retinopathies.

Class III beta-tubulin in human retinal pigment epithelial cells in culture and in epiretinal membranes.

The class III beta-tubulin isotype (beta III) is expressed exclusively by neurons within the normal human retina and is not present in normal retinal pigment epithelial (RPE) cells in situ or in 1 day-old primary cultures; however, beta III is present in RPE cells in 5-day primary cultures and in passaged RPE cells grown in monolayer cultures as determined by immunohistochemistry and Western blotting. beta III-positivity in cultured RPE cells is not affected by cell density or hydroxyurea- or retinoic-acid-mediated growth inhibition, but only a few cells weakly express beta III in cyclohexamide-treated cultures and RPE cells maintained in serum-free medium fail to produce beta III. When monolayer-cultured RPE cells grown in normal, serum-containing medium, are transferred to irradiated bovine vitreous, beta III is undetectable in most cells. Cultured RPE cells coexpress beta III with keratin and cellular retinaldehyde-binding protein (both RPE cell markers), but not with glial fibrillary acidic protein. Some cultured RPE cells also express neuron-specific (gamma) enolase, which is neuron-associated but not neuron-specific, and occasional cells in confluent or super-confluent cultures contain the 200-kDa neurofilament protein. Retinal glia, fibroblasts, endothelial cells, and smooth muscle cells do not express beta III under the same culture conditions. We have detected beta III in 45 of 56 epiretinal membranes, frequently in cells with a bipolar or dedifferentiated morphology, where its expression coincides with other RPE cell-associated antigens. Cells with morphological features resembling normal RPE cells in epiretinal membranes are usually negative for beta III, but RPE cells appearing to be in the early stages of dedifferentiation express the isotype weakly. Electron microscopic immunocytochemistry localizes beta III to microtubules, ribosomes and cytoplasm. beta III may be a useful marker for recognizing the fraction of RPE cells in epiretinal membranes that are no longer identifiable by morphological criteria or other RPE cell markers. These findings demonstrate that mature human RPE cells have the capacity to express a neuron-associated gene in response to conditions that promote dedifferentiation.

Long-term visual results of children after initially successful vitrectomy for stage V retinopathy of prematurity.

PURPOSE: To assess the effectiveness of vitrectomy for stage V retinopathy of prematurity (ROP) at the authors' institution, 33 patients with ROP who had initially successful total or partial anatomic retinal attachments (51 eyes) were evaluated for visual function and long-term anatomic stability. In addition, this study was an attempt to differentiate levels of visual function in children with very low vision and attendant developmental delays. METHODS: Visual function was assessed before retinal examination by an experienced pediatric vision specialist. The behavioral visual assessment was divided into seven segments with two to five tasks in each segment designed to establish a level of functional vision, ranging from light perception to form identification (and ambulation). The status of the retina was classified by the patient's retinal surgeon. RESULTS: The median follow-up was 61 months, and median age at the time of examination was 68 months. Of 51 eyes treated, form identification was achieved in 5, and all five patients had ambulatory vision. Of 51 eyes, 15 had no light perception, 11 had light perception, 6 could localize light, 10 could follow lights, and 4 were able to detect form. Only one eye in ten children with comparable ROP in each eye underwent surgery, and vision improved in six of ten of the surgical eyes. Redetachment was high, with 35 retinas totally or partially detached and only 13 retinas fully attached 61 months after surgery. CONCLUSION: The visual results are very low and disappointing. Initially successfully attached retinas can detach. There is some evidence that vitrectomized eyes function better than nonvitrectomized eyes. There is also evidence that visual function lower than form identification is useful to these children and that they are able to use their limited vision better than previously though.

Experimental retinal tolerance to emulsified silicone oil.

Vitreous replacement by silicone oil has become increasingly popular in the treatment of severe and complicated retinal detachment. Several studies have suggested that silicone oil may be toxic to the retina or may stimulate periretinal proliferation. To better understand its effects, emulsified or nonemulsified silicone oil was injected into rabbit eyes that had undergone mechanical vitrectomy. Silicone oil was labeled with phthalocyanine blue to aid in histologic localization. Retinal changes were compared by light microscopy at 1, 4, and 12 weeks after intraocular injection. Emulsified silicone oil was found to penetrate the inner retina at 1 week and cause epiretinal membrane formation as early as 4 weeks after injection. Nonemulsified oil produced no histologic changes in the retina. No cytotoxic effects were observed in eyes treated with ether emulsified or nonemulsified silicone oil. It is concluded that emulsified silicone oil can both penetrate the retina and stimulate epiretinal membrane formation in the vitrectomized rabbit eye.

Advanced retinopathy of prematurity. The anatomic and visual results of vitreous surgery.

The anatomic and visual results of vitreous surgery in 140 eyes of 108 children with stage 4 and 5 retinopathy of prematurity (ROP) were reviewed. Macular attachment was achieved in 9 (64%) of 14 eyes with stage 4. In stage 5 eyes, partial posterior attachment was obtained in 38 (31%) of 121 eyes and complete posterior attachment was obtained in 11 eyes (9%). Final visual acuity of fix and follow or greater occurred in 6 (43%) of 14 eyes with stage 4 and in 13 eyes (11%) with stage 5 ROP. Retinal detachment (RD) funnel configurations were classified according to the International Committee on ROP. The funnel type which was wide anteriorly and wide posteriorly had the best anatomic (63%) and visual (19%) success. Reoperation rarely improved visual acuity (4%), although reattachment was possible in 6 (22%) of 27 eyes. All children in this series underwent surgery by 2 years of age. Anatomic and visual success was achieved less often in children who underwent surgery at age 6 months or younger.

Retinopathy of prematurity: approaches to surgical therapy.

Retinopathy of prematurity (ROP) is a vasoproliferative disease with infiltration of the vitreous gel. Contraction of the infiltrate results in traction detachment with typical peripheral trough formation. Cryotherapy inhibits proliferation in the active stages of the disease (Stage 3, 'plus'). With development of traction detachment involving the macula (Stage 4B) encircling buckling procedures should first be tried. Closed vitrectomy is considered when high retinal detachment and opacification by vitreous strands occur. The surgical technique is described. Anatomical (64%) and functional (43%) successes are reasonably high for Stage 4 cases, but disappointing (anatomical 40%, functional 16%) for Stage 5 ROP. Open funnels of detached retina fare better than closed ones. It is probably best to perform surgery not before the cicatricial stage, i.e. six months after birth.

Retinopathy of prematurity. Surgical technique.

Retinal detachment, as the end result of severe retinopathy of prematurity (ROP), continues to account for many cases of blindness. Vitreous surgery can result in retinal reattachment in a significant percentage of these patients. The authors report their current techniques, which are based on improved understanding of the pathoanatomy and experience with more than 100 cases of retinal detachment in ROP treated with vitreous surgery.

Hemichorea-hemiballism and lacunar infarction in the basal ganglia.

We present a case of acute hemichorea-hemiballism associated with lacunar infarct documented by computerized tomography scan in the contralateral putamen and caudate nuclei. The pathoanatomic data of similar cases in the literature are reviewed with reference to the location of the responsible lesions. Acute hemichorea-hemiballism is most frequently caused by lacunar infarcts in the basal ganglia contralateral to the dyskinesia.

Isotope effects in the binding of NADH to equine liver alcohol dehydrogenase.

The isotope effect upon the binding constant of NADH to equine liver alcohol dehydrogenase is determined with a method in which the isotopic ratio is measured concurrently in the free and the bond form of the coenzyme, by use of a propellent-pressurized ultrafiltration apparatus for separation of the two. The value for KH/KD for the binding constants was 1.00 +/- 0.02 at pH 10.3 and 25 degrees C.