Fuchs' heterochromic cyclitis. Clinico-histopathologic findings of nodular iritis

BACKGROUND: Despite the fact that in 1906 Fuchs described the first case of Fuchs' heterochromic cyclitis histopathologic reports of this disease are still rare. PATIENT AND METHODS: A clinicopathologic correlation of findings in Fuchs' heterochromic cyclitis is presented. In a patient with a history of Fuchs' heterochromic cyclitis for 15 years a secondary open-angle glaucoma developed. Several operations were performed including intracapsular cataract extraction, goniotrephanation (Elliot) and repeated cyclocryotherapy. The eye finally had to be enucleated because of a painful absolute glaucoma. RESULTS: Clinical hallmarks of Fuchs' heterochromic cyclitis in this patient include cataract formation and secondary open-angle glaucoma. Histology revealed accumulations of mononuclear cells on the surface of the iris and the corneal endothelium, as well as sparse inflammatory cells within the anterior chamber. The trabecular meshwork showed an infiltration of mononuclear inflammatory cells, chiefly lymphocytes and plasma cells. DISCUSSION: Accumulations of mononuclear cells on the surface of the iris, which histopathologically have not been described before, could represent the clinicopathologic correlate of Koeppe and Busacca nodules. Histologically, the cell deposits on the iris were similar to those in the anterior chamber and to larger corneal precipitates. It is supposed that the cells, which originally emigrated from the iris vessels, may form primary cell deposits on the iris surface or endothelium. Such iris precipitates may also be secondarily attracted by the endothelium in whole. An autoimmune-reaction against the corneal endothelium may be the underlying reason.     

Treatment of persistent glaucoma secondary to periocular corticosteroids

PURPOSE: To describe two patients with uveitis who developed increased intraocular pressure that was unresponsive to maximum medical therapy eight and 13 months after periocular injection of triamcinolone acetonide. METHODS: Excised periocular tissue was analyzed for corticosteroid activity by gas chromatography and mass spectrometry. RESULTS: Excision of the periocular tissue, which contained visible triamcinolone acetonide, resulted in a normal intraocular pressure within 14 days in both patients. Analysis of the excised tissue disclosed residual corticosteroid in one of the two patients. CONCLUSION: Removal of periocular tissue containing injected corticosteroids may facilitate the management of patients developing increased intraocular pressure unresponsive to maximum medical therapy.     

Trabeculectomy and postoperative ocular hypertension in secondary angle-closure glaucoma

I performed trabeculectomies to reduce the introacular pressure to 20 mm Hg or lower, in 56 eyes with medically uncontrollable primary open-angle glaucoma or secondary angle-closure glaucoma. In the former group, I achieved success in 85% of cases, 65% without further antiglaucomatous therapy. In the latter group, 59% obtained a successful result, 41% without additional treatment. The readings of applanation tonometry on the first postsurgical day were compared to those obtained after one year. Although approximately 50% of eyes in both glaucoma categories had an initially elevated pressure after trabeculectomy, it decreased steadily in most of those with primary open-angle glaucoma. In the secondary angle closure glaucoma population, this immediate postoperative ocular hypertension was significantly correlated with eventual failure of the operation.     

Etiology of secondary glaucoma at university clinics in Munich and Nairobi

Glaucoma is one of the most common blinding diseases worldwide. For early detection and treatment of this insidious ailment investigations of risk factors are necessary, most of which require extensive technically demanding and time consuming procedures. Basic information on risk factors for the development of glaucomatous damage is essential for diagnosis of glaucoma, for the identification of groups at risk, and for the planning of prevention and intervention programs. Epidemiological data on secondary glaucomas is especially scarce, while at the same time the strict distinction between primary and secondary glaucomas has been abandoned with changing pathophysiological rationale. We compared the distribution of the main causes of secondary glaucomas in the university eye clinics in Munich and Nairobi, with the aim of finding possible risk factors and obtaining basic information that might be used in preventive programs. We examined 150 patients in Munich and 132 in Nairobi in 1991 and 1992. In addition to tests of visual acuity and intraocular pressure, gonioscopy, ophthalmoscopic assessment of the optic disc and perimetry were performed. Eyes with intraocular pressures above 22 mmHg and a detectable causative condition were selected for the study. The average age of the patients in Munich was 65 years, and most of them presented with glaucoma caused by iris neovascularization (42%), followed by exfoliation syndrome (14%), intraocular inflammation (11%), trauma (10%) and preceding ocular surgery (9%). In Kenya patients were significantly younger, with an average age of 41 years. Here most glaucomas were posttraumatic (40%); 70% of these patients were aged under 30. Other causes were earlier operations (17%), inflammation (16%), lentogenous changes (10%) and neovascularizations (10%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Treatment and prognosis of hemiballismus

Acute hemiballismus due to a cerebrovascular lesion may have a grave prognosis. In the past nine years, we have treated 11 patients who had an acute onset of hemiballismus believed to be the result of an acute vascular lesion with neuroleptic drugs (most frequently haloperidol). None of the 11 died, and the movement disorders were greatly reduced or eliminated. In eight patients the drugs were withdrawn within six months, without recurrence of the movement disorders. Spinal-fluid homovanillic acid levels were increased in three patients, suggesting that altered dopaminergic feedback mechanisms may be involved in the pathophysiology of hemiballismus. Our observations suggest that the prognosis of hemiballismus is not necessarily as grave as has been believed, and that neuroleptic therapy may alter the outcome of this disorder.     

Course and dynamics of immunologic iridocyclitis in the rabbit

1 The catabolism of injected 14 C-putrescine was studied in mice treated with nandrolone phenpropionate, an anabolic steroid. 2 The putrescine was rapidly metabolized; almost 50% of the injected radioactivity was recovered within 2 h as 14 CO2 in the expired air. 3 Considerable amounts of radioactive gamma-aminobutyric acid (GABA) and an unidentified compound were found in the kidney and in the urine in addition to radioactive putrescine, spermidine and spermine both in controls and nandrolone-treated mice. 4 Nandrolone elevated the concentration of endogenous putrescine in the kidney and urine, eightfold and twentyfold, respectively, and the concentrations of spermidine and spermine were also increased 5 after the injection of 14C-putrescine the incorporation of 14C into spermidine was significantly increased in the kidney of mice receiving nandrolone.     

The importance of disc hemorrhage in the prognosis of chronic open angle glaucoma

The progression of field damage of 48 eyes with chronic simple glaucoma and a splinter hemorrhage on the disc was compared with that of 48 chronic simple glaucoma eyes without hemorrhage. The incidence of visual field progression was substantially higher among those with a hemorrhage. Similar visual field progression was substantially higher in 29 eyes with elevated introcular pressure and a disc hemorrhage when compared with 29 ocular hypertensive patients with no hemorrhage. The prognostic importance of a disc hemorrhage is discussed.     

Treatment and prognosis of post-transplant lymphoproliferative disease

Post-transplant lymphoproliferative diseases (PTLDs) are a clinically and morphologically heterogeneous group of lymphoid proliferations. They represent a life-threatening complication of solid organ transplantation. The mechanisms of their pathogenesis are not yet fully understood. A combination of impaired immunity, oncogenic consequences of immunosuppressive therapy and EBV infection may play a role. Studies on incidence, treatment and prognosis are difficult because of the small number of cases occurring at each transplant center and the lack of reliable classification. Overall mortality remains high even though 25% of patients require no other measure than reduction in immunosuppression which must be the first step of treatment. Several treatments are currently used but more adequate classification as well as multicenter studies are urgently needed because many questions remain with regard to therapeutic strategy. Late-onset monoclonal tumors may be treated by conventional chemotherapy, while EBV-positive PTLDs may benefit from other approaches such as antiviral therapies or immunologic modulation of tumor functions.     

Treatment and prognosis of lobar and segmental atelectasis in cystic fibrosis

Studies are presented of the effect of procaine group anesthetics on rat brain synaptosome stability to dodecyl sulfate and on catalytic properties of the membrane bound alkaline phosphatase. The dose curves of detergent stability are characterized by two maxima, one at 3.10(-4) M for tetracaine, 2.10(-6) M for lidocaine and 5.10(-5) M for procaine; the other being at 10(-3) M for all anesthetics. The curves of Vmax and KM versus procaine concentration to exhibit the minimum at 5.10(-7) M and maximum at 3,2.10(-6) M. Procaine at 5.10(-7) M increases enthalpy and enthropy of membraneous alkaline phosphatase. It is suggested that interactions between anesthetics and centers of high affinity lead to synaptosome structural rearrangements, which affect the properties of membraneous enzymes.     

Diode laser cyclophotocoagulation of secondary glaucoma caused by anterior, necrotizing scleritis

PATIENT: A 60-year-old female patient presented with recurrent anterior, necrotizing scleritis with inflammation and a newly developed secondary glaucoma in the right eye. Anterior uveitis occurred some years before. Severe scleral thinning was circumferentially present and focal scleral ectasia was found. Physical examination revealed no systemic association of scleritis. Immunosuppressive therapy with metotrexate was initiated and control of scleritis achieved. Intraocular pressure elevation persisted and was refractory to glaucoma medication. Diurnal pressure curve showed IOP-values of 40 mm Hg despite the use of systemic carbonic anhydrase inhibitors. Visual acuity was 20/50 in the right and 20/25 in the left eye. METHOD: Diode laser cyclophotocoagulation (Oculight SLx 810 nm, Iris Medical Instruments Inc. California, USA) was performed under general anaesthesia using reduced parameters for application (12 laser spots, 1 second, 1.25 W). No complications occurred during and after laser application. Postoperatively, intraocular pressure was within normal range between 14 and 18 mm Hg. No reactivation of scleritis or uveitis was seen. CONCLUSION: In our experience, diode laser cyclophotocoagulation is effective and safe in treating secondary glaucoma associated with anterior, necrotizing scleritis with inflammation and uveitis using reduced parameters for application.     

Functional results of cataract surgery with implantation in Fuchs'' heterochromic cyclitis

Cataract removal with implantation of an intraocular lens (IOL) was performed in 66 cases of Fuchs' heterochromic cyclitis. After an average postoperative follow-up of 40 months (6 months to 10 years, 81.6% of cases obtained visual acuity superior or equal to 5/10 (16.6% with a final visual acuity of 10/10). Thirty cases were analysed, 27 had satisfactory binocular vision. Two complications explained this limited visual performance: vitreal disorders observed in 45.5% of cases were responsible for visual acuity inferior or equal to 5/10 in 23% of cases, glaucoma observed in 12.1% of cases (3 cases were secondary to cataract surgery), 25% of these patients with glaucoma lost all visual acuity and 62.5% had a high intraocular pression uncontrolled by surgery (5 cases). Other risk factors were less important: loss of transparency of intraocular lens caused by precipitates observed in one case, Irvine-Gass syndrome and retinal detachment observed in one case. The restoration of satisfactory binocular vision justifies the risks of intraocular lens implantation in cases of Fuchs' heterochromic cyclitis.     

Multidrug-resistant tuberculosis. 4. Treatment and prognosis of multidrug-resistant tuberculosis

Mucinous gastric carcinoma is a rare pathologic subtype of gastric adenocarcinoma. Whether the mucin behaves aggressively as in mucinous colorectal carcinoma is still controversial. Most mucinous gastric carcinomas are diagnosed from surgical specimens. The mucinous gastric carcinoma in this case report was discovered preoperatively according to its characteristic presentation. An upper gastrointestinal endoscopic examination showed a round protruding tumor of greater than 4 cm in size on the mid-body of the stomach; it had an uneven, friable and shiny surface. The surface was coated with a sticky layer of mucin-like substance, which persisted even after the aspiration of the gastric juice. Endoscopic ultrasonography (EUS) revealed a large heterogeneous hyperechoic tumor mass, originating from the mucosal and submucosal layers, on the body of the stomach. The mass was covered with a thick layer of hypoechoic amorphous substance. Hence, a mucin-producing tumor was suspected. Subsequent surgical biopsy proved the mass to be a moderately differentiated mucinous adenocarcinoma. This case illustrates the first endoscopic ultrasonographic report of an intraluminal mucin pool as a hypoechoic substance, which is quite different from the hyperechoic presentation of intramural mucin lakes. In preoperative evaluation, EUS is not only important for determining the depth of tumor invasion, but it is also useful in differentiating mucinous gastric carcinoma from nonmucinous gastric carcinoma.     

Treatment and prognosis in a series of primary extranodal lymphomas of the ocular adnexa

BACKGROUND: The aim of this study was to assess clinicopathological characteristics and outcome in a series of primary ocular adnexal lymphomas (POALs). PATIENTS AND METHODS: Nineteen patients with localised (stage IE) POAL were followed for a median of 96 months (24-156). The diagnosis was based on surgical biopsies followed by immunohistochemistry in 16 cases or fine-needle aspiration followed by immunocytophenotypic analysis in three cases. Twelve patients were treated with local radiotherapy (RT), five with chemotherapy (CT), and two refused further therapy after apparently radical tumour removal achieved by the diagnostic excisional biopsy. RESULTS: The histological and immunological pattern was consistent with a diagnosis of MALT-type lymphoma (11 cases), follicular center non-Hodgkin's lymphoma (three cases). a large-cell variant of Burkitt's lymphoma (one case), and large-cell transformed MALT lymphoma (one case). Low-grade lymphoma was diagnosed in the three cases which underwent fine-needle aspiration biopsy. All of the patients achieved and maintained complete remission except for those treated with surgical excision alone (two MALT conjunctival lymphoma cases): one of these relapsed locally, the other experienced the systemic spread of a transformed diffuse large-cell lymphoma and died 72 months after diagnosis. The side effects consisted of two cases of RT-related cataract after 52 and 72 months. CONCLUSIONS: Regardless of histology, prognosis was excellent when surgery plus RT was adopted, and CT seems to be a valid alternative to RT. Surgery alone may be sub-optimal.     

Perimetric motion thresholds are elevated in glaucoma suspects and glaucoma patients

The purpose of this study was to determine if a clinically feasible perimetric motion test utilizing random-dot kinematograms could identify glaucomatous visual field defects. Using a staircase procedure, an automated perimetric motion test and a larger foveally presented target were given to normal (n = 30), glaucoma suspects (n = 31) and primary open-angle glaucoma patients (n = 19). Motion thresholds at specific locations throughout the whole visual field were significantly elevated in glaucoma patients (P < or = 0.001). Perimetric motion testing identified 84.2% of the primary open-angle glaucoma patients and 25.8% of the glaucoma suspects as abnormal. A larger foveal stimulus was unable to distinguish between the different subject groups (P < or = 0.185). Perimetric motion thresholds were significantly correlated with Humphrey standard visual field thresholds in the glaucoma and glaucoma-suspect patients (P < or = 0.0002).     

Treatment of solitary subconjunctival cysts of filtration pad after fistulizing surgery of glaucoma

The clinical picture and cytostatic treatment of solitary subconjunctival cysts of filtration pad after fistula-forming antiglaucoma surgery are described. Twenty-seven eyes with hypertension which developed as a result of subconjunctival cysts formed in the early postoperative period in 7% of patients operated on for open-angle glaucoma. Probable mechanisms of the pathogenesis of the formation of solitary cysts are discussed and 3-staged therapy proposed, including beta-blockers, perforation of the cyst wall by YAG laser, and, in 10% of cases with rigid cysts, microsurgical revision of filtration pad.