Clinical, pathologic, and biochemical features of a cholesterol lipidosis accompanied by hyperlipidemia and xanthomas. We describe the unique clinical and histopathologic features of a child with biochemical and immunocytochemical features of Niemann-Pick disease type C (NPC). Clinically, she was found to have multiple xanthomas of the upper aerodigestive tract with dysphagia and expressive language delay, splenomegaly, bony infarcts, and type IIb hyperlipidemia. Neurologic examination was otherwise normal. Microscopy revealed foam cells in her bone marrow, liver, tongue, tonsils, glottis, and in normal-appearing peritonsillar mucosa. Lipid analysis of a liver biopsy specimen showed a small increase in phospholipids, a twofold increase in sphingomyelin, a fivefold increase in cholesterol, and a marked (25-fold) increase in bis(monoacylglycerol) phosphate. Lysosomal acid hydrolase activities in cultured skin fibroblasts were nondiagnostic. Biochemical and immunocytochemical studies of cultured fibroblasts demonstrated lysosomal accumulation of unesterified LDL-derived cholesterol as well as delayed induction of homeostatic responses to endogenous cholesterol consistent with a diagnosis of NPC. Based upon these observations, we speculate that this patient could have a new phenotypic expression of NPC or represents a new cholesterol lipidosis biochemically resembling NPC. The chance occurrence of two separate lipid disorders seems less likely.


Premature chain termination mutation causing Duchenne muscular dystrophy. We identified a premature chain termination mutation in two brothers with Duchenne muscular dystrophy and correlated the mutation in one of the brothers with immunologic detection of dystrophin in skeletal muscle. Southern and polymerase chain reaction (PCR) studies of genomic DNA from the affected boys showed no major gene rearrangements. However, the noted absence of a HindIII Southern fragment containing the proximal portion of exon 48 led to the identification of a point mutation that creates a new HindIII restriction site in that exon. Exon 48 was amplified by PCR from DNA of the patients and other family members and digested with HindIII to show the mutation in the two boys and also in their mother and maternal grandmother. Direct DNA sequencing demonstrated a cytosine-to-thymine transition at nucleotide 7163 of dystrophin that converts a glutamine codon (CAA) to an ochre chain termination codon (UAA). This mutation predicts a truncated dystrophin missing the distal spectrin-like repeat region, the cysteine-rich domain, and the carboxy terminal. Immunohistochemistry of skeletal muscle from one of the affected boys revealed membrane-localized dystrophin in the majority of fibers detected by anti-dystrophin antibodies against (1) the amino terminal and (2) part of the spectrin-like repeat region; both regions would be present in the truncated dystrophin predicted by the chain termination mutation. This suggests that the carboxy terminal may not be an absolute requirement for dystrophin membrane localization. Very few muscle fibers also showed peripheral immunostaining using anti-dystrophin antibodies against the carboxy terminal, suggesting gene reversion, suppression, or read-through in these rare fibers.


Detection of Duchenne and Becker muscular dystrophy carriers by quantitative multiplex polymerase chain reaction analysis. We developed a method for the detection of Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) carriers. The method is based on the quantitative analysis of the products of standard multiplex polymerase chain reaction (PCR) from 18 different exons of the dystrophin gene, and is designated "QM-PCR." We detected deletions of one or more exons by standard multiplex PCR in DMD/BMD patients in 14 of 18 families examined (77.7%). The same deletions were readily demonstrated by QM-PCR in nine of 14 mothers (64.3%) and in another six of 22 possible carriers in these families. In five families where deletions were detectable in DMD/BMD patients, the mothers did not exhibit any deletions in their peripheral blood (35.7%). We obtained evidence for germinal mosaicism in at least two of these families and confirmed carrier identification by haplotype analysis using CA repeat polymorphisms at the 5' and 3' ends of the dystrophin gene. Furthermore, analysis of 17 coded DNA samples from normal females and obligatory carriers by QM-PCR showed that this technique could directly identify carriers of deletions in any of 18 different exons of the dystrophin gene. Its application in combination with existing techniques is expected to significantly improve the accuracy of carrier diagnosis in many families, and it may also be applicable to families in which pedigree and polymorphism information is insufficient for carrier diagnosis.


Acute hydrocephalus in nonaneurysmal perimesencephalic hemorrhage: evidence of CSF block at the tentorial hiatus. The acute hydrocephalus in patients with nonaneurysmal perimesencephalic hemorrhage suggests an extraventricular obstruction of CSF flow. We studied the occurrence of acute hydrocephalus and the site of cisternal blood in 40 consecutive patients with perimesencephalic hemorrhage. In all 11 patients with hydrocephalus, all perimesencephalic cisterns were filled with blood; this occurred in only five of the 29 patients (17%) without hydrocephalus (p less than 0.0001). We conclude that in the absence of intraventricular blood, filling of all perimesencephalic cisterns with blood is a necessary factor for the development of acute hydrocephalus.


Metabolism of glucurolactone to glucarate in Parkinson's disease. The metabolism of oral glucurolactone to serum D-glucarate by the hepatic cytochrome P450 enzyme system was no different in 20 untreated Parkinson's disease (PD) patients as compared with 20 age- and sex-matched controls. There was no evidence for a deficit in hepatic enzymes in PD.


Phenotypic expression of the myotonic dystrophy gene in monozygotic twins. Phenotypic expression of the myotonic dystrophy (DM) gene is highly variable even within the same family. To investigate the importance of genetic and nongenetic factors on phenotypic variability, we studied phenotypic expression in two DM twin sets with monozygosity confirmed by DNA polymorphism analysis. Our observations suggest that genetic factors are primarily responsible for modulating pleiotropic expression of the DM gene.


Treatment of cerebral aspergillosis after liver transplantation. We report the treatment of cerebral aspergillosis with amphotericin B, flucytosine, surgery, and liposomal amphotericin B (L-AmB) after a liver transplant. The patient died 2 months after cessation of antifungal therapy, as a consequence of multiple-system organ failure. The only relevant postmortem finding in the brain was a small, encapsulated abscess containing hyphae. This case indicates that L-AmB is an effective alternative drug for cerebral aspergillosis.


Nurse practitioners & reimbursement.

Nurse practitioners & reimbursement. Nursing's Agenda for Health Care Reform (1991) embraces primary health care as the focus of a restructured health care system. As part of this reformed system, consumers would access the most cost-effective providers in community-based settings. Removal of financial and regulatory barriers that limit consumer access to providers, such as lack of direct reimbursement by Medicare for nurse practitioners, should be eliminated according to this plan. Senate bills S2103 and S2104 have been recently introduced to the U.S. Senate mandating reimbursement for services provided by nurse practitioners, clinical nurse specialists, nurse midwives, and physician assistants at 97% of physician payment. The aim of this global legislation is to eliminate the current piecemeal mechanisms for nurse practitioner reimbursement and remove financial disincentives. Case examples presented in this article illustrate how obstacles to reimbursement limit access to care for consumers. Quality of care, opportunities for autonomous practice, and control of nursing practice issues have been highlighted as well by the case format. It is intended that these cases would be useful to support changes in patterns of nurse practitioner reimbursement.


Nursing at the grassroots.

Nursing at the grassroots. A new model of what constitutes political activity--recognizing grassroots issue involvement as well as partisan politics as legitimate political activism--offers hope for the prospect of the nursing profession becoming a strong political force in the future. Increasing involvement by nurses in health and environmental issues will be the nurses' means to achieve political strength. After all, it is that unique ethic of compassion, common to all nurses, that distinguishes a great political leader.


The healing web. A transformative model for nursing. Part II. The author and contributors continue the article that began in the February issue of Nursing & Health Care on the Healing Web project, "a collaborative effort of creative spinning and weaving." The purpose of the creative web management is to facilitate the healing of wounds within nursing and between nursing and medicine.


The migrant farmworker: health care challenge. Migrant farmworkers comprise a severely medically underserved population, both nationally and in New Jersey. This article defines the migrant population, reviews their specific health problems, and illustrates the urgent need for the medical community's attention and resources.


Monocyte activation in acquired immunodeficiency syndrome. The monocyte plays a key role in the pathophysiology of AIDS and ARC. This preliminary report adds insight into monocyte activation associated with HIV seroconversion, by comparing recalcification times in healthy controls and HIV-positive patients.


HIV infection in kidney transplant recipients. Four HIV-infected patients received cadaver kidney transplants. A fifth kidney transplant patient acquired infection through a blood transfusion. The course and prognosis of these patients with HIV infection are described and a review of the literature is presented.


CLIA-88 final rule: Part 1.

CLIA-88 final rule: Part 1. The final rules implementing the Clinical Laboratory Improvement Act (CLIA) of 1988 were published. Physicians will see their office laboratories fall under control of the federal government as of September 1, 1992. Physicians need to understand the regulations.


Alcoholism-induced bone necrosis.

Alcoholism-induced bone necrosis. A total of 164 patients with alcoholism-induced osteonecrosis were seen over a 22-year period, from 1962 to 1984. Twenty-three percent of patients were female and 30.5% were black. The average duration of alcohol abuse was 9.5 years, ranging from 8 to 20 years. The presence of femoral head necrosis was diagnosed in patients aged 21-67 years; 28% of patients were under 40 years of age and 76% were under 50 years. Bilateral hip necrosis was present in 44.5% of patients and, within three years of the diagnosis of FHN, the presence of multifocal necrosis became evident in 23 cases at sites away from the hip (shoulders and knees). Hyperlipidemia was found in 38.4% of cases, involving both cholesterol and triglycerides. Serum amylase was elevated in 33 patients; liver dysfunction was present in 50; hepatomegaly was found in 32; and biopsy-confirmed cirrhosis was present in 22 cases. Hyperuricemia was found in 22 patients, some of whom had received steroids. Disabling hip pain was the first manifestation of disability related to alcohol abuse in 158 patients, most of whom required total hip joint replacement. This study supports the hypothesis that alcoholism-induced bone necrosis is caused by fat embolism linked to co-existent hyperlipidemia. The treatment of hyperlipidemia by dietary means or lipotropic medication and the cessation of alcohol abuse is advised. Multi-center studies employing such treatment should provide evidence of its effect on the evolution of necrosis as well as the incidence of bilateral hip femoral head necrosis and multifocal lesions.


Lead screening and follow-up in an urban pediatric clinic. The purpose of this study was to examine screening and follow-up procedures used in testing for lead toxicity at an urban pediatric clinic. A retrospective chart review of all patients with elevated zinc protoporphyrin levels was undertaken. In the first four months of 1990, 66 of 438 patients screened (15.1%) had elevated zinc protoporphyrin levels. Sixty charts were located and reviewed to evaluate five key interventional strategies. Iron therapy was implemented in 31 (51.2%), and follow-up was scheduled in 21 (35.0%). Two exposure histories and two dietary histories were documented (3.3% each). Only 26 children (43.3%) had venous blood drawn for lead-level determination. Eleven patients (18.3%) had none of these five steps documented, and an additional 26 (43.3%) received only one. Fifteen children (25.0%) received two interventions, six (10.0%) received three, and two (3.3%) received four. No patients received all five steps. Better procedures are needed at this site to ensure the implementation and documentation of diagnostic and therapeutic interventions in children with elevated zinc protoporphyrin levels. Other screening programs may benefit from examination for similar methodologic problems.


Double-tracer SPECT in patients with AIDS encephalopathy: a comparison of 123I-IMP with 99Tcm-HMPAO. Single photon emission computed tomography (SPECT) using N-isopropyl-p-(123I)iodoamphetamine (123I-IMP) and 99Tcm-hexamethylpropyleneamine oxime (99Tcm-HMPAO) was performed in 25 patients with different clinical stages of AIDS encephalopathy. The average interval between the two examinations was 7 days. In 15 of the 25 cases (60%) 99Tcm-HMPAO scans were different from 123I-IMP scans. Uptake defects of different extent were observed in 8 of 25 cases (32%), of different extent and different location in 3 of 25 cases (12%) and of identical extent but of different location in 4 of 25 cases (16%). Differences in the uptake patterns of 123I-IMP and 99Tcm-HMPAO with regard to extent and/or location were more commonly shown in patients with early acquired immunodeficiency syndrome (AIDS) encephalopathy (P = 0.0372). In this group, 99Tcm-HMPAO showed uptake defects of greater extent more frequently than did 123I-IMP (P = 0.0156). Our data indicate different brain uptake mechanisms of 123I-IMP and 99Tcm-HMPAO in early and advanced AIDS encephalopathy.


Leg muscle scintigraphy with 99Tcm-MIBI in the assessment of peripheral vascular (arterial) disease. A technique for using 99Tcm-methoxyisobutylisonitrile (MIBI) to evaluate leg muscle perfusion in the assessment of peripheral vascular disease (PVD) is described and evaluated. The uptake of MIBI in muscle groups is quantified and normalized to whole body activity. Eleven patients with PVD undergoing angiography and nine controls were studied. There was a significant difference in MIBI uptake in the calf (P less than 0.000 01) and thigh (P less than 0.0001) between the two groups on exercise. The technique has a sensitivity of 91% and specificity of 94% for the diagnosis of PVD. The technique can also effectively evauate the severity of disease as shown by significant correlations between exercise calf flow and angiographic severity (P less than 0.05) and Doppler ankle/arm pressure measurements (P less than 0.0005). Single photon emission tomography (SPET) of the calves was also performed in five controls and five patients with PVD. Uptake was significantly reduced in all muscle areas in patients with PVD and, amongst those with PVD, uptake was lower in muscle groups by occluded arteries. The potential role of 99Tcm-MIBI in the assessment of PVD and its advantages over other methods of assessment are discussed.


High-resolution cardiac SPET study using fanbeam collimators in infants. High-resolution three-headed single photon emission computed tomography (SPET) equipped with fan-beam collimators was applied to myocardial perfusion imaging in infants aged from 1 to 11 months (n = 5). A tabletop designed specifically for infants was fixed on the SPET couch to reduce the radius of camera rotation to 13.2 cm. Significant improvement in resolution was achieved with the fan-beam collimators compared to parallel-hole high-resolution collimators. With the administration of approximately 37 MBq (26-44 MBq) 201Tl, 5 min acquisition time was possible for SPET imaging, which provided good image quality in all patients. Thus, a smaller administration dose is possible within a practical short acquisition time. High-resolution fan-beam SPET imaging can be a routine diagnostic method for heart disease in newborn babies and infants.


Evaluation of ventricular diastolic function in normal children using equilibrium radionuclide angiography. Twenty children, aged 10.3 +/- 4.5 (3.3 to 17.5) years, were studied by equilibrium radionuclide angiography to establish a normal range for diastolic parameters. Ejection fraction (EF), peak ejection rate (PER) and time to peak ejection rate (TPER), peak filling rate (PFR) and time to peak filling rate (TPFR) were obtained from ventricular time-activity curves and their first derivative curves, and PFR and TPFR were considered as the diastolic parameters. Normal ranges obtained were as follows: EF, 60 +/- 8%; PER, 3.73 +/- 0.70 EDV-1; TPER, 109 +/- 25 ms; PFR, 3.84 +/- 0.51 EDVs-1; TPFR, 136 +/- 21 ms. There were significant correlations between PER and EF (P less than 0.001), PFR and EF (P less than 0.05), while age and heart rate had no influence upon these variables. Such normal ranges will be useful for evaluation of systolic and diastolic function in children with heart disease.


Cell-targeted 114Inm and drug (BCNU) combination therapy in a rat acute lymphoblastic leukaemia. A proportion of syngeneic female rats inoculated intramuscularly with a lethal T-cell lymphoblastic (Roser) leukaemia are cured by a single intraperitoneal injection of bischloroethylnitrosourea (BCNU) (Carmustine) (10 mg kg-1) given towards the end of the preleukaemic phase (day 7). Additional therapy on day 4, using intravenous leukaemia cells lethally labelled with the radionuclide 114Inm, enhanced the overall cure rate by 30%. The spleen is a major site of indium concentration from the targeting cells so that the continuous local radiation field appears to result in a substantial reduction of the body load of leukaemia cells in the enlarged spleen particularly, thus enhancing the curative potential of the drug. The results demonstrate in principle that in patients in remission a single dose of targeted radiotherapy in the spleen combined sequentially with an appropriate drug might provide considerable aid in eliminating a residual population of leukaemia cells.


Antenatal diagnosis of pulmonary sequestration: a review. The prenatal diagnosis of pulmonary sequestration has been demonstrated in 17 published reports, including a new case report presented here. In 11 cases (65 per cent), the definitive diagnosis was not appreciated until after birth, although a fetal mass was recognized on ultrasonographic study in the antenatal period. Seventy-five per cent of cases were thoracic sequestrations, and 25 per cent were abdominal lesions. Fetal hydrops, found in 35 per cent of cases, was universally associated with stillbirth or neonatal death. Polyhydramnios, pleural effusions, mediastinal shifts, pulmonary hypoplasia, and preterm labor were not uncommon findings. The high incidence of related malformations, well described in the postnatal literature, was remarkably absent in this antepartum series. Although the perinatal outcome for abdominal lung sequestrations is reasonably good, the prognosis in cases of thoracic sequestration remains guarded. Aggressive respiratory support after birth will not salvage those infants with underlying severe pulmonary hypoplasia. Early in utero catheter drainage may provide the best treatment for the pleural effusions associated with thoracic sequestrations, although this therapy remains under investigation.


Risk factors for Candida vulvovaginitis. Although Candida vulvovaginitis occurs commonly, the reasons for its occurrence and recurrence are often unclear. Several potential risk factors have been described, including the recent use of antibiotics and oral contraceptives, the presence of diabetes mellitus, dietary practices, gastrointestinal colonization by the organism, clothing and sanitary protection practices, sexual communicability of the organism, and specific immunological defects. However, the data supporting each of these factors are conflicting, and to date none are predictive of infection. In this review, the data evaluating these potential risk factors are described. From this information, implications for clinical practice are discussed.


Lead poisoning.

Lead poisoning. Construction workers who weld, cut or blast structural steel coated with lead-based paint are at significant risk of lead poisoning. Although technology to control these exposures may not have existed when the lead standard was promulgated, it is available today. Employers who do not take steps to protect their employees from lead exposure may be cited and fined severely for their failure.


Intraocular pressure level in glaucomatous and nonglaucomatous eyes after complicated cataract surgery and implantation of an AC-IOL. The effects of a semiflexible, one-piece, open-loop anterior-chamber intraocular lens (AC-IOL) implanted after intracapsular or extracapsular cataract extraction complicated by posterior-capsular or zonular rupture on intraocular pressure (IOP) level and the control of previous glaucoma were studied in 48 eyes with primary implantation and in 10 eyes with secondary implantation. Fifty-four percent of the eyes with primary implantation had exfoliation syndrome; anterior vitrectomy was performed in 60.4%. An immediate pressure rise (IOP greater than or equal to 30 mm Hg) was observed in 29.3% of the eyes. The long-term IOP level (median follow up, 21.5 months) was less than or equal to 20 mm Hg in 83.7% and between 21 and 29 mm Hg in the remaining 16.3%. In three of the nine glaucomatous eyes, the medication had to be increased; in the remaining six, the IOP could be controlled with the previous or reduced medication or with none at all. In three out of the 49 (6.1%) nonglaucomatous eyes, glaucoma medication was started during the follow up. All of these eyes had exfoliation syndrome and two of the fellow eyes had similar IOPs and were receiving similar medication. The results indicate that the semiflexible, open-loop AC-IOL has little effect on IOP and seems to be a safe alternative, even in glaucomatous eyes, if a posterior chamber lens cannot be used.


Direct scleral fixation of posterior chamber intraocular lenses using a special needle-holder. We report a modified technique of direct scleral fixation of a posterior chamber intraocular lens (PC-IOL) using a specially designed intraocular needle-holder. The procedure was carried out in three eyes with posttraumatic subluxated cataracts; one with aphakic bullous keratopathy and with an accidental posterior capsular rent, and one with a superior zonulodialysis. The needle-holder greatly facilitated the procedure, enabling us to place the PC-IOL precisely in the ciliary sulcus with no subsequent decentration. This method avoids iris fixation and provides more secure scleral fixation of the PC-IOL.


Central visual field, visual acuity, and sudden visual loss after glaucoma surgery. The relationship between Snellen visual acuity and central visual field loss as determined by the Humphrey 10-degree test was examined in 96 glaucomatous eyes of 79 patients. The severity of the field defect was determined by the number of affected quadrants, defined as a sensitivity loss of at least 10 decibels from normal at the most central point of 1.4-degree eccentricity. The decrease in median acuity was gradual, one-half line per quadrant for one and two affected quadrants, and an additional one and one-half line to two lines for three and four quadrants. Loss of acuity was disproportionate when both temporal quadrants were affected. The major source of error was difficulty with fixation. One type, a prolonged fixation shift, was not related to short-term fixation losses. There was a significant correlation between acuity and foveal threshold over a wide range of both variables. Sudden visual loss from additional optic nerve damage was studied retrospectively in 96 eyes with advanced glaucoma and a central field defect. A frequency of 3% for any loss of visual acuity and a frequency of 1% for a loss to 20/200 or worse were noted. There were no apparent predictive factors.


The effect of trabeculectomy on corneal topography. Trabeculectomy is increasingly being performed earlier in the treatment of primary open-angle glaucoma (POAG). Surgically-induced alterations in corneal curvature resulting from filtering surgery may have a significant impact on patients, especially younger ones, whose vision may already be compromised by visual-field loss. Using data obtained by computer-assisted topographic analysis performed preoperatively and at 12 weeks postoperatively, we longitudinally studied the corneal surface changes induced by primary trabeculectomy in eight eyes undergoing surgery for POAG or normal-tension glaucoma. Additional data collected included refraction, keratometry, axial length, intraocular pressure, and pachometry. Five of eight eyes developed 1.50 to 2.50 diopters of steepening in the 90-degree meridian. One patient developed flattening in the 180-degree meridian without vertical steepening. Two patients had little change in the central optical zone. Of the six eyes with induced with-the-rule astigmatism, keratometry was less sensitive than topographic analysis in detecting the changes induced by trabeculectomy. Our data indicate that changes in corneal curvature are induced by filtering surgery, but may be undetectable without topographic analysis.


Chronic corneal perforations.

Chronic corneal perforations. We report the etiological profile and management with simple patch, tarsorrhaphies, conjunctival flaps, tissue adhesive, or penetrating keratoplasty of 104 chronic corneal perforations in a North India population. Chronic corneal perforations were observed in infective keratitis, degenerative keratolysis, neurotrophic keratitis, chemical burns, dry eyes, collagen vascular diseases, and following cataract extraction. A two-stage tissue adhesive application and adhesive-assisted debridement of epithelial lining at the cornea surface of perforation were important factors in healing. Although penetrating keratoplasties brought comparable anatomical and functional success in these cases, in developing countries, where facilities for keratoplasty and availability of corneal donor is poor, detection and management of small perforations in diseased cornea with tissue adhesive is recommended.


Concurrent benign teratoid medulloepithelioma and pineoblastoma. Teratoid medulloepithelioma of the ciliary body is a rare tumor usually occurring in young children. Primary tumors of the pineal gland are also quite rare and have a similar age distribution. We report the case of a 2-year-old girl who had a leukocoria of the right eye. Cataract surgery was performed; however, the patient developed a total retinal detachment refractory to treatment. She eventually developed early changes of phthisis bulbi and underwent an evisceration. Histopathologic examination revealed a benign teratoid medulloepithelioma containing islands of hyaline cartilage and rhabdomyoblasts. During the course of her evaluation, a pineoblastoma was discovered and surgically excised. While the association of pineal tumors with retinoblastomas has been well established, no such association has been reported for medulloepitheliomas. To our knowledge, this is the first recorded case of a benign teratoid medulloepithelioma occurring concurrently with a pineoblastoma.


An epidemiologic and pathologic study of globes enucleated following trauma. This retrospective study examined demographic, clinical, and histopathologic factors in 24 traumatically ruptured globes that were enucleated at Wills Eye Hospital during a 2-year period. The majority of these injuries occurred in a violent assault setting with a blunt mechanism, during the evening and early morning hours, and in the fall and winter months. Most patients were black males, and 67% were substance abusers. Clinically, the initial visual acuity in 96% of the eyes was light perception or worse. Five of the eyes were enucleated primarily. Gross examination of the globes revealed that 92% of the wounds involved the sclera, 83% of the eyes had hyphema, and 71% of the lacerations were longer than 10 mm. Histopathologic examination demonstrated that the majority of eyes had fragmented or missing lenses, disrupted ciliary bodies, and detached choroids. Ninety-six percent of the retinas were detached. There was one case of acute endophthalmitis.


Orbicular muscle akinesia: a comparison, using electromyography, of three techniques. Ninety patients scheduled for elective cataract extraction under local anesthesia received an inferolateral intraconal injection of 4 mL of etidocaine mixed with hyaluronidase. They were divided into three groups of 30 patients each according to the method used to provide orbicular akinesia. Those in group I had a nasal, intraorbital injection; those in group II underwent electrostimulation to locate branches of the facial nerve in the eyelids; and those in group III had the anesthetic agent injected subcutaneously into the lids. Ten minutes after the regional blockade, orbicular muscle activity of the upper eyelid, as measured by electromyography, was found to be higher in group I than in the other two groups. The muscular activity of the lower lid at 10 minutes, or of either of the lids at 20 minutes, was similar in all three groups. The use of electrostimulation did not yield better orbicular akinesia than the infiltration technique alone. Nasal injection improved globe akinesia.


The tarsal pillar technique for narrowing and maintenance of the interpalpebral fissure. We describe a tarsorrhaphy technique whereby an ipsilateral upper-eyelid tarsal pillar is sutured to a corresponding lower-eyelid recipient site. This technique allows maintenance of a narrowed interpalpebral fissure indefinitely, yet is easy to reverse without incurring lid-margin damage. Additionally, the procedure can be adjusted postoperatively to either narrow or widen the initial surgical result. We report our combined surgical experience in 35 consecutive procedures using this technique to treat eyes with exposure-related keratopathy of varied etiology, including facial nerve palsies, combined facial nerve palsy and trigeminal neuropathy with an anesthetic cornea, Graves' disease, congenital craniofacial anomalies, and severe keratitis sicca syndrome. The procedure was successful in improving exposure keratopathy symptoms in all 35 cases. Complications, reflecting the authors' learning curve with this new procedure, included intermarginal pyogenic granulomas, stretching of the tarsal pillar, minor lower-eyelid-margin eversion, and tarsal pillar dehiscence.


Intraobserver and interobserver reproducibility of the Nidek EAS-1000 Anterior Eye Segment Analysis System. The NIDEK EAS-1000 is a camera and computer system designed to facilitate measurement and analysis of the anterior segment of the eye. To evaluate the interobserver reproducibility of the system, three examiners assessed the anterior chamber depth and peripheral angle measurement in 20 disease-free eyes. Intraobserver reproducibility was determined by each investigator's photographing and analyzing the same eye on three different occasions. Interobserver correlation for the anterior chamber depth (using the first three readings of the same eye made by each examiner) was 0.97, with an 95% CI of 0.94 to 0.98. Interobserver correlation for angle measurement (again using the first three readings of the same eye made by each examiner) was 0.89, with a 95% confidence interval (CI) of 0.81 to 0.95. Intraobserver correlations for anterior chamber depth were 0.98 for each of the three examiners (mean, 0.98), wiht a 95% CI of 0.91 to 0.99. Intraobserver correlations for anterior chamber depth were 0.98 for each of the three examiners (mean, 0.98), with a 95% CI of 0.91 to 0.99. The intraobserver CI for angle measurement was 0.97 (range, 0.95 to 0.99). The intraobserver and interobserver reproducibility of the NIDEK EAS-1000 system was excellent.


Anterior segment ischemia.

Anterior segment ischemia. I present, to my knowledge for the first time, a case of anterior segment ischemia following a trabeculectomy performed under anesthetic.


Superficial punctate keratopathy and bacterial growth in patients with unilateral aphakia using extended-wear soft contact lenses. We prospectively examined corneal conditions and bacterial growth in 77 individuals with unilateral aphakia who were using extended-wear soft contact lenses. The ratios of positive bacterial growth (70.6-79.4%) from 34 patients with superficial punctate keratopathy were significantly higher than those (41.9-46.5%) from the 43 subjects with normal corneas. Bacterial growth was found frequently in patients with superficial punctate keratopathy who were older than 80 years and in those using soft contact lenses for more than 22 days. Several kinds of bacteria grew from the specimens. Among the most common were Staphylococcus epidermidis and Corynebacterium species. Pseudomonas aeruginosa grew from patients with superficial punctate keratopathy who were using extended-wear soft contact lenses.


Damage to the crystalline lens in infants of diabetic mothers: a pathology so far neglected? Congenital cataract occurs in 90-95% of diabetic rat fetuses. The pathogenetic mechanism is triggered by fetal hyperglycemia and presents the following steps: (1) a high glucose concentration in the lens; (2) reduction of glucose to sorbitol by aldose reductase; (3) accumulation of sorbitol into the fibers of the lens creating a hyperosmotic effect, leading to (4) an infusion of liquid into the fibers, which (5) become hydropic and degenerate (vacuolization). This series of manifestations might also occur in fetuses of pregnant diabetic mothers. Post birth glycemia diminishes rapidly, and this favorable condition which decreases vacuolization is perhaps the reason why such degeneration has not yet been observed. Since the fibers of the lens are permanent cells, damage in the fetal period might later bring about negative consequences. We hope that someone will study whether this ocular pathology occurs in human infants born to diabetic mothers.


Practically corrected visual acuity after extracapsular cataract extraction with or without intraocular lens implantation. We examined retrospectively a total of 171 patients (236 eyes) who had undergone extracapsular cataract extraction (ECCE) with or without intraocular lens implantation (IOL). The best and practically corrected visual acuities were determined 6 months after surgery. Practically corrected visual acuity of the ECCE group was significantly worse than that of ECCE plus IOL group of patients who had undergone unilateral cataract surgery. In patients who had undergone bilateral surgery, visual improvement was almost optimal in both groups. With regard to practically corrected visual acuity, ECCE plus IOL was the preferable procedure for elderly patients who had had unilateral cataract.


Intraocular muscle function in pseudoexfoliation syndrome. Pseudoexfoliation (PE) material has been studied pathologically. However, there are no reports about intraocular muscle function in pseudoexfoliation syndrome (PXS). We studied intraocular muscle function in 12 patients (70.3 +/- 10.1 years of age) with ipsilateral PE material by measuring the time course of pupillary diameter change and accommodogram. Initial intraocular pressure (16.3 +/- 4.2 mmHg) was significantly higher in eyes with PXS than in normal fellow eyes (13.1 +/- 3.5 mmHg). The pupillary diameter of an affected eye was smaller than that of a fellow eye after bilateral topical application of tropicamide. Continuous near-point testing revealed no significant difference; accommodative contractile time, relaxation time, and/or accommodopattern showed different patterns from the fellow eye. The results suggest that intraocular muscle function is disturbed in PXS.


Mortality and morbidity in patients with central retinal vein occlusion. We investigated the risk of mortality and morbidity in 78 patients with central retinal vein occlusion (CRVO) followed for more than 2 years (mean follow-up 7.2 years). Thirteen subjects died at an average of 7.0 years after CRVO. Five subjects developed myocardial infarction at an average of 2.8 years after CRVO, and 1 developed a cerebrovascular accident 3 years after CRVO. Patients with CRVO do not carry a higher risk of mortality and morbidity than matched controls derived from national surveys.


Perimetric testing of tritan deficiency. Three members of a family with dominantly inherited juvenile optic atrophy tested with a computerized perimeter employing violet and blue-green test lights and low-intensity white background, all showed larger reduction in the relative sensitivity to violet light in the more central parts of the visual field compared with the periphery within 30 degrees from the center. Two subjects had typical optic atrophy, centrocecal scotoma and lower than normal visual acuity. In 1 subject with good visual acuity of both eyes, no optic atrophy was observed but there was impairment in the luminosity function (tested with white test object on white background) of the peripheral visual field.


Goniodysgenesis of the eye with arthrogryposis multiplex congenita. We report an autopsy case of 4-day-old male infant with arthrogryposis multiplex congenita studied by histological methods in respect to the ocular tissues. The eye examined was normal in size, and the retina, optic nerve, choroid, sclera and extracocular muscle showed no remarkable histological changes. However, the cornea was thickened, and the iris, trabecular tissue and ciliary body showed maldevelopmental changes, which were all compatible with goniodysgenesis. The clinical data of this case did not demonstrate any signs of congenital glaucoma, but the present study indicates that an infant with arthrogryposis multiplex congenita has a potential for infantile glaucoma with goniodysgenesis.


Spectral response curves of congenital dichromats. In a previous paper I have derived spectral response curves for the foveal cones of the CIE normal observer. These are based on the 1931 mixture data, the Judd 1951 V (lambda) curve, and the absorbance data of the pigments in the human cones. In the present paper I have found that the spectral response curves of congenital dichromats may be assumed to be similar to those of the CIE normal observer.


Corneal exhaustion syndrome with long-term wear of contact lenses. After many years of successful contact lens wear, 3 long-term wearers of polymethyl methacrylate (PMMA) lenses (14, 15, and 18 years) and 1 long-term wearer of thick hydrogel lenses (11 years) suddenly developed intolerance to their lenses. Symptoms included ocular discomfort, reduced vision, and photophobia. All patients exhibited an excessive open-eye edema response with low to moderate Dk lenses. Posterior corneal changes included distortion of the endothelial mosaic and moderate to severe endothelial polymegethism. Patients were successfully refitted with lenses having higher oxygen transmissibility. It is proposed that long-term hypoxia and acidosis accompanying PMMA and thick hydrogel contact lens wear may be responsible for a syndrome characterized by endothelial dysfunction which results in inadequate regulation of corneal hydration and subsequent intolerance to contact lens wear. This condition has been termed Corneal Exhaustion Syndrome (CES).


Vision and task performance with monovision and diffractive bifocal contact lenses. We measured vision and task performance on 26 presbyopes, ages 46 to 65 years, fitted with diffractive bifocal contact lenses (BFCL) and monovision contact lenses (MVCL). Distance contact lenses combined with reading spectacles (DCL) served as the control condition. Twenty subjects completed the 6-week study. All subjects wore BFCL and MVCL daily for a period of 3 weeks each. Performance times for three near tasks were 6 to 8% longer with BFCL compared with DCL and 2 to 6% longer for MVCL compared with DCL. There were significant reductions in distance visual acuity with BFCL (0.4 to 1.5 Snellen lines) and MVCL (0.5 to 0.8 Snellen lines) compared to DCL. At the conclusion of the study, given a choice between BFCL and MVCL, 2 of the 20 subjects chose to continue wearing BFCL, whereas 18 of the 20 subjects chose MVCL. Our results show greater visual compromise and decreased task performance with BFCL and MVCL compared to DCL and greater patient preference for MVCL.


Comparison between near retinoscopy and cycloplegic retinoscopy in the refraction of infants and children. We investigated the validity of replacing cycloplegic retinoscopy with a noncycloplegic, "near" retinoscopy technique. We refracted a group of 31 infants (less than 2 years) and 43 children (greater than 2 years) with both techniques, grading our level of confidence in the result. Near retinoscopy gave on average a less hypermetropic result than cycloplegic retinoscopy by 0.39 D. The difference was significant in infants and for low levels of examiner confidence. However, a repeatability study showed that much of the variability in the infant group could be attributed to the poor repeatability of either retinoscopy technique. Agreement between the two techniques is improved by changing the suggested adjustment factor from 1.25 to 1.00 D for children and to 0.75 D for infants.


Vision defects in albinism.

Vision defects in albinism. We have examined the possible presence of color vision anomalies in 9 individuals (17 eyes, 1 blind) with fundus findings suggesting ocular albinism using the Ishihara plates, the 28-hue Roth test, and the Davico anomaloscope. Results indicate that four of these individuals show no sign of the anomalies expected in an albino in either of the two eyes. Of the remaining cases, two are simple deuteranomals in both eyes, according to Pickford's classification criteria. The rest have protanomaly; however, in these the deviation toward red appears in both eyes in only one subject, whereas in the other two subjects it appears in only one eye, their binocular color vision being basically normal. Our study shows that a large proportion of these albinos have photophobia, pendular nystagmus, strabismus, noticeable refractive errors (astigmatism and high myopia), and poor visual acuity [usually less than 6/30 (20/100) with correction]. The measurement of contrast sensitivity function (CSF) indicates that the frequency of 12 cpd cannot be perceived, even in binocular vision.


Estimation of dioptric power from measurements of meridional power and curvature, sagitta, lens thickness, and prismatic effect. A method published elsewhere for estimating dioptric power from meridional measurements is generalized here to allow for measurements of sagitta, lens thickness, and prismatic effect as well. Measurements may be of only one type or of combinations of types. Any number of measurements may be used. Within the usual limitations of first-order optics the method always works and gives all solutions when solutions exist. When no solutions exist it gives approximate solutions called least-squares estimates. At least one least-squares estimate always exists. A wide class of ostensibly distinct problems reduces to a single standard routine that is easy to execute with matrix-handling software. If there is reason to believe that the dioptric power is of some particular form then constrained estimation may be applied to find that form.


The "L" in Dk/L.

The "L" in Dk/L. We measured the Dk (oxygen permeability) of one specific hydrogel contact lens material (phemfilcon A, nominally 38% water content and ionic) by use of the conventional single chamber polarographic technique at 35 degrees C. When corrected for the boundary and edge effect, Dk was found to be 13 x 10(-11) cm2 ml O2/s ml mm Hg. (These units will be used for this term throughout the remainder of this report.) We also used the polarographic cathode as a model cornea to measure the Dk/L (oxygen transmissibility) of 7 powered contact lenses (-5 to +15 D) made from the same material by the same manufacturer. We found values ranging from 5 to 15 x 10(-9) cm ml O2/s ml mm Hg. (These units will also be used for this term throughout this report.) From analysis of these data, we found that any reasonable model (of the several previously proposed) for L could be used to predict the polarographically measured oxygen transmissibility of the low minus (-5 to -1 D) powered contact lenses, but that plus powered lenses, at least on this measurement apparatus, give Dk/L values that are closer to predictions based on the observed Dk and central thickness rather than any version of average thickness.


Vertical diplopia onset with first-time bifocal. A 39-year-old white female presented with symptoms of constant diplopia onset with a first bifocal correction. The association of these conditions required a careful differential diagnosis and special management considerations. Testing indicated an esotropia with a longstanding nonconcomitant superior oblique paresis which became manifest when she began wearing bifocals. A regimen of horizontal vergence range training in combination with a relieving vertical prism in a near correction were prescribed. An amount of prism which allowed comfortable sensory-motor fusion through both the distance and near portion of a bifocal spectacle correction was eventually ascertained. Information regarding etiology, etiologic incidence, differential diagnosis, and management of superior oblique paresis is also presented.


Effect of ibuprofen on contrast sensitivity. Therapeutic doses of ibuprofen (2-4'-isobutylphenyl-propionic acid) have been shown to have many deleterious effects on the nervous system. However, visual disturbances have been reported in fewer than 1% of the patients taking recommended doses of ibuprofen. The most commonly reported visual disturbances include: amblyopia, scotomata, and changes in color vision. To our knowledge, no studies have examined the effects of ibuprofen therapy on the contrast sensitivity function of an affected individual. Contrast sensitivity, Snellen visual acuity, color vision (D-15 test), and Goldmann visual fields were measured on 1 affected subject during and after ibuprofen therapy (800 mg/day for 2 days). Snellen visual acuity, color vision, and Goldmann visual fields were unaffected by the treatment. However, the contrast sensitivity was significantly depressed at low spatial frequencies while the subject was taking ibuprofen. The results, in concert with previous reports concerning the visual effects of ibuprofen, suggest that this drug can result in transient multifocal lesions of the visual pathway.


Opaque contact lenses for YAG laser iridotomy occlusion. Although a laser-produced iridotomy effectively controls angle-closure glaucoma the iridotomy can cause annoying visual effects. One solution is to fit a toric contact lens with an opaque portion to cover the iridotomy.


Contact lens failure in keratoconus management. Surgery is indicated for keratoconus when management with contact lenses fails. The authors sought to determine the relative contribution of various preoperative patient and ocular factors to the ultimate causes of contact lens failure. The records of unoperated eyes of keratoconus patients whose contact lenses were managed intensively before undergoing penetrating keratoplasty (PK) at the authors' institution between 1981 and 1990 were selected for study. Univariate and multivariate analyses were performed to identify risk factors for early contact lens failure. The records of 99 keratoconic eyes of 75 patients with an average age of 34 years and average keratometry readings of 57.5 diopters at presentation were studied. Cases had been followed for an average of 27 months before PK. The primary reasons for PK were a best-corrected visual acuity of under 20/40 (despite good contact lens fit) causing disability for the patient (43%), contact lens intolerance (32%), frequent lens displacement (13%), and significant peripheral thinning of the cornea (12%). The referral source of the patient, sex, a history of PK in the fellow eye, or of contact lens wear in either eye did not alter the relative contributions of these parameters to surgery. Poor best-corrected visual acuity at presentation, higher keratometry readings (greater than or equal to 55 D), age (greater than or equal to 40 years), and duration of disease (greater than 5 years) were significantly associated with failure due to poor functional acuity and peripheral thinning, frequently leading to surgery within the first 12 months after presentation.


Corneal epithelial alterations induced by disposable contact lens wear. To study the effect of disposable extended-wear soft contact lenses on the corneal epithelium. Thirteen healthy patients (1 male, 12 females; average age, 26.3 +/- 7.6 years) with or without histories of previous contact lens use were recruited for this study. Specular microscopic pictures of the corneal epithelium and endothelium were taken with the help of a specular contact lens, before and after 3 months of contact lens use. The pictures were analyzed by means of a computer-assisted morphometric analysis system. The mean cell area and coefficient of variation (CV) of the mean cell area of the corneal epithelium before contact lens use were 639.4 +/- 84.0 microns 2 and 29.1 +/- 13.2, respectively. After lens wear, the mean cell area increased to 819.7 +/- 99.2 microns 2 (P less than 0.01), whereas the CV decreased to 20.0 +/- 6.1 (P less than 0.05). The corresponding values for the endothelium were 300.8 +/- 22.5 microns 2 and 36.4 +/- 7.3 before contact lens use, and remained at 322.3 +/- 27.8 microns 2 and 32.8 +/- 3.7 after contact lens use, respectively (P greater than 0.05). Based on the 3-month results, disposable extended-wear soft contact lenses caused similar enlargement of the mean cell area of the superficial corneal epithelium, as has been reported previously. It would appear that disposable lenses may cause the same metabolic and physiologic changes in the corneal epithelium as do conventional extended-wear soft contact lenses.


Enhanced killing of Acanthamoeba cysts in vitro using dimethylsulfoxide. Acanthamoeba keratitis is difficult to treat and requires prolonged therapy despite the well-documented in vitro effectiveness of a variety of drugs. The authors propose that this may be due to the cysts formed by the organism in response to hostile conditions. Consequently, the study concentrates on increasing penetration of drugs effective against the parasite into the cysts using dimethylsulfoxide (DMSO). The organism is forced to encyst in vitro on solid media by nutrient deprivation. In the first set of experiments, serial dilutions of a standard treatment regimen are applied to the organisms, and these treated cysts are then subcultured onto nutrient-rich material and observed for growth. The experiments are then repeated with DMSO added to the serially diluted standards. In a second set of experiments, the effects of retreatment on a larger concentration of organisms is examined. When applied to a cyst-only population of Acanthamoeba, none of three standard drugs, propamidine isethionate 0.1%, neomycin 1%, or miconazole 1%, was cysticidal. When combined with DMSO 30%, propamidine isethionate was clearly cysticidal even in low dilution. This was confirmed by the retreatment experiments using a larger, standardized cyst population. The authors propose that DMSO is acting as a "carrier" for the propamidine isethionate and increases its penetration into the normally drug-resistant cyst form of the organism. Because DMSO has been used topically in the past and shown to be quite safe, this may be a viable new therapy for this difficult condition.


In situ collagen gel mold as an aid in excimer laser superficial keratectomy. The aim of this study is to evaluate the potential use of bovine type I collagen as an adjuvant to excimer laser keratectomy. A suspension of collagen with the capability to polymerize into a gel was applied to the anterior corneal surface of freshly enucleated porcine eyes, using 35.0 diopter (D), 45.5 D, or 52.0 D contact lenses as molds. Keratometry, photokeratoscopy, slit-lamp photography, scanning electron microscopy, and light microscopy were performed on the new surfaces. Furthermore, an irregular corneal surface was created and a suspension of collagen was applied to mask protruding irregularities, therefore creating a smooth surface that was subjected to excimer laser keratectomy. Ablation rates for both collagen and cornea were measured. Collagen suspension placed on a cornea and molded with contact lenses created a smooth-surfaced gel that conformed to the shape of the contact lens and adhered to the anterior cornea; it was optically smooth and regular as shown by photokeratoscopy, keratometry, and scanning electron microscopy. The corneal curvature was altered in accordance with the base curvature of the contact lens used. Results of keratometry showed resolution of pre-existing astigmatism without induction of new astigmatism. The ablation rate of the gel was not measurably different than that of cornea; hence, when applied to an irregular corneal surface, a smooth surface was created after excimer laser ablation. This study supports the potential value of collagen gel as an adjuvant to excimer laser keratectomy for removal of corneal irregularities as well as for correction of myopia or hyperopia with or without astigmatism.


Excimer laser photorefractive keratectomy. 18-month follow-up. This study, comprising 120 patients (follow-up, 12 to 22 months; mean, 18 months), was designed to evaluate the efficacy and safety of excimer laser photo-refractive keratectomy. Ablation zone diameter (4 mm), ablation rate (0.22 microns/pulse), fluence (180 mJ/cm2), and frequency (10 Hz) were kept constant, and all patients used a standard topical corticosteroid regimen. Overcorrection was followed by regression to a stable refraction by 4 months. At 1 year, 95% and 70%, respectively, of patients undergoing - 2.00 diopters (D) and -3.00 D corrections and 40% and 20% of those undergoing -6.00 D and -7.00 D corrections were within +/- 1.00 D of intended refraction. Anterior stromal "haze," maximal at 6 months and diminishing thereafter, was detected in 110 patients (92%). However, best-corrected Snellen visual acuity was reduced in only 22 (18%). Good correlation existed between haze and regression (r = 0.68). Night "halos," due to the relatively small 4-mm diameter ablation zone, were reported by 94 patients (78%) in the early postoperative period, and, at 1 year, 12 (10%) declined treatment of the other eye because of persistence of this problem. Marked individual variation was found after photorefractive keratectomy. However, in low myopia, predictability is "fair," and the procedure is safe. The authors conclude that excimer laser photorefractive keratectomy holds considerable promise for refractive surgery in the future.


Ultrasound biomicroscopy of anterior segment tumors. Ultrasound biomicroscopy is a new method of imaging the anterior segment of the eye at microscopic resolution using high frequency ultrasound. A prospective study was performed to evaluate the use of ultrasound biomicroscopy in imaging anterior segment tumors. Forty-five patients underwent clinical examination followed by slit-lamp photography, anterior segment B-scan ultrasonography, and ultrasound biomicroscopy according to an established protocol. All lesions were clearly imaged by ultrasound biomicroscopy, while only 17 were detectable by conventional B-scan ultrasound. Ultrasound biomicroscopy allowed precise measurement and visualization of subsurface features in small tumors. Differentiation between solid and cystic lesions was easily achieved. The margins of ciliary body tumors could be more accurately defined. Histopathologic correlation was possible in four cases managed surgically. Ultrasound biomicroscopy images compared favorably with low-power microscopy. No complications were encountered. Ultrasound biomicroscopy proved a valuable new noninvasive technique in the evaluation of anterior segment tumors.


Soemmering's ring support for posterior chamber intraocular lens implantation during penetrating keratoplasty. Changing trends in bullous keratopathy. Changing trends in cataract extractions have resulted in a new category of bullous keratopathy: corneal decompensation after complicated extracapsular cataract extraction. These cases of bullous keratopathy are associated with rupture of the posterior capsule, vitreous loss, and significant intraocular inflammation at the time of the original complicated extracapsular cataract extraction. The authors reviewed 14 consecutive cases of penetrating keratoplasty for bullous keratopathy in which posterior chamber intraocular lens implantation was supported by remnants of the posterior capsule and/or Soemmering's ring without suture fixation. All 14 patients had a history of complicated extracapsular cataract extraction with capsule rupture and vitreous loss. All 14 patients had clear, compact grafts without migration of the intraocular lens with a mean follow-up of 12.1 months. Vision improved in 93% of cases, and there was no significant worsening of glaucoma. Pseudophakic bullous keratopathy after traumatic extracapsular cataract extraction with an anterior chamber intraocular lens and aphakic bullous keratopathy after traumatic extracapsular cataract extraction are two relatively new clinical entities that present new intraocular lens management options. Bullous keratopathy after complicated extracapsular cataract extraction should be recognized as a distinct clinical entity. Intraocular lens implantation into the ciliary sulcus with Soemmering's ring and peripheral capsular support provide the advantages of a posterior chamber intraocular lens without the risk of iris or scleral sutures. The authors predict that bullous keratopathy associated with traumatic extracapsular cataract extraction will become one of the more common indications for penetrating keratoplasty.


Extracapsular cataract extraction and posterior chamber intraocular lens implantation in uveitis patients. Intraocular lens implantation in uveitis patients has been a controversial issue. The purpose of this study is to evaluate the visual and surgical outcomes of extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PC IOL) implantation in a diverse group of uveitis patients. The results of 39 cases of ECCE and PC IOL implantation in 30 patients with uveitis were retrospectively analyzed. Five patients (six eyes) had pars plana vitrectomies combined with ECCE and PC IOL implantation. Patient age ranged from 26 to 71 years (average, 53.0 years). Specific uveitic syndromes were determined for 22 patients (73.3%). The postoperative follow-up period ranged from 6 to 43 months (average, 20.3 months). Visual acuity improved postoperatively in 38 eyes (97.4%), and this improvement ranged from 1 to 11 Snellen lines (average, 7.5 Snellen lines). Visual acuity improved postoperatively to 20/40 or better in 32 eyes (82%). Seven eyes had visual acuity worse than 20/40, which was attributed to posterior segment abnormalities after ECCE and PC IOL implantation. Uveitis recurred in 20 eyes (51.3%), and postoperative cystoid macular edema (CME) was observed in 18 eyes (46.2%). In all cases, the recurrent uveitis and CME improved or resolved with corticosteroid therapy. These results suggest selected uveitis patients can have improved vision without unacceptable risk for 1 to 3 years after ECCE and PC IOL implantation.


Fibrinous uveitis and intraocular lens implantation. Surface modification of polymethylmethacrylate during extracapsular cataract surgery. The causes of fibrinous uveitis after cataract surgery are unclear, but surface modification of polymethylmethacrylate (PMMA) is known to influence post-operative inflammation. One hundred twenty-five patients were entered into a prospective investigation designed to assess the effect of intraoperative surface modification of PMMA, by coating with a 2% hydroxypropyl methylcellulose solution, on the incidence of fibrinous uveitis after extracapsular cataract surgery and lens implantation. Of the 125 patients entered into this prospective study, 90 received pretreatment with a 1% indomethacin solution. Fibrinous uveitis developed in 18(33%) of 54 eyes with dry lens implantation and in 1 (3%) of 36 eyes with coated lens implantation (P less than 0.005). Thirty-five eyes were not pretreated with indomethacin, and fibrin formation occurred in 6 (30%) of 20 dry implanted eyes and in 0 of 15 eyes with coated lens implantation (S = 0.02). Intraoperative modification of the PMMA surface of an intraocular lens during implantation significantly reduces the severity of postoperative inflammation, as manifest by the incidence of fibrinous uveitis.


Effect of heparin surface modification of polymethylmethacrylate intraocular lenses on signs of postoperative inflammation after extracapsular cataract extraction. One-year results of a double-masked multicenter study. A heparin surface modified posterior chamber intraocular lens (IOL) was compared with a conventional polymethylmethacrylate (PMMA) IOL regarding postoperative complications caused by inflammation. Five hundred twenty-four patients from 10 different centers were included in a parallel group, double-masked, multicenter study. The cumulative number of patients with inflammatory cellular deposits on their IOLs during the first postoperative year differed significantly in favor of the heparin surface modified group, with 29.8% of the patients having cellular deposits compared with 48.8% of patients in the control group. Cellular deposits were observed most frequently at 3 months after surgery, and the difference between the groups was most pronounced and statistically significant at this time. The same results were seen at 1 year, but the difference was not significant. The number of cellular deposits per patient, however, was significantly lower in the heparin surface modified group at 1 year. Cumulatively, there were significantly more patients with posterior synechiae in the PMMA group than in the heparin surface modified group during the 1-year follow-up. Complications were few and comparable between the groups. The results of this study indicate that heparin surface modification reduces the inflammatory response to PMMA IOLs.


Treatment of postcataract fibrinous membranes with tissue plasminogen activator. The purpose of this study is to investigate the efficacy and toxicity of tissue plasminogen activator (tPA) in treatment of postcataract fibrinous membranes. The authors injected 25 micrograms of tPA into the anterior chamber of 52 pseudophakic eyes with moderate to severe fibrinous membranes that developed after cataract surgery. Intraocular tPA injection resulted in complete fibrinolysis in 47 of 52 eyes (90%) and partial fibrinolysis in 5 of 52 eyes (10%). In cases of complete fibrinolysis, resolution of the fibrinous membrane occurred within 30 minutes in 22 of 47 eyes (47%) and within 1 hour in 25 of 47 eyes (53%). No evidence of toxicity was observed as measured by slit-lamp biomicroscopy, intraocular pressure, and corneal endothelial cell density, size, and morphology. Complications of tPA administration included periorbital pain (4 eyes), anterior chamber hemorrhage (4 eyes), and anterior chamber turbidity (3 eyes). The authors believe that intraocular tPA is effective and safe in the treatment of postcataract fibrinous membranes.


Management of dislocated lens fragments during phacoemulsification. Dislocation of nuclear lens fragments during phacoemulsification can lead to a high incidence of glaucoma, uveitis, and poor visual acuity. The correct approach to these patients is uncertain. The authors report on eight patients who underwent pars plana vitrectomy with removal of lens fragments. Charts of eight consecutive patients who developed dislocation of nuclear lens fragments into the vitreous cavity during phacoemulsification were retrospectively reviewed. All patients underwent a standard three-port pars plana vitrectomy with removal of the dislocated nuclear fragments by pars plana fragmentation. After the vitrectomy, the retina was inspected with indirect ophthalmoscopy. Tears were treated with cryopexy. A fluid-air exchange and scleral buckle were performed when indicated. Retinal tears were located at the vitreous base in four of eight patients. After vitrectomy, visual acuity improved in all patients, with 7 of 8 patients achieving visual acuity of 20/40 or better. The type of pseudophakia did not influence the final visual acuity. There were no cases of glaucoma, uveitis, or macular edema with up to 22 months of follow-up. These results suggest that large nuclear fragments dislocated into the posterior segment during phacoemulsification can be removed safely with pars plana vitrectomy and lensectomy with an excellent visual prognosis. Attempts to remove lens fragments during the phacoemulsification through an anterior wound should be avoided because of excessive vitreous traction, leading to retinal break formation.


Retained intravitreal lens fragments after cataract surgery. The purpose of this study is to review the possible benefits and complications of vitrectomy for retained lens fragments after cataract surgery. The authors reviewed the charts of 65 patients referred over a 12-year period for retained lens fragments after cataract surgery. Of these, 56 underwent vitrectomy and 9 were followed. Of these 56 eyes, 29 (52%) had received an intraocular lens (IOL) at the time of cataract surgery. Resulting complications from retained lens material included glaucoma (52%), corneal edema (46%), uveitis (56%), and decreased vision (100%). These sequelae responded equally to vitrectomy in eyes with or without an IOL and irrespective of type of cataract surgery (phacoemulsification or extracapsular cataract extraction). The timing of surgery did not statistically influence the final vision or the incidence of glaucoma. Removal of retained lens fragments allows rapid visual restoration, enhances resolution of uveitis, and improves control of glaucoma. Insertion of an IOL at the time of cataract surgery in the face of dislocated lens fragments is not contraindicated provided that it could be performed safely.


Aniseikonia and stereoacuity in pseudophakic patients. Unilateral and bilateral cases. To evaluate the efficacy of intraocular lens (IOL) implant procedures, analyzing visual function of the operated eyes and the resulting binocular vision. The authors measured aniseikonia and stereoacuity in patients with both bilateral and unilateral posterior chamber intraocular lenses (PC IOLs). The aniseikonia was measured with the New Aniseikonia Test; the stereoacuity was evaluated with the Titmus Stereotest. In 41 patients with bilateral PC IOLs, aniseikonia measured with the New Aniseikonia Test ranged from 0% to 4% (mean, 0.76%; standard deviation = 1.04%). The average stereoacuity evaluated with the Titmus test was 7.68 circles (less than 60 seconds; range, greater than 800 to 40 seconds of arc), with 36 of 41 patients (87.8%) showing a stereoacuity less than or equal to 100 seconds of arc. In 37 patients with unilateral PC IOLs, the aniseikonia ranged from 0% to 6% (mean, 0.97%; standard deviation = 1.13%). Their stereoacuity also ranged from greater than 800 to 40 seconds (mean, 7.67 circles) (less than 60 seconds). In this group, 34 of 37 (91.8%) patients showed a stereoacuity less than or equal to 100 seconds of arc. Although the problem of aniseikonia still remains, a significant number of patients attain good binocular function after unilateral and bilateral PC IOL implantation.


Corneal diameter, axial length, and intraocular pressure in premature infants. Seventy premature infants 25 to 37 weeks' postconceptional age were examined during their first week of life to determine the correlation of corneal diameter, axial length, and intraocular pressure with gestational age and birth weight. Corneal diameter measurement was determined with corneal templates, total axial length with standardized A-scan ultrasound, and intraocular pressure with a Tonopen II tonometer. Corneal diameter and total axial length showed parallel linear increases from 6.2 mm to 9.0 mm and 12.6 mm to 16.2 mm, respectively; however, no significant correlation was found between intraocular pressure and gestational age or birth weight. The mean intraocular pressure was 10.3 mmHg (standard deviation, 3.5). Normative values are established for corneal diameter and total axial length as they relate to birth weight and gestational age, and a mean and standard deviation for intraocular pressure in the premature newborn. These values will aid the ophthalmologist in assessing ocular dimensions in premature infants.


Improvement of compensatory head postures after strabismus surgery. To determine the incidence and relative frequencies of orientations of compensatory head postures (CHP) and success in surgically treating the CHP seen in patients with pure lateral rectus paresis (group I), superior oblique paresis (group II), Duane syndrome (group III), Brown syndrome (group IV), and congenital motor nystagmus (group V). The authors retrospectively reviewed all patients assessed and treated between 1985 and 1991 with these five conditions. Frequencies and orientations of the CHP were determined in all patients in each group. The success of surgery in eliminating the CHP in the subgroups of patients who underwent surgery to treat the CHP also was determined. The frequencies of CHP were 29.0% of 93 group I cases, 71.2% of 139 group II cases, 68.1% of 91 group III cases, 17.4% of 35 group IV cases, and all 23 group V cases, for an overall incidence of 56.7% of 381 patients. For patients who underwent surgery to eliminate a CHP, success rates were 85.7% of 21 group I cases, 75.6% of 41 group II cases, 87.2% of 47 group III cases, 100% of 5 group IV cases, and 78.3% of 23 group V patients, for an overall success rate of 82.5% of 137 surgical cases. Because CHP is seen frequently in strabismus and nystagmus disorders, ocular causes must be ruled out in any case of an anomalous head posture. Appropriately planned surgery for CHP caused by incomitant strabismus or eccentric nystagmus null zones has a high rate of success in eliminating CHP.


Effects of halothane on children's electroretinograms. At times, anesthesia is necessary to test children's electroretinographic (ERG) responses. Halothane, an anesthetic commonly used for pediatric patients, affects some aspects of ERG responses, but it is unknown if halothane affects ERG parameters evaluated by contemporary clinical protocols. Scotopic and photopic ERG responses were recorded from children when awake and then under halothane. Halothane has no effect on scotopic b-wave stimulus/response parameters, including amplitude, sensitivity, and implicit time. Scotopic a-wave amplitudes, implicit times, model parameters, and ratio of a- to b-wave amplitudes are unaffected by halothane. The amplitudes and implicit times of photopic responses to red flashes and 30 Hz flickering white light are not altered by halothane. Halothane causes no significant change in amplitudes and implicit times of the oscillatory potential wavelets. These results suggest that significant departures of ERG responses (studied with the protocol described herein) from a laboratory's normal values cannot be attributed to halothane.


Magnetic resonance imaging of orbital lymphangioma with and without gadolinium contrast enhancement. Lymphangioma is a vascular tumor of the orbit with a propensity for recurrent hemorrhage. These tumors may be difficult to diagnose in young patients who present with sudden proptosis due to hemorrhage into a previously unrecognized lesion. Magnetic resonance imaging (MRI) should be ideally suited for evaluating lymphangioma due to the unique ability of MRI to characterize hemorrhage because of the paramagnetic qualities of hemoglobin. The authors performed T1-, T2-, and proton density-weighted MRI on 12 patients with orbital lymphangioma. Six patients underwent MRI with gadolinium-DTPA contrast enhancement. The MRI studies were performed using a 1.5 Tesla super-conducting magnetic resonance unit, except for 3 early studies performed with a 0.5 Tesla unit. All studies were performed with orbital surface coil imaging. Computed tomography (CT) was performed in 10 patients. Tumor was visible on MRI in all 12 patients. Magnetic resonance imaging delineated clearly the internal structure of subacute and chronic hemorrhagic cysts, and differentiated between these tumors because of the different paramagnetic qualities of subacute hemorrhage compared to chronic hemorrhage. In two patients, MRI detected large tumor feeding vessels by the flow void phenomenon unique to MRI. Computed tomography did not detect these vessels. Gadolinium-contrasted T1-weighted MRI did not further delineate or characterize the tumor. Magnetic resonance imaging is the modality of choice for imaging orbital lymphangioma because of its unequalled differentiation of hemorrhagic cysts, and its unique ability to detect tumor feeding vessels by the flow void phenomenon.


Immunohistochemical evidence for C3bi involvement in Graves ophthalmopathy. To determine by immunohistochemical methods if components of the complement system are present in Graves ophthalmopathy extraocular and periocular tissues compared with non-Graves ophthalmopathy ocular tissues, and, if so, whether a qualitative difference exists. Orbital muscle, periorbital muscle, and adipose tissue from 10 Graves ophthalmopathy patients were studied with in situ assays using monoclonal antibodies for C3bi and C5b-9 (the terminal attack complex) complement components. Extraocular muscle, periocular muscle, and adipose tissue from 12 patients treated for unrelated orbital disorders were used as controls. All nine Graves extraocular and periocular muscle tissues exhibited C3bi positive staining in an intense, localized oval- to spindle-shaped reaction that appeared to represent cells on a diffuse staining background of the endomysial and perimysial connective tissues with no staining of the muscle fibers themselves. Some reactivity was seen in 6 of the 12 control muscles, but this was much less intense than that of Graves ocular muscle tissue. Only two Graves muscle samples stained minimally with the monoclonal antibody for the C5b-9 terminal attack complex while none of the control muscle samples demonstrated reactivity. Orbital fat from Graves and control patients did not demonstrate any reactivity for C3bi or C5b-9. C3bi and not C5b-9 (the terminal attack complex) is present in Graves ophthalmopathy extraocular and periocular tissues in a qualitatively greater way than in control non-Graves ophthalmopathy ocular tissue. Consequently, C3bi may contribute to the pathophysiology of Graves ophthalmopathy.


Keratophakia and keratomileusis: safety and effectiveness. American Academy of Ophthalmology. The purpose of the Committee on Ophthalmic Procedures Assessment is to evaluate on a scientific basis new and existing ophthalmic tests, devices, and procedures for their safety, efficacy, clinical effectiveness and appropriate uses. Evaluations include examination of available literature, epidemiological analyses when appropriate, and compilation of opinions from recognized experts and other interested parties. After appropriate review by all contributors, including legal counsel, assessments are submitted to the Academy's Board of Directors for consideration as official Academy policy.


A comparative histological study of the number and size of the myenteric ganglia and neurones in the fore-stomach and abomasum of grey, white and black Karakul lambs. Homozygous grey Karakul lambs are born with a lethal genetic factor responsible for death at weaning age. When put on a high roughage diet under field conditions they develop distended, thin-walled rumens and sand impacted abomasa. Homozygous white Karakul lambs have a similar factor but survive for a longer period. Black Karakul lambs are not affected. The present study was undertaken to compare by image analysis the number and size of the myenteric ganglia, and the number of myenteric neurones in the walls of the fore-stomach and abomasum of 24-h-old grey, white and black Karakul lambs. One square centimetre samples were taken from analogous areas of the rumen, reticulum, omasum and abomasum of 38 embalmed Karakul lambs. Haematoxylin and eosin stained histological sections of each sample were studied with a Vids 2 Image Analyzer. One way analysis of variance indicated a significant difference between the groups regarding the number and size of the myenteric ganglia and in the number of myenteric neurones in the reticulum, rumen and abomasum. The number and size of the ganglia and the number of neurones was greatest in the black lambs and decreased progressively in the white and grey lambs. The omasum was not affected. It is suggested that the paucity of myenteric ganglia and neurones in the regions examined is instrumental in causing the lethal condition described above.


Cardiotoxicity of the skin of the red-banded rubber frog, Phrynomerus bifasciatus (Smith 1847). The skin of the red-banded rubber frog is said to secrete an unidentified toxin. Whole skin extract as well as HPLC fractions were tested for toxicity on viable, isolated cardiomyocytes. The skin extract and one of its fractions were shown to be cardiotoxic. Whole-cell clamping tests demonstrated that both extract and fraction interfered with the function of the potassium channels of the cardiomyocytes and that the toxic substance has an affinity for the IK, channels. Investigations are in progress to isolate and characterize the toxic substance.


Experimental Albizia versicolor poisoning in sheep and its successful treatment with pyridoxine hydrochloride. Five sheep developed severe nervous signs after being drenched with Albizia versicolor pod-material. Four of these sheep were treated with pyridoxine hydrochloride (a vitamin B6) when the symptoms of toxicity became life-threatening. All the treated sheep recovered dramatically and completely after treatment while the untreated one died 2 h after receiving pod-material. A therapeutic dose of 20-25 mg pyridoxine hydrochloride/kg body mass given twice with an 8 h interval is the recommended treatment regimen. The route of administration will depend on the severity of symptoms. Chemical pathology and post-mortem findings are discussed.


Bioactive peptides and serotonin in the gut endocrine cells of the crocodile, Crocodylus niloticus (Laurenti 1768): an immunocytochemical study. Little is known about peptide-storing endocrine cells in the gut of the Nile crocodile. As in the case of other reptiles, particularly the alligator, a limited range of peptide-storing cells was found in the gut of the crocodile. They were somatostatin, glucagon, gastrin, neurotensin and pancreatic polypeptide. The topographical distribution of cells immunoreactive to somatostatin and gastrin in the gut of the crocodile is comparable to the situation in the alligator. Glucagon and neurotensin immunoreactive cells have a much wider distribution in the gastro-intestinal tract of the crocodile compared to the alligator. Cholecystokinin and bombesin cells previously reported in the small intestine of the alligator were not detected in this study. This is the first report to demonstrate pancreatic polypeptide and serotonin immunoreactivity in the gut of a crocodilian specie.


Production and properties of monoclonal antibodies against African horsesickness virus, serotype 3. Four polyethylene glycol-mediated cell fusions yielded a total of 23 monoclonal antibodies (McAbs) specific for African horsesickness virus (AHSV). Two recognised the major core structural polypeptide, VP7, while one each was specific for the outer capsid proteins, VP2 and VP5. The remainder co-precipitated both VP2 and VP7. An inhibition ELISA and radio-immunoprecipitation revealed two types of co-precipitating McAbs, distinguishable from each other by the different relative amounts of the two proteins they precipitated. Only co-precipitating McAbs reduced the size and number of plaques formed by AHSV on VERO cell monolayers, but even at low dilution did not completely abolish virus infectivity. A McAb specific for VP7 showed potential as a group-reactive diagnostic reagent since guinea pig antisera to all nine serotypes of AHSV, as well as an anti-serotype 4 horse serum and an anti-serotype 3 rabbit serum, inhibited its binding in ELISA to AHSV serotype 3.


Experimentally-induced Cestrum laevigatum (Schlechtd.) poisoning in sheep. Dried, milled Cestrum laevigatum plant material was drenched to 6 ewes at doses ranging from 2,5 to 10 g/kg/day for 1 to 47 days. The most noticeable clinical signs were depression, anorexia and ruminal stasis. These signs were accompanied by clinical pathological changes indicative of liver involvement such as increases in the serum activities of aspartate transaminase, lactate dehydrogenase and gamma-glutamyltransferase. Hepatosis characterized by accentuated lobulation, and centrilobular to midzonal coagulative necrosis, haemorrhage and congestion occurred in 2 of the 3 ewes given high doses of plant material. Liver lesions in the other animals included disappearance of hepatocytes and collapse of the reticulin stroma in the centrilobular areas. Spongy changes in the cerebral white matter were evident in the ewes of the high-dose group. Ultrastructural changes in the liver comprised degeneration and necrosis of hepatocytes and occasionally endothelial cells, and disruption of sinusoidal walls.


Afrotropical Culicoides: C. (Avaritia) loxodontis sp. nov., a new member of the Imicola group (Diptera: Ceratopogonidae) associated with the African elephant in the Kruger National Park, South Africa. Culicoides (Avaritia) loxodontis sp. nov., is described and illustrated from both sexes collected in South Africa. It is the 5th species of the Imicola group of the subgenus Avaritia to be described from the Afrotropical Region, and is presently known only from the Kruger National Park where it has been collected in light-traps and reared from the dung of the African elephant (Loxodonta africana) on various occasions. A number of character states, and statistical analyses of antennal and palpal measurements, are used to separate the new species from its taxonomic congeners C. imicola Kieffer, 1913, C. pseudopallidipennis Clastrier, 1958, C. bolitinos Meiswinkel, 1989 and C. miombo Meiswinkel, 1991. It is suggested that the occurrence of the African elephant is the primary factor that determines the distribution of Culicoides loxodontis sp. nov., and that this close association, coupled with the fact that C. loxodontis sp. nov. can be locally abundant, may result in the cycling of certain arboviruses between this biting midge and the elephant.


Anaplasmosis in Uganda. III. Parasitological and serological evidence of Anaplasma infection in Ugandan goats. Randomly selected goat sera from north-western, central, and south-western regions of Uganda were analyzed parasitologically and serologically for evidence of anaplasmosis. Prevalence rates of 3.2% by parasitemia, 4.8% by card-agglutination test, and 12.9% by DOT-ELISA combined with western blotting were established. Parasitologically positive samples were consistently serologically positive. Positive samples were all from either the north-western or south-western regions of the country. Goats in these regions graze with cattle and are presumable exposed to the same tick species. There was no evidence of clinical caprine anaplasmosis, whereas bovine anaplasmosis cases are very common. Rhipicephalus evertsi was frequently observed on goats which cograze with cattle.


Adult Amblyomma hebraeum burdens and heartwater endemic stability in cattle. Several conclusions of importance to studies on the epidemiology of heartwater were drawn from an investigation in which the numbers of adult Amblyomma hebraeum ticks, to which a closed herd of Hereford cattle were exposed over a period of 6 1/2 years, were manipulated. With a tick Cowdria ruminantium infection rate of 3-5%, an endemically stable situation was created by dipping the herd only when an average of 10 adult male and female A. hebraeum ticks were counted on 10 animals. When the average was increased to 15 during the calving period, 97% of calves acquired a tick-mediated immunity at the age of 6 months. Because only adult ticks confined to the hindquarters are counted, this procedure is recommended as a feasible and practical guideline to stock owners wishing to determine a dipping programme that would ensure endemic stability. The indirect fluorescent antibody test gave a true reflection of the infection rate through ticks in calves 3-6 months old, but not in older animals that had been re-infected more than once. This is because on one hand antibody may persist for 2 years after withdrawal from tick exposure and on the other the artificial re-infection of cattle with a tick acquired immunity is not always followed by a rise in antibody titres and may even result in seronegativity. Four cows infected and re-infected through ticks, remained immune to challenge for 2 years after withdrawal from tick exposure. Within the confines of one farm 3 isolates of C. ruminantium that differed in pathogenicity and immunogenicity were recovered from ticks. One of these isolates was almost non-pathogenic to cattle.


The effects of salt loading via two different routes on feed intake, body water turnover rate and electrolyte excretion in sheep. The effect of dosing identical amounts of sodium chloride, via 2 different routes, on feed intake and water and electrolyte balance was investigated in sheep. Feed intake and plasma sodium concentrations were unaffected by salt loading, while water intake, fractional turnover of body water, plasma and urine potassium concentrations and urine sodium concentration changed significantly from control values (P less than 0.05). With a few exceptions, parameters were in general similar irrespective of the route whereby sodium chloride was administered.


Description of Aegyptianella botuliformis n. sp. (Rickettsiales: Anaplasmataceae) from the helmeted guineafowl, Numida meleagris. Aegyptianella botuliformis n. sp. (Rickettsiales: Anaplasmataceae) isolated from helmeted guineafowls Numida meleagris from the Kruger National Park is described. The rickettsia occurs within a membrane-bound vacuole in the cytoplasm of erythrocytes with up to 8 organisms in a mature inclusion. The initial body resembles that of Aegyptianella pullorum. The tightly packed, sausage-shaped intermediate forms are a distinctive morphological feature, seen as irregular, pleomorphic forms under light microscopy. While more larvae and nymphs of Amblyomma hebraeum and Amblyomma marmoreaum were found on the birds than larvae of an Argas sp., it is believed that the latter are the vectors of A. botuliformis n. sp. In addition to the Kruger National Park, positive blood smears were obtained from guineafowls at other localities in the Transvaal.


Desipramine potentiates spinal antinociception by 5-hydroxytryptamine, morphine and adenosine. The effects of pretreatment with desipramine, a selective noradrenaline (NA) uptake blocker, on spinal antinociception by 5-hydroxytryptamine (5-HT), morphine and an adenosine analog (NECA) in the rat hot-plate test were examined to determine if endogenous NA is involved in the spinal action of these agents. Desipramine, 25 mg/kg, had no significant intrinsic effect in the hot-plate test but potentiated spinal antinociception by NA and 5-HT. Potentiation was more prominent at higher doses of NA and 5-HT. Desipramine also enhanced the action of morphine and NECA, but, in these instances, the greatest enhancement occurred at lower doses. These results, in conjunction with others, suggest that 5-HT releases NA from the spinal cord while morphine and NECA interact synergistically with endogenously released NA.


The prevalence of pain in hospitalized patients and resolution over six months. Pain was assessed in 2415 randomly selected hospitalized patients. Fifty percent of the sample reported pain at the time of the interview, and 67% had experienced pain during the past 24 h. High levels of pain were more frequent in postpartum women, patients with diseases of the musculoskeletal systems and after injury or poisoning, but in all diagnostic categories there were patients whose lowest pain level in the preceding 24 h was moderate or severe. Patients who had undergone a surgical procedure during the past 7 days were more likely to report moderate or severe pain, but 21% of non-surgical patients reported moderate or severe pain. Twenty percent of those with pain reported that it had existed for more than 6 months. Patients reported significant impairment of function and distress as a consequence of pain. Use of analgesic medications was low overall and even lower for non-surgical patients. A decrease in pain over 3 weeks was predicted by pain of shorter duration, a shorter duration of hospitalization in the past year, and if a surgical procedure had been performed. None of these variables predicted pain resolution between 3 weeks and 3 or 6 months. Impairment of function did not increase with continuing pain but distress did. Medication use remained low at follow-up. The data indicate that current strategies to improve pain management need to be critically reviewed.


Reversible pain and tactile deficits associated with a cerebral tumor compressing the posterior insula and parietal operculum. Extensive psychophysical tests were conducted on a patient with a well circumscribed tumor located just inferior and posterior to the retroinsular cortex of the right hemisphere. Statistically significant laterality differences were observed, with the left hand exhibiting: (1) a higher mechanical pain threshold, (2) a higher heat pain threshold, (3) a greater cold pain tolerance, and (4) a poorer ability to discriminate roughness. The patient was re-examined 2.5 months after operative removal of the tumor and was found to have regained normal sensitivity in his left hand. Pre- and postoperative MRIs showed resolution of the tumor's mass effect on the retroinsular and neighboring parietal operculum, which likely included the second somatosensory cortex. This dramatic change in sensory capacity signifies an essential role for the posterior insula and parietal operculum in normal pain and tactile perception.


Comparative study of the validity of four French McGill Pain Questionnaire (MPQ) versions. Four different French versions of the McGill Pain Questionnaire (MPQ) have been published: 3 are MPQ translations in Canadian French and 1 (QDSA) is an MPQ reconstruction in (France) French. The aim of our work was to study the validity of these available questionnaires for use in France. The validity was evaluated by 44 French physicians. Various validity criteria were studied: item, dimension, subclass and pain descriptor intensity. A new French MPQ was also developed. Significant validity differences emerged between the different MPQ versions. This study confirms the satisfactory validity of the QDSA. The validity of the newly developed French MPQ was equal but not better than the QDSA. A 15-item short MPQ-QDSA version was also developed. For studies with patients from France, it is recommended that the QDSA or the short MPQ-QDSA versions be used.


The Pain Anxiety Symptoms Scale: development and validation of a scale to measure fear of pain. Fear of pain has been implicated in the development and maintenance of chronic pain behavior. Consistent with conceptualizations of anxiety as occurring within three response modes, this paper introduces an instrument to measure fear of pain across cognitive, overt behavioral, and physiological domains. The Pain Anxiety Symptoms Scale (PASS) was administered to 104 consecutive referrals to a multidisciplinary pain clinic. The alpha coefficients were 0.94 for the total scale and ranged from 0.81 to 0.89 for the subscales. Validity was supported by significant correlations with measures of anxiety and disability. Regression analyses controlling for measures of emotional distress and pain showed that the PASS made a significant and unique contribution to the prediction of disability and interference due to pain. Evidence presented here supports the potential utility of the PASS in the continued study of fear of pain and its contribution to the development and maintenance of pain behaviors. Factor analysis and behavioral validation studies are in progress.


Activation of normal and inflamed fine articular afferent units by serotonin. In cats anesthetized with alpha-chloralose, extracellular recordings were made from fine afferent units belonging to the medial articular nerve (MAN) of the knee joint. The excitatory and sensitizing effects on articular afferents of serotonin (5-HT) applied intra-arterially close to the joint were examined. The joints were either normal or an experimental arthritis had been induced some hours before the recording session. Bolus injections of 1.35-135 micrograms 5-HT excited about 43% of group III (CV: 2.5-20 m/sec) and 73% of group IV units (CV: less than 2.5 m/sec) from normal joints. The latency was usually between 10 and 30 sec, and the duration and size of the responses were dose-dependent. Fast group III units (CV: greater than 16 m/sec) and group II units (CV: greater than 20 m/sec) were never excited by 5-HT. Repetitive administration led to pronounced tachyphylaxis of the 5-HT response. Inflammation induced an enhanced sensitivity of group III articular afferent units to close intra-arterial application of 5-HT. In particular the total duration of each response was considerably prolonged (4-10 min against 1-2 min under normal conditions). At the same time the tachyphylaxis seen under normal conditions was greatly reduced. In contrast, group IV articular afferent units did not become sensitized to 5-HT in the course of inflammation. In normal joints 5-HT did not sensitize fine afferent units for movement-induced responses. However, after inflammation, a distinct sensitization to such movements by 5-HT application could be observed both in group III and group IV fiber ranges. The sensitization had a short time course not exceeding 7 min. The tonic component of the movement-induced response was more enhanced than the phasic one. The bolus application of 5-HT led to temporary vasoconstriction of the knee joint vessels. This vasoconstriction was especially pronounced in inflamed joints and impeded the access of subsequently applied substances to the terminal regions of the afferent units under observation. It is concluded that the present results support the notion that 5-HT may participate in the mediation of pain from inflamed tissue such as an arthritic joint by exciting and sensitizing fine afferent units. During inflammation group III units are particularly sensitive to 5-HT and, thus, may carry the bulk of the 5-HT-induced nociceptive messages.


Comparative United States and European trials of loracarbef in the treatment of acute otitis media. Acute otitis media with effusion is one of the most common infectious diseases of childhood. Two multicenter randomized controlled clinical trials were conducted to assess the relative safety and efficacy of loracarbef and either amoxicillin/clavulanate or amoxicillin in the treatment of acute otitis media. Patients were evaluated clinically and bacteriologically at a pretherapy visit (within 48 hours of study drug administration), a posttherapy visit (within 72 hours after completion of therapy), and a late posttherapy visit (10 to 16 days after completion of therapy). In both studies, etiologic agents were assessed by tympanocentesis. In both studies patients had to have a pathogen susceptible to both study drugs to be continued in the study and declared evaluable. The first study, conducted at 24 United States centers, compared loracarbef 30 mg/kg/day in two divided doses and amoxicillin/clavulanate 40 mg/kg/day in three divided doses each for 10 days. At the posttherapy visit 124 (87.3%) of 142 evaluable loracarbef-treated patients and 130 (91.5%) of 142 evaluable amoxicillin/clavulanate-treated patients had favorable (cure or improvement) clinical outcomes (P = 0.247). Loracarbef-treated patients were significantly less likely to experience adverse events, notably diarrhea, than amoxicillin/clavulanate-treated patients (P less than 0.001). The second study, conducted at 12 European sites, compared loracarbef 30 mg/kg/day in two divided doses and amoxicillin 40 mg/kg/day in three divided doses each for 7 days. At the posttherapy visit 120 (81.1%) of 148 evaluable loracarbef-treated patients and 125 (87.4%) of 143 amoxicillin-treated patients had favorable clinical outcomes (P = 0.139). Loracarbef and amoxicillin displayed comparable safety, although vomiting appeared more frequently among patients receiving amoxicillin (P = 0.011).(ABSTRACT TRUNCATED AT 250 WORDS)