The Aging Eye: Preventing and treating eye disease

StrongSight Vision Ebook

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Easy Clear Vision Summary

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Chronic Allergic Eye Diseases

Chronic allergic ocular disease encompasses several disorders, such as seasonal atopic conjunctivitis, perennial atopic conjunctivitis, atopic keratoconjunctivitis (AKC) and vernal keratoconjunctivitis (VKC) 7 . Seasonal atopic conjunctivitis (SAC) is a time-limited disease and in most cases conjunctivitis is only one manifestation of additional allergic reactions (rhinitis, hay fever or a hay fever like symptomatology, and in severe cases conjunctivitis is associated with different forms of pulmonary affection). Atopic keratoconjunctivitis is a severe, bilateral, ocular allergic disease affecting adults. A familial history for atopy and an association with systemic atopic dermatitis are common. Symptoms commonly include itching, burning, and tearing. Signs include involvement of mainly upper conjunctiva in the form of a papillary conjunctivitis. The corneal epithelium reveals mild to moderate inflammatory changes that can result in scarring and neovasculariza-tion leading to...

Vitamin E and Age Related Eye Diseases

Cataract and age-related macular degeneration (AMD) represent the two most frequent disease states leading to vision loss worldwide. Both diseases usually occur in older adults. Oxidative stress with accumulation of free radical damage to the lens and retina has been considered causative to development of both cataract and AMD. Thus, the role of dietary and supplementary antioxidants, including vitamin E, -carotene, other carotenoids, vitamin C, and selenium, in preventing or slowing such age-related eye diseases has been extensively investigated. The DRI panel (1) in 2000 noted the existence of nine epidemiological studies (138-146) and one clinical intervention study (147) relating vitamin E status and supplementation to risk of cataract. The epidemiological studies were inconclusive, and the intervention study (147) showed no effect at 50mg -T per day.

Toxoplasma and glaucoma

Ocular toxoplasmosis appears to have a weak but important association with glaucoma. However, there is no prospective study that has examined the relationship between toxoplasmosis and glaucoma. Unlike herpetic uveitis, which is frequently associated with glaucoma, ocular toxoplasmosis in a retrospective study found the highest incidence (38 percent) of elevated intraocular pressure in patients with active ocular toxoplasmosis (Westfall et al., 2005). There was, however, no associated glaucomatous nerve damage. The elevated intraocular pressure appeared to resolve with resolution of the retinochoroiditis. A prospective study will be required to further examine any possible association.

Crosseyes And A Wandering Or Lazy Eye Strabismus Squint

If the eye sometimes wanders like this, but at other times looks ahead normally, usually you need not worry. The eye will grow straighter in time. But if the eye is always turned the wrong way, and if the child is not treated at a very early age, she may never see well with that eye. See an eye doctor as soon as possible to find out if patching of the good eye, surgery, or special glasses might help. IMPORTANT The eyesight of every child should be checked as early as possible (best around 4 years). You can use an 'E' chart (see Helping Health Workers Learn, p. 24-13). Test each eye separately to discover any problem that affects only one eye. If sight is poor in one or both eyes, see an eye doctor.

To Dry Eye Disease Non Sjogrens Dry

Inflammatory affections in dry eye disease are not only found in the lacrimal gland. Even in the clinically inflammation free and primary tear deficient non-Sjogren's dry eye an elevation of inflammatory cytokines (ILia, IL6, IL8, TNFa) is found in the tear film and inside the tissue of the conjunctiva 48 . The ability of conjunctival epithelial cells to release inflammatory cy-tokines has been reported 12 . This indicates a shift of the cellular immune response into the direction of an inflammatory Thi response similar to the inflammatory affections in the lacrimal gland and may similarly lead to a destruction of the epithelium and the underlying extracellular matrix 48,58 . The primary affection seems to lie in the epithelial cells, similarly

In Immune Mediated Dry Eye Disease

Common mechanisms in immune mediated dry eye disease. Different types of dry eye disease share an immune modulated inflammatory process that can similarly occur in the lacrimal gland (e.g. in Sjogren's syndrome) and at the ocular surface. It appears to start from epithelial defects resulting in a loss of immunological tolerance. Epithelial cells produce inflammatory cytokines (e.g. TNF-a, IL-i, IL-6, IFN-g), upregulate MHC class II and co-stimulatory molecules on their surface and allow uncontrolled antigen (AG) influx through defects. Together this leads to an uncontrolled activation of normal resident mucosal T cells into the inflammatory Thi type that also pro- Fig. 6.6. Common mechanisms in immune mediated dry eye disease. Different types of dry eye disease share an immune modulated inflammatory process that can similarly occur in the lacrimal gland (e.g. in Sjogren's syndrome) and at the ocular surface. It appears to start from epithelial defects resulting in a loss of...

Cataracts

When you have had diabetes for a long time, you are more susceptible to cataracts because of a build-up of sugars in the lenses of the eyes. These make the lenses of your eyes opaque, interfering with the transmission oflight to the back ofyour eyes, and can be a particular nuisance in bright sunlight. Fortunately, this problem can be treated quite easily with a simple operation to replace your damaged lenses with plastic ones. It can often be done under a local anaesthetic, and you will normally only have to be in hospital for 24 hours. The results are generally excellent.

Cataract

The lens of the eye, behind the pupil, becomes cloudy, making the pupil look gray or white when you shine a light into it. Cataract is common in older persons, but also occurs, rarely, in babies. If a blind person with cataracts can still tell light from dark and notice movement, surgery may let him see again. However, he will need strong glasses afterward, which take time to get used to. Medicines do not help cataracts. (Now sometimes during surgery an artificial lens is put inside the eye so that strong eyeglasses are not needed.)

Glaucoma

Uveitic eyes with glaucoma should be evaluated for the feasibility of implantation of a glaucoma drainage device (GDD) at the time of PPV. Anterior segment inflammation can cause early failure of trabeculectomies and also severe complications of fibrosis surrounding anteriorly placed tubes of GDDs 3 . Placement of the GDD in the posterior segment through the pars plana can avoid these severe complications. Excellent cleanup of the peripheral vitreous and posterior cortical vitreous is necessary to prevent aspiration of vitreous with possible retinal complications.

Naming of the vitamins

By 1915, Osborne and Mendel and also McCollum and Davis had between them distinguished two types of accessory factors based on their solubilities and called them 'fat-soluble A' and 'water-soluble B'. Fat-soluble A was present in butterfat and egg yolk a deficiency of this substance produced an infectious eye disease (xerophthalmia) and growth retardation in young rats. Water-soluble B was present in wheat germ and milk powder its deficiency produced the avian form of beriberi in pigeons. In 1920, the terminal '-e' was dropped from the word 'vitamine' and fat-soluble A and water-soluble B were renamed vitamin A and vitamin B, respectively. The anti-scurvy factor was named vitamin C. For some time it was considered probable that the anti-rickets factor might be identi

Dysfunction of the Afferent System

Surgical damage or amputation of trigemi-nal afferent nerves is a common cause of reduced corneal sensation. It has long been recognized that surgical sectioning of the trigeminal ganglion (to relieve trigeminal neuralgia) leads to LKC. Experimental trigeminal ablation in animal studies decreased conjunctival goblet cell density and corneal epithelial glycogen, and resulted in morphological alterations of ocular surface epithelia similar to those characteristic of LKC. Ocular surgical procedures that decrease corneal sensation include penetrating keratoplasty, photorefractive keratectomy, and LASIK.

Risk of Full Thickness Macular Hole in the Fellow

The majority of full-thickness macular holes are unilateral. Since many affected individuals have normal visual acuity in their fellow eye at the time of presentation, the risk of macular hole development in the fellow eye is an important consideration in clinical management. While a stage 1 macular hole is associated with an estimated 40-50 risk of progression to a full-thickness hole, the presence of a complete posterior vitreous detachment, as indicated by a Weiss ring, is associated with a risk of progression of less than 1 . In normal fellow eyes without a Weiss ring the incidence of macular holes has been estimated as 7.5 at 18 months and 15.6 at 5 years after presentation 18 . In clinically normal fellow eyes, abnormalities in focal electroretinogra-phy and in color contrast sensitivity 18 suggest that subclinical foveal dysfunction appears to be predictive of an increased risk of macular hole development.

Susruta Describes an Otoplasty

The Susruta-samhita is mainly a surgical compendium but also includes medicine, pathology, anatomy, biology, obstetrics, ophthalmology, hygiene, and psychology. The document contains descriptions of about 1,120 diseases. It also attempted to outline the philosophy of medical teaching what sort of student should be selected, how he should be trained, the oath he should take, and the qualifications a physician should have before entering into practice. The oath in the Susruta-samhita has been noted to be strikingly similar to that of Hippocrates and this has led many scholars to compare other points of the Greek and Indian medical systems. The two systems shared many fundamental beliefs such as the 3 stages of fever and that the body was composed of humors, whose derangement led to the development of disease.

To Macular Hole Surgery

Doses of TGF- 2 suggested a beneficial effect on visual outcome 44 , studies of nonbovine (recombinant) TGF- 2 demonstrated no significant benefit to vision. In a randomized controlled trial including 130 eyes, application of recombinant TGF-P resulted in anatomical closure in 78 of eyes compared with 61 in the placebo group (p 0.08), but there was no statistically significant difference in visual acuity between the groups 45 . Although the adjunctive use of APCin macular hole surgery results in a significantly higher rate of anatomical hole closure, no significant effect on functional outcome has been demonstrated. In a randomized controlled trial of surgery in 110 eyes the adjunctive use of APC resulted in 98 primary closure versus 82 in the control group (p 0.009), but visual acuity was not significantly different between the two groups 46 and subsequent study suggested relatively high rates of the late re-opening of macular holes.

Amniotic Membrane Transplantation

Amniotic membrane transplants (AMT) were first used in ophthalmology by De Rotth in 1940, who reported partial success in the treatment of conjunctival epithelial defects after symble-pharon 4 . Human amniotic membrane is derived from placenta, which consists of the inner amniotic membrane made of a single layer of amnion cells fixed to collagen-rich mes-enchyme six to eight cells thick loosely attached to chorion. It is composed of three layers a single epithelial layer, thick basement membrane, and avascular stroma. Human amniotic membrane is nonimmunogenic and has a unique combination of anti-inflammatory proteins and growth factors that promote wound healing. otic membrane is placed over the entire anterior surface of the globe, tacked down to conjunctiva, with 8-0 nylon interrupted sutures. A bandage soft contact lens is applied over this, and the amnion melts over the ensuing 4 weeks, typically revealing a total healing of the previously persistent epithelial defect.

Steroidsparing agents have fewer preventable and reversible side effects in comparison to steroids for treatment of OCP

Donnenfeld ED, Perry HD, Wallerstein A, et al. (1999) Subconjunctival mitomycin C for the treatment of ocular cicatricial pemphigoid. Ophthalmology 106 72-78 10. Foster CS (1993) Immunologic disorders of the conjunctiva, cornea, and sclera. In Albert DM, Jakobiec FA (eds) Principles and practice of ophthalmology, vol 1. Philadelphia, Saunders, pp 196199 12. Foster CS, Wilson LA, Ekins MB (1982) Immunosuppressive therapy for progressive ocular cica-tricial pemphigoid. Ophthalmology 89 340-353 19. Miserocchi E, Baltatzis S, Roque MR, Ahmed AR, Foster CS (2002) The effect of treatment and its related side effects in patients with severe ocular cicatricial pemphigoid. Ophthalmology 109 111118 20. Mondino BJ, Brown SI (1981) Ocular cicatricial pemphigoid. Ophthalmology 88 95-100 22. Mondino BJ, Brown SI, Lempert S, Jenkins MS (1979) The acute manifestations of ocular cicatricial pemphigoid diagnosis and treatment. Ophthalmology 86 543-555 24. Neumann R, Tauber J, Foster CS (1991) Remission...

Complications of Macular Hole Surgery

Peeling of the posterior vitreous cortex from the retinal surface can result in iatrogenic retinal tears. In the MMHS, retinal tears occurred in 3.2 of eyes and were effectively treated intraop-erativelyby retinopexy 13 . Retinal detachments occurred in 5.6 of eyes in the MMHS and in 11 of eyes in the VMHS 73 . Retinal detachments generally occur within the first 6-8 weeks postoperatively and have a high success rate of anatomic re-attachment following further surgery 13 . Although retinal detachment does not preclude improved final visual acuity, involvement of the macula and the development of proliferative vitreo-retinopathy indicate poorer prognosis 13 . The development of cataract is almost inevitable following macular hole surgery. Lens opacity has been reported in 46 of eyes at 3 months postoperatively 75 , and in greater than 80 by 2 years 33 . Since the development of cataract is predictable, combined cataract and vitrectomy surgery for macular hole has been advocated in...

Actuarial Survival Data on Corneal Transplantation

The probability of a complicated outcome is only part of the concept of risk. The consequences of an adverse outcome must also be considered. Outcome data should be applied to patients in their particular clinical context. For patients undergoing corneal transplantation the consequences of success or failure can be quite different from patient to patient. For patients with corneal disease in one eye and a normal contralateral eye very little is to be gained by the patient in a functional sense from a successful outcome. Visual ability is determined by how good the vision is in the better eye rather than the level of vision in the poorer eye. Grafts in anything but the favourable circumstances of keratoconus or stromal dystrophy are best avoided when vision is normal in the contralateral eye. Other patients have much to gain from achieving a functioning graft in high risk situations. Those with most to gain are those with poor vision due to corneal disease in an only...

Prognosis Following Macular Hole Surgery

Visual recovery following surgical closure of macular holes may be gradual. Although substantial improvement in visual acuity occurs soon after cataract extraction, further improvement may be observed for up to 2 years 79 . Visual recovery is inversely correlated with vision in the fellow eye, tending to be greater where vision in the fellow eye is subnormal 80 . Bilateral visual function improves in a significant proportion of patients after macular hole surgery, particularly where vision in the fellow eye is subnormal 30 . Successful closure improves stereoacuity 81 and has a beneficial effect on patients' subjective perception of visual function 82 , but the effect of macular hole surgery on patients' quality of life has yet to be fully evaluated. of symptoms, but is not dependent on the age of the patient. Anatomic and visual outcomes are inversely correlated to the stage of the hole and are greatest following surgery for small stage 2 holes 13 . The closure rate in patients...

What are the physical consequences

The importance of this cannot be overemphasised, and that knowledge may help to give you the incentive you need to stop or drastically reduce your smoking habit. This chapter will discuss the physical consequences of diabetes, in particular the short-term complications which include hypoglycaemia, hyperglycaemia and diabetic ketoacidosis (DKA) and how they can be avoided and treated. The chapter will also discuss the long-term complications, which may include heart disease, eye disorders, kidney disease, nerve disorders and foot and leg problems.

And Endotamponading with HSO Oxane HD

We have reported 5, 22, 23 the efficacy and safety of HSO (Oxane HD) as a heavier-than-water endotamponade in the treatment of persistent macular holes, after failure of vitrectomy, ILM peeling, long-acting gas endotamponading, and prone positioning. Oxane HD was removed after 3 months. The main outcome measures were anatomic success rate (closure of the macular hole) and best corrected visual acuity (BCVA). Anatomic closure of the macular hole was achieved in all patients. Postoperative BCVA improved, ranging from 20 40 to 20 100 with regard to preoperative BCVA ranging from 20 100 to 20 600. In our series OCT images showed that HSO, due to its specific gravity, achieved effective endotamponading of the foveal region in the upright position, allowing a good anatomic and functional recovery (Fig. 2.2). Therefore, HSO can be a safe and effective tool in the treatment of persistent macular hole.

Monoclonal Antibody Fragments

A problem with conventional antibody-based therapies for eye disease is that the molecules are too large to gain access to the eye by crossing the cornea. They cannot be administered as eye drops but instead must be given sys-temically. This has prompted the development and application of monoclonal antibody fragments which retain their ability to interact with the appropriate receptor but are small enough to cross the cornea if delivered topically into the precorneal tear film 100 . Antibody fragments have been engineered which interfere specifically with the elements operating in the proximal end of the afferent limb of the allograft response. They have been shown to retain their essential reactivity and to be absorbed across the cornea. Whether they are effective in abrogating the corneal allograft response remains to be determined.

Histology of the Mucosa

Mucosal tissues consist of two sheets (Fig. 6.1). The superficial sheet represents a unilayered or, at the ocular surface, a multilayered arrangement of epithelial cells. They usually have a strong mechanical connection by intercellular adherence junctions (e.g. desmosomes and zonulae adherentes) and are sealed by an apical tight junction complex that prevents entrance of foreign materials including potential antigens. Impairment of the epithelial integrity is a major reason for a deregulation of mucosal immunity and is observed in dry eye disease and in allergic eye disease but is also caused by the surgical trauma during corneal transplantation.

Longterm complications

The possibility ofdeveloping long-term complications is one ofthe most frightening aspects of diabetes. Prolonged periods of high blood sugar increase the risk of complications in people with diabetes. Common ailments include cardiovascular disease (such as high blood pressure and atherosclerosis), eye disorders, kidney disease, nerve disorders, and foot and leg problems. Most of these conditions result from years of chronic high blood sugar levels. The good news is that many ofthe possible problems can be treated, and often the treatment is most effective when the complications are noticed at an early stage. This is why you will be asked to go for regular medical check-ups.

Detachments in Eyes Undergoing Vitrectomy and Gas Exchange PVR

A total of 174 patients were recruited. Internal tamponade was achieved using SF6 gas in approximately 50 , C3F8 gas in 41-46 , and unplanned use of silicone oil was carried out in 3-8 of patients. The incidence of postoperative PVR was significantly lower in the treatment group (12.6 ) than in the placebo group (26.4 p 0.02). Patients in the placebo group had significantly worse final visual acuity (p 0.048) and showed a trend toward more re-operations resulting from PVR. The total numbers of primary successes and patients undergoing re-operation did not appear to be influenced by the treatment regime. Complication rates were low and evenly distributed between the two groups. The high rates of PVR in the patient groups in this

In Eyes Undergoing Vitrectomy and Silicone Oil Exchange PVR

Patients with retinal detachment who had developed PVR grade C or greater (anterior or posterior) 22 and who were to undergo vitrectomy and silicone oil exchange were recruited. A total of 157 patients were randomized to surgery with or without adjunctive 5FU and LMWH. Forty-five to fifty patients had not had previous vitreoretinal surgery. There were no significant differences in primary (retinal re-attachment without further vitreoretinal intervention at 6 months) or secondary (complete or posterior retinal re-attachment, visual acuity, hypotony, cataract, keratopathy) outcome measures although there was a lower incidence of macular pucker in the treatment group that marginally failed to reach statistical significance (p 0.068). No toxic effects of the adjunctive treatment were observed. Based on these results adjunctive 5FU and LMWH was not recommended for cases of established PVR.

Unselected Primary Retinal Detachments in Eyes Undergoing Vitrectomy and Gas Exchange PVR

The overall primary success rate of surgery was 84.4 and the complete anatomical attachment rate at 6 months was 98 . There was no significant difference in the rate of PVR - in the treatment group 7 developed PVR compared with 4.9 in the placebo group, or in mean final visual acuity. Notably, in patients with macular sparing retinal detachments the final visual acuity was significantly worse, raising the possibility of a toxicity effect of the adjunctive medications.

Summary for the Clinician

The use of a preoperative combined adjunctive regime of 5FU and LMWH to prevent PVR or recurrent PVR following retinal detachment has now been investigated in three large, prospective, randomized, controlled trials. These have demonstrated improved results in high-risk retinal detachments, but no benefit in unselected primary detachments or established PVR. Reduced visual acuity was observed in unselected macula-sparing retinal detachments receiving the adjuncts and may be due to a toxic effect.

How is retinopathy treated

Laser treatment developed in recent years can do a great deal to repair the damage caused by diabetic retinopathy. It is normally directed at the peripheral part of the retina, well away from the macula, and can remove hard exudates and prevent new blood vessels from growing. The earlier the treatment is given, the more successful it is, which is why it is essential that you should have your eyes checked at least once a year. An optician, a specialist ophthalmologist or a doctor who is skilled at this type of examination can do eye checks.

Alternative Routes Of Vitamin A Supply

In 1999, we described a novel case of two sisters aged 14 and 17 years with very low plasma retinol (0.19 mmol L) and RBP concentrations below the limit of detection (< 0.6 mmol L) (Biesalski et al., 1999). The levels of plasma REs, all-trans RA, and 13-cis RA were within normal ranges. The affected sisters came to attention because of ocular manifestations of vitamin A deficiency (night blindness). Eye examination (Seeliger et al., 1999) showed no signs of xerophthalmia but dark adaption was raised and visual acuity was reduced with atrophy of the RPE. No other abnormalities were detected. Growth and physiological functions were all normal and other clinical signs of severe vitamin A deficiency were lacking. A noninvasive liver store test revealed no depletion of vitamin A storage. A fat absorption test demonstrated normal fat and vitamin A absorption. Plasma levels of other fat-soluble vitamins (b-carotene, a-tocopherol) were normal so that a nutritional vitamin A deficiency could...

Activation of TLymphocytes by Cytokines

Pathophysiological events in allergic eye disease. Allergic eye disease is an inflammatory process that starts with the activation of mast cells (mc) by allergens crosslinking IgE bound to the high affinity IgE receptor on mc. This initially leads to degranulation of mc with release of vasoactive substances resulting in vascular exudation and edema. In the chronic forms this is accompanied by a release of Th1 and Th2 cytokines by mc. These cytokines activate several other cell types such as (counterclockwise in the figure) stromal fibroblasts, vascular endothelial cells, eosinophils (eos), conjunctival epithelial cells (ec), dendritic cells (dc) and lymphocytes (Ic). The activated cells in turn produce further mediators that reinforce the inflammatory process. Activated cells produce adhesion molecules (dendriform lines) like ICAM-1, VCAM-1, E-selectin and chemokines (small circles) and or their receptors (dendriform lines and excavated squares) that allow The inflammatory...

Eye Assessment Procedures

Visual acuity is clearness or sharpness of vision. A visual acuity test should be a routine examination of all patients. There are several special charts of test letters used, but the most commonly used chart is the Snellen chart. The patient is seated twenty feet from the chart. He places a clean card in front of one eye without putting pressure on the eye globe. The chart has several rows of progressively smaller letters. The patient is asked to read the letters down the chart as far as possible. A patient who can read the letters on the 20 20 line from a distance of twenty feet is said to have 20 20 vision in that eye. The same process is repeated for the other eye. If the patient normally wears glasses for distance, the test should be repeated with his glasses on. Results should then be recorded as uncorrected and corrected.

Visuospatial and Constructional History

This section of inquiry focuses upon disorders of complex visual processing.20 These disorders are very complicated. They can be screened and evaluated based on history and neurological examination, but a comprehensive appraisal of defects and quantification of these defects requires neuropsychologic, neuroimaging, or neuro-ophthalmologic evaluations. There are some very simple

Electron Microscopic Methods

(caption continued from the previous page) antirhodopsin by the immunogold procedure with silver intensification. The gold particles and the melanin granules in the retinal pigment epithelium (R) appear as bright white dots. Original magnification, X160. In the normal retina, rhodopsin labeling is restricted to the outer segments (*), while in the RP retinas the labeling is present in the tiny rod outer segments (short arrows) and the surface membranes of the rod inner segments (long arrows), somata (open arrows) and neurites (arrowheads). N, inner nuclear layer. (*) in bottom two panels, inner limiting membrane. Reprinted from ref. 13 with permission of the Association for Research in Vision and Ophthalmology.

Etiology and Classification

The pathogen maybe exogenous or endogenous. Of the former, we distinguish between those caused by trauma or surgery the latter may follow trabeculectomy or other types of surgery (most commonly cataract extraction). Such postoperative endophthalmitis may be acute (presenting within a few weeks of surgery) or chronic. eyes with the same inclusion criteria as those in the Endophthalmitis Vitrectomy Study (EVS) acute postoperative endophthalmitis occurring within 6 weeks of cataract extraction with intraocular lens implantation or of secondary intraocular lens implantation. Treating eyes with endophthalmitis of other etiologies or chronicity requires a somewhat modified strategy, including timing and surgical details. These are not discussed here.)

Gainof Function Bcl2 Transgenics

Bcl2 has also been expressed at high levels in a variety of tissues to determine the effect of perturbing apoptosis during normal development. Expression of Bcl2 in neurons results in hypertrophy of the central nervouse system (CNS) associated with a reduction in cell death during early neural development (130). In a similar manner, targeted expression of Bcl2 to the lens of the eye disrupted normal fiber-cell differentiation, causing cataracts, vacuolization, disorganization, and inhibited fiber-cell enucleation (131). Formation of the mouse vaginal opening at puberty requires apoptosis, and expression of Bcl2 in the suprabasal epithelial cells and subepithelial cells of the vaginal mucosa blocks vaginal formation entirely (132). Such studies demonstrate the importance of PCD during normal development, and show that Bcl2 can function in these tissues to block apoptosis, at least when expressed at supraphysiological levels.

Consequences of the EVS Recommendations

Vitrectomy for endophthalmitis was becoming increasingly popular 3 when the publication of the EVS in 1995 dramatically and abruptly changed the treatment philosophy. As advocated by the EVS, vitrectomy is now reserved for the most severe cases, and this vitrectomy is limited to the anterior vitreous. (Systemic antibiotics are still used by many ophthalmologists.) The following quote is a typical example If a vitrectomy is indicated (e.g., a patient with visual acuity of light perception ), a core vitrectomy should be performed, and no attempt should be made to excise the cortical vitreous 6 . This management approach is now typical even in countries where the ophthalmologist's decisions can still be made based on purely medical, rather than on medicolegal or insurance company-forced reasoning.

Control Measures In The Military

Individuals routinely using Class 3 or Class 4 lasers in any research, development, testing, and evaluation (RDTE) effort where adequate protective measures are not feasible should be tested. Those people who are involved in only one laser test of short duration would not normally receive preplacement or termination eye examinations. They would be examined only if an injury caused by laser radiation was suspected. (2) Hazardous laser equipment. Certain laser equipment, such as tripod-mounted, hand-held or airborne laser range finders, designators, or illuminators may be determined to be of sufficient hazard to operators and related personnel that the Surgeon General may require such persons to be examined. The warning page of the operator's and maintenance manuals for each laser device shall indicate which types of user or related personnel should be examined. Operators of currently fielded tactical laser systems are not required to receive this eye examination. (b)...

Medical Terms Related To The Eyes

Astigmatism--refractive error which prevents the light rays from coming to a single focus on the retina because of different degrees of refraction in the various meridians of the cornea. b. Cataract--a lens opacity a loss of transparency of the lens of the eye, resulting in partial or total blindness. Surgery results in improvement of vision in 95 percent of those affected. k. Glaucoma--a group of eye diseases characterized by abnormally high intraocular pressure (pressure in the eyeball). This pressure can damage the optic nerve and, if untreated, lead to a gradual loss of vision -- and eventually blindness. l. Hyperopia (farsightedness)--a refractive error in which the focal point of light rays from a distant object is behind the retina. o. Myopia--a refractive error which the focal point for light rays from a distant object is anterior to the retina. r. Presbyopia--old sight, physiologically blurred vision, often occurs soon after 40 if at all.

Symptoms Of Laser Injury

A reduction in the clearness of vision and pain are the main symptoms of laser injury. It may not be known that lasers are in use therefore, medical personnel should suspect that a soldier has been exposed to lasers if he reports seeing bright flashes of light, he experiences eye discomfort and poor vision, and he has a feeling of unexplained heat. Obvious lesions such as corneal burns, retinal injury, retinal hemorrhage, and skin burns make the diagnosis of injury from lasers more certain.

The clinical features of ocular toxoplasmosis

Because of overlapping visual fields and the fact that ocular toxoplasmosis is usually active unilaterally not bilaterally - a change in vision may not be initially detected unless unilateral daily screening occurs. An Amsler Grid, a graph paper like grid of boxes, mounted to a flat surface may help compliance with self-vision screening. In addition to decreased vision in the area of reactivation, patients will likely have floaters or other media opacity related complaints that will vary depending on the degree of inflammation when the lesion was active and may persist after resolution of the underlying reactivation secondary to inflammatory debris being trapped within the vitreous.

First Aid For Laser Injuries

The best eye protection from lasers is the protective eyewear made for this purpose. If such eyewear is lost or damaged, use any protective gear that is available. Ordinary eyeglasses or sunglasses will afford a very limited amount of protection. Even squinting can limit the amount of laser energy that enters the eye. h. Have periodic eye examinations because certain laser devices can cause damage to the eye.

Clinical Features of Uveitis in JCA

The onset of uveitis in children with JCA is usually insidious, bilateral and anterior in type 8 . It is almost characteristic that even severe intraocular inflammation does not lead to ex-traocular signs and no alarming symptoms are recognized by the parents. Because of this asymptomatic onset there is often a significant delay of adequate diagnosis and treatment. It is not rare that children first seen by an ophthalmologist already present with secondary ocular complications such as persistent synechiae or cataract formation. In contrast, a more symptomatic, acute onset is more probably seen in HLA-B*27 positive boys at the age of 8-15 years who often develop spondylarthropathy later. Intraocular inflammation occurs bilaterally in more than 70 of children and involves the second eye within a few months 34, 67 . Only rarely will the contralateral eye be involved after more than a year has elapsed from the primary manifestation. Most commonly ocular signs are unspecific and present as...

Classification systems for uveitis and chorioretinitis

Freidmann and Knox (1969) described three types of chorioretinal lesions found in a cohort of patients with no other clinical manifestations of T. gondii infection. Of these patients, 56 percent had 'large destructive lesions'. This type of lesion is characterized by its size a large destructive lesion is usually larger than the optic disk and is likely to be associated with vision loss and or complications such as retinal detachment, cataracts, cystoid macular edema, glaucoma, and chronic intraocular inflammatory reactions. 'Punctate inner lesions' accounted for 27 percent of the patients these were described as being smaller and less likely to be associated with vitreous traction. 'Punctate deep lesions' appeared in 17 percent of the patients this type of lesion is always located in the macula or peripapillary area. Because the infected tissue is separated from the vitreous by uninvolved retinal layers, punctate deep lesions are usually not associated with vitreous inflammation.

Complications of Uveitis in JCA

The overall prognosis and functional outcome in children with JCA may have improved nevertheless a number of ocular complications can lead to poor prognosis for vision. The most frequent complications include band keratopathy, secondary glaucoma, posterior synechiae, cataracta complicata, and cystoid macular edema (Table 9.3). Secondary glaucoma has been frequently associated with a poor prognosis in children with uveitis. Up to 27 of glaucomatous eyes in JCA ended with no light perception 77 . A number of factors may contribute to this unsatisfactory Cataract Glaucoma Fig. 9.1. Typical (unspecific) clinical presentation of chronic uveitis in JCA displaying band keratopathy, posterior synechiae and secondary cataract in a 7-year-old girl with oligoarthritis Fig. 9.1. Typical (unspecific) clinical presentation of chronic uveitis in JCA displaying band keratopathy, posterior synechiae and secondary cataract in a 7-year-old girl with oligoarthritis outcome including difficulties in...

Topical Steroid Treatment

Any severe anterior inflammation should be carefully monitored for formation of posterior synechiae. Development of cataracts seems to be a particularly characteristic in children following these sequelae. Short acting mydriatics are sufficient to control synechiae formation in most of the patients with moderate inflammation when applied once at bedtime. In more severe manifestations scopolamine twice daily might be necessary. It has to be kept in mind that the pupil should be kept mobile and not constantly dilated, which bears the risk of synechiae formation in a mydriatic state of the pupil. Therefore long-acting agents such as atropine should be avoided. In addition, long-term unilateral cycloplegia may result in amblyopia in young children.

Complications and Their Management

It must be emphasized that the decision whether to undergo surgery is the patient's the ophthalmologist should inform the patient about the condition and the risks benefits of each treatment option in a way that allows the patient to make a choice that he is comfortable with 9 . The authors strongly believe that the primary line of treatment for the vast majority of eyes with endophthalmitis should be vitrectomy i.e., purely medical treatment is the exception, not the rule (Fig. 5.6). The decision whether surgery

Eent Diseases And Disorders Section I Ocular Diseases And Disorders 31 Introduction

Disorders which affect our ability to see, hear, smell, or speak cause considerable anxiety because such conditions affect those functional areas which influence the way we interact with our environment. Most of the EENT problems seen in the field setting can be treated adequately without extensive medical intervention. Learning to differentiate, however, between those EENT disorders which must be evacuated and those which will soon be resolved will be critical in the management of casualties. Common ocular diseases and disorders include the following exudation (conjunctival discharge) gonococcal conjunctivitis inclusion conjunctivitis (swimming pool disease) herpes simplex keratitis (dendritic) uveitis cataracts corneal ulcer eye strain floaters (spots before the eyes) blepharospasm (tics) hordeolum (stye) lid disorders and other related diseases and disorders.

Herpes Simplex Virus HSV Infection

However, anterior uveitis may occur with no active corneal inflammation. Recurrent episodes can damage the eye and spread to the posterior segment, involving the vitreous and the retina. Despite virological confirmation, mostly by polymerase chain reaction, it is still not known if uveitis is due to a viral cytopathic effect or an immunopathologic phenomenon 24 . Redness, photophobia, pain and visual impairment are frequently observed. Intraocular inflammation is usually acute, unilateral, and granulomatous with posterior synechiae and sectoral iris atrophy (Fig. 10.3). Iris masses have been reported. Secondary glaucoma due to trabeculitis is a major sign of herpetic uveitis. Glaucoma may be temporary, but chronic forms without concomitant active infection or inflammation are also possible. Mild to severe cell and flare reaction in the aqueous humor is common. Hypopion can be observed in severe forms, but hyphema is also possible. Van der Lelij et al. have reported molecular diagnosis...

Varicella Zoster Virus VZV

Uveitis is much more common after herpes zoster ophthalmicus. Nearly two-thirds of patients with herpes zoster involving the ophthalmic division of the trigeminal nerve may present ocular involvement, especially without acyclovir prophylaxis. Uveitis is less frequent after an episode of varicella. Ocular inflammation is often delayed relative to the onset of cutaneous lesions. An interval of 2-4 weeks may separate both diseases. Uveitis seems to be more severe when it is delayed and associated viral retinitis should be eliminated, especially in im-munocompromised or elderly patients. Grey or brown keratic precipitates are localized in the inferior part of the cornea, but may be more diffuse with a leopard pattern (Fig. 10.4). Ischaemia of the anterior segment is classically associated with VZV uveitis. The presence of sector and patchy atrophy may be related to virus-induced ischaemia. Anterior uveitis is often acute, unilateral, granulomatous, and associated with posterior synechiae...

Cytomegalovirus CMV Uveitis

Ocular inflammation lasts for a long time and seems to be mild to moderate. Small size KPs are brown and scattered in the lower part of the cornea. This disease occurs more frequently in elderly patients. Sectorial iris atrophy is not a common finding and posterior synechiae are rarely observed. Secondary glaucoma seems to be a consistent complication and becomes resistant to medical anti-glaucomatous therapy in the absence of specific anti-CMV therapy. It is important to note that the posterior segment of the eye is usually not involved.

Epstein Barr Virus EBV Uveitis

Benign and transitory uveitis has been described during the course of EBV-associated infectious mononucleosis. Different forms of anterior uveitis, multifocal choroiditis and panuveitis have been attributed to EBV infection 58 . However, it is difficult to isolate a distinct entity to characterize EBV infections of the eye. This is probably due to the risk of blood contamination associated with the presence of EBV in mononuclear cells, which may be found after anterior chamber paracentesis. Uveitis may be chronic, uni-or bilateral, granuloma-tous, and associated with diffuse iris atrophy and severe glaucoma.

Posner Schlossman Syndrome

Posner-Schlossman syndrome is strictly unilateral associating a granulomatous anterior uveitis with central KPs and secondary glaucoma. Posterior synechiae are absent. Intraocular synthesis of anti-CMV antibodies was previously reported by Bloch-Michel and associates 7 . The disease is probably multifactorial and different entities must be considered. Antiviral

Role of Ultrasonography

Gram-positive bacteria cause by far the most cases of acute endophthalmitis after cataract surgery. The number of Gram-negative cases is decreasing and current data suggest an incidence of considerably less than 10 11 . A survey of studies investigating the microbiologic aspects of postoperative endophthalmitis reveals that co-agulase-negative staphylococci represent about half of all culture-positive acute endophthalmitis cases, followed by Staphylococcus aureus and P-hemolytic streptococci 1, 9, 11 . Figures 6.5-6.7 give an idea of the microbiologic view of endo-phthalmitis.

Fuchs Heterochromic Cyclitis FHC

Fuchs' heterochromic iridocyclitis is frequently diagnosed in young patients. The disease is usually unilateral even though bilateral cases have been rarely reported. Pain and redness are absent. Small stellate keratic precipitates are uniformly scattered over the endothelium. Different infectious conditions such as toxoplasmosis have been described during FHC, but the putative role of a pathogen is still under debate. Recently, Barequet et al. have analysed the aqueous humor and the anterior capsule of the lens obtained during cataract surgery in a patient with FHC. HSV DNA was identified in the ocular fluid but not in the lens capsule 5 . More specific data are needed before drawing further conclusions about the pathophysiology of the disease.

Anterior Chamber Paracentesis ACP

ACP seems to be safe, but it should be considered a surgical procedure and be performed by an experienced ophthalmologist. It can be performed at the slit lamp or under a microscope in the operating room after instillation of topical antibiotic and anaesthetic drops. Up to 0.2 ml can be obtained. In a retrospective study of 36i patients, Van der Lelij and Rothova reported no serious complications, such as cataract, keratitis or endophthalmitis after paracentesis 62 . Hy-phema was reported in seven cases. The same degree of safety was reported in another series

Early Pars Plana Vitrectomy

Since the results of the Endophthalmitis Vitrectomy Study 10 have been published it has generally been believed that immediate pars plana vitrectomy (PP V) is not advantageous over simple intravitreal administration of antibiotics. However, some surgeons still prefer early PPV, possibly together with extraction of the intraocular lens implant, in the case of endophthalmitis after cataract surgery. Early PPV supports the ancient surgical principle of relieving an abscess immediately ( Ubi pus, ibi evacua). On the other hand, vitreoretinal surgery in the severely inflamed endophthalmitis eye includes a number of significant risk factors.

Clinical Features

The late stage appears from 5-15 years after the primary infection, and it develops in 10-15 of patients. There are nodules that darken and ulcerate, palmar and plantar hyperkeratosis and hypertrophic lesions with bone and joint abnormalities. Chronic osteitis causes so-called Sabre tibia Nasal deformities (goundou) or nasal and palatal perforation (gangosa) occur. Neurological and ophthalmologic involvement is controversial. Yaws in this stage spares skin folds.

Differential Diagnosis

Patients may also present with a zone of active retinitis adjacent to the optic nerve. Differentiating this lesion from an optic neuritis may be difficult. The optic nerve head often will become hyperemic, but vision and visual fields are usually preserved until the optic nerve becomes infected with CMV 17 . Rapid initiation of therapy is required. Optic neuritis may be a manifestation of other viral infections such as zoster retinitis where rapid initiation of therapy is also required 18, 19 . Often these patients have a more significant visual impairment or have other manifestations of disease.

The answers are 403c 404a 405e 406b 407d

(Levinson, pp 302, 306, 307, 320-335.) All the diseases listed in the question have significant epidemiologic and clinical features. Toxoplasmosis, for example, is generally a mild, self-limiting disease however, severe fetal disease is possible if pregnant women ingest Toxoplasma oocysts. Consumption of uncooked meat may result in either an acute toxoplasmosis or a chronic toxoplasmosis that is associated with serious eye disease. Most

Ocular Toxoplasmosis

In patients with underlying immunosuppres-sion or immune defects, such as with bone-marrow transplantation or HIV, toxoplasmic chorioretinitis is often associated with concurrent toxoplasmic encephalitis (TE) or disseminated infection (for review, see Montoya et al., 2004). However, even in AIDS patients toxoplasmic chori-oretinitis is encountered relatively infrequently (Holland et al., 1988a), so most of the human cases of ocular toxoplasmosis are found in immunocompetent patients. Indeed, T. gondii is one of the most frequently identified causes of uveitis and the most commonly identitified pathogen infecting the retina of otherwise immunocompetent individuals (Holland, 1999) and, regardless of whether ocular toxoplasmosis is due to a reactivated congenital infection or to an infection that is acquired after birth, it usually presents in the immunocompetent host as a more-or-less localized eye disease (Montoya et al., 2004). Therefore, an animal model, particularly one that may be...

National Adult Reading Test

The National Adult Reading Test (NART) has been restandardized against the Wechsler Adult Intelligence Scale-Revised (WAIS-R).26 This restandardization allows the reading score taken from the NART to be used to predict the WAIS-R full-scale, verbal, and performance IQs, which are predicted from the number of errors made on the NART. This allows the estimation of a predicted full-scale IQ within the interval of 69 to 131. If a person has a language disturbance following a brain injury, the NART may underestimate premorbid ability. Therefore, patients who are aphasic, dyslexic, or who have articulatory or visual acuity defects probably should not be screened using this instrument.27 Moreover, the standardization sample did not include subjects of more than 70 years age.

Wide Angle Viewing System

A wide-angle viewing system using a binocular indirect ophthalmomicroscope (BIOM) or contact lens has become popular because the surgeon can see a wider area of the fundus simultaneously (Fig. 7.11) 37 . By viewing a wider area of the fundus, the surgeon can recognize the fundus pathology better and can treat lesions more safely and efficiently. The focus of the new BIOM system can be adjusted by the surgeon using a foot-pedal, while the focus needs to be adjusted by a handle in the old BIOM model. The new contact lens for a wide angle viewing system has a smaller diameter (Fig. 7.12) 28 . The reduction of the diameter of the lens has made it possible to visualize the scleral port directly so that the insertion of surgical instruments through the scleral port can be accomplished without any problems.

Anterior Segment Changes

Structural changes of the anterior portion of the eye, including posterior synechiae, iris atrophy, and peripheral anterior synechiae, may develop during the course of repeated ocular inflammatory attacks. The presence of peripheral anterior synechiae or iris bombe from pupillary seclusion may lead to secondary glaucoma.

Neuropsychological Tests of Attention

The major strength of this test is its easy administration and the fact that it can be given at the patient's beside. Not only is it sensitive for patients who have sustained traumatic brain injuries, but also it has been shown to be sensitive to early attentional changes in those afflicted with cerebral AIDS. It may not be appropriate for individuals who demonstrate poor vision or those who are severely anxious at the time of testing. Patients with significant motor impairment or psychomotor retardation may perform poorly on this test.12

Staining of Internal Limiting Membrane with Indocyanine Green

There are several reports with favorable results following ICG-assisted ILM peeling. Meta-analysis of these reports showed MH closure after initial surgery in 96 and improved visual acuity in 79 (Table 7.2) 18, 19-23 . On the other hand, there are also reports with unfavorable results (Table 7.3) 2, 11, 16 . Visual field defects could be one ofthe postoperative complications following ICG-assisted ILM peeling for MH or epireti-nal membrane 16, 19 . Kanda et al. found that visual field defects were strongly related to the concentration of ICG 19 . When they stained ILM with 0.5 ICG for 3 min during MH surgery, visual field defects developed in all 12 eyes. They changed their technique to the injection of 0.5 ICG followed by immediate aspiration of ICG. With this technique, visual field defects developed in 1 out of 4 eyes. Then they diluted ICG more and used 0.25 ICG with immediate aspiration and did not find any visual field defects. Therefore, ICG is potentially toxic however, this...

The Neuropsychological Measurement of Memory

The Ruff-Light Trail Learning Test assesses visuospatial learning and memory in adults. The test was specifically developed to avoid requiring the patient to possess drawing skills, keen eyesight, good motor control, and refined visuospatial integration. Thus, it is very useful in traumatically brain-injured persons.90 This test makes a direct measure of immediate visual memory as well as visuospatial learning. It also has a delayed recall section, and it allows for the development of learning curves over the course of the testing. It has been standardized for use with individuals ages 16 to 70 years, and normative data are available for two age groups 16 to 54 years and 55 to 70 years. It is not validated for individuals under the age of 16.

Perfluorocarbon Liquid and Heavy Silicone

Asami T, Terasaki H, Kachi S, et al. (2004) Ultrastructure of internal limiting membrane removed during plasmin-assisted vitrectomy from eyes with diabetic macular edema. Ophthalmology 111 231-237. Burk SE, Da Mata AP, Snyder ME, et al. (2000) Indocyanine green-assisted peeling of the retinal internal limiting membrane. Ophthalmology 107 2010-2014. Charles S. (1977) Fluid-gas exchange in the vitreous cavity. Ocutome Fragmatome Newsletter 2 1 Coll GE, Change S, Sun J, et al. (1995) Perfluo-rocarbon liquid in the management of retinal detachment with proliferative vitreoretinopathy. Ophthalmology 102 630-638. 9. Da Mata AP, Burk SE, Foster RE, et al. (2004) Long-term follow-up of indocyanine green-assisted peeling of the retinal internal limiting membrane during vitrectomy surgery for idiopathic macular hole repair. Ophthalmology 111 2246-2253. 14. Fujii GY, de Juan E, Humayun MS, et al. (2002) A new 25-gauge instrument system for transconjunctival sutureless vitrectomy surgery....

Bleeding Behind The Cornea Hyphema

Blood behind the cornea is a danger sign. It usually results from an injury to the eye with a blunt object, like a fist. If there is pain and loss of sight, refer the person to an eye specialist immediately. If the pain is mild and there is not loss of sight, patch both eyes and keep the person at rest in bed for several days. If after a few days the pain becomes much worse, there is probably hardening of the eye (glaucoma, p. 222). Take the person to an eye doctor at once.

Postoperative Management

All patients are re-examined on the first postoperative day and then within 7 days of surgery at our center or by the referring ophthalmologist. Topical antibiotic, steroid, and cycloplegic drops are administered in the standard fashion as for other vitrectomy procedures.

Diabetes complications

Annual test for urine microalbumin if urinalysis negative for protein Annual dilated eye examination Smoking cessation Microvascular disease affecting the eyes, kidneys, and feet can be devastating for the patient with diabetes. Annual dilated ophthalmology examinations, urine screening for protein or microalbumin, and a careful foot examination at each healthcare visit can help to detect complications early, allowing for stabilization and improved outcomes. Preventive care suggestions in the management of diabetes are outlined in Table 15.8.

Clinical Symptoms and Findings

Patients with MEWDS usually present with unilateral visual impairment consisting of visual loss of diverse importance (severe visual loss in some cases) and scotomatas objectively identified by visual field testing. Characteristic symptoms include photopsias that are usually spontaneously reported by the patient. The disease usually hits only once and the evolution is spontaneously favourable with restoration of visual function within 6-12 weeks.

Rhegmatogenous Retinal Detachment

We have not seen rhegmatogenous retinal detachment in any of our patients, despite omitting retinopexy and internal tamponade (although one of our patients was treated surgically for retinal detachment by the referring ophthalmologist despite our reassurance that this was exudative and not rhegmatogenous). Our encouraging experience is similar to that of trans-retinal FNAB, which is generally performed without laser treatment or intraocular gas injection. Our impression is that the tumor itself and any associated exudation tamponade the retinotomy.

Genotype Phenotype Correlations

Dilation is achieved within 5 min (after applying 1 drop of Mydriacyl per eye) and lasts for up to 2 h. The eye should be evaluated within 15 min after application of the dilating drops. Under high magnification, a slit beam is passed across the anterior segment. Oblique illumination by the slit beam, will provide an optical cross-section of the lens and cornea. If opacification of the lens is detected, direct illumination along the visual access will allow the cataract to be visualized against the fundus reflex (red reflex). This is often useful in determining its density and position.

Visual Field Testing

Corticosteroid and or immunosuppressive treatment were not proven to be useful in APMPPE. Visual acuity and visual fields are known to recover spontaneously in most patients. In cases with profound bilateral visual loss, being aware of the vasculitic component in APMPPE, we empirically prescribed systemic corticosteroids in some severe cases with a consecutive good functional recovery. Recovery could probably also have occurred without treatment, but the high level of anxiety of the patient has to be taken into account, which is moreover enhanced by his knowing of the inflammatory nature of the disease.

Test of Nonverbal Intelligence

Who have language dysfunction, hearing impairment, poor English skills, or cultural differences. It may be difficult for patients who have significant visual impairment. Thus, a patient who has a visual field cut or a neglect syndrome may not be appropriate for this examination. Moreover, it will not provide a measure of verbal skill, and its ability to measure intellectual functioning is not equivalent to the Wechsler Scales.12

Surgical Treatment for Vitreous Floaters Important Studies

Activities, mental health and peripheral vision all significantly improved following surgical intervention. Most importantly, no complications occurred. Since cataract and floaters sometimes coexist in elderly patients, Mossa et al. suggested combined phacoemulsification and deep anterior vitrectomy via a posterior capsulorhexis 20 . They reported on a series of 10 eyes and called this procedure floaterectomy. However, this procedure is not appropriate for the safe and controlled removal of posterior located floaters which are more likely to cause symptoms. Possible intraoperative posterior segment complications cannot be treated adequately with this approach 27 .

Hooper Visual Organization Test

This test consists of showing children 30 pictures of objects that have been cut up and placed in different positions. Norms exist in order to assess children as young as age 5 years.134 The child is required to visually examine each picture and decide what it would be if it were assembled and write down the name of the particular object, such as fish, ball, or key. Test items are arranged in increasing difficulty, and most children can complete the test in approximately 15 min. It is sensitive to posterior brain damage. Poor performance on this test can be due to poor visual acuity, low intellectual functioning, psychiatric disease, and poor effort.12

Surgical Technique

The surgical procedure was technically uncomplicated in all patients. No severe postoperative complications occured in our small group of patients. Nuclear sclerosis requiring lens removal developed in 2 of 5 phakic patients. These two patients were 50 and 57 years old. In 3 younger phakic patients (40 years, 40 years, 46 years) no cataract progression was observed during the follow up period of 13 months and VA remained stable. No cataract surgery related complications occured. Objectively, their visual acuity - tested with standardized methods - had remained the same. Two patients who underwent cataract extraction, stated that this complication and the subsequent operation would not have changed their initial decision for the vitrectomy. No PVD occured in the follow-up period in any of the 3 eyes having an attached posterior hyaloid prior to surgery. He reported diminished productivity and inability to read for extended periods. Ocular history was otherwise unremarkable. On initial...

Analysis of Clinical Studies

What is the central question that we can answer after the analysis of previously published small case series and our small group of patients Due to the small number of patients included we most certainly can not comment on the frequency rate of complications. A much higher complication rate after pars plana vitrectomy for secondary vitreous opacities due to branch retinal vein occlusion, uveitis, vasculitis, sickle cell retinopathy and other severe ocular disorders was reported in an early article of Peyman et al. published in 1976 23 . In these early vitrectomy years complications of vitrectomy were markedly higher than nowadays with markedly improved instrumentation and techniques. But this experience caused the very restraining and conservative indication for vitrectomy in eyes with good visual acuity. Today, iatrogenic tears, retinal detachment and other complications in this group of patients seem to be low, but will definitely occur with increasing number of patients. The...

Christian Science Medicine

Christian Science was a good experience for me. And there was always testimony of healing and how you saw it interact in your life. You sort of shared in conducting that experience and where you found quotes within the bible that would help you along that turning point. I heard stories of people getting over cancer, people who were born blind seeing without glasses.

Alternative Assessment of Visual Function

Snellen visual acuity is the most widely used measure of vision testing. This parameter is often misleading in patients with visually disturbing vitreous floaters. Floaters are not recognized as a disease. The clinician cannot understand the complaints of affected patients who then feel frustrated and misunderstood. Other measures, including contrast sensitivity, stereopsis, reading speed, colour discrimination, visual field, and glare testing, have demonstrated that visual acuity is a descriptor of one simple aspect of vision rather than a comprehensive assessment of visual function. Standard clinical tests, such as Snellen visual acuity, are unable to quantify many aspects of a visual disturbance and how the disability interferes with day-to-day functioning and overall quality of life. Nevertheless, objective testing is necessary to help quantify the degree of disability and to define criteria used to recommend surgical intervention. Further tests should be established that may...

Diagnostic Usefulness

Knowledge of the normal appearance of anatomic structures in the image and visual acuity in noting deviations from the normal are the tools that the radiologist uses in making his interpretations. Because an essential point in the radiographic diagnosis often appears in an inconspicuous portion of the image, a systematic analysis and evaluation of the entire image is necessary. This requires the entire image to be diagnostically informative and to have translucent silver deposits representative of the anatomic structures. The radiographic images must represent the true anatomic situation, and their appearance should always be fairly consistent. Standardized projections of an anatomic part always portray the structures in the same manner.

Supratentorial Tumors

The patient may present to the physician because of short stature secondary to pituitary-hypothalamic involvement. Peripheral vision loss may occur secondary to pressure or injury to the optic chiasm. If the patient has hydrocephalus, then papilledema is present. A 4-year-old boy with neurofibromatosis presents to the ophthalmologist with complaints of decreased visual acuity according to his parents. On physical examination the patient has proptosis and papilledema. Definition. Optic gliomas are low-grade astrocytomas that cause decreased visual acuity and pallor of the discs. Presentation. Patients with optic gliomas may present with papilledema , decreased visual acuity, proptosisj and optic atrophy. If a child has a chiasmatic tumor, asymmetric nystagmus may be the presenting sign.

Adverse Effects Associated With Glucocorticoid Therapy

Posterior Subcapsular Cataract Formation. This type of cataract formation is associated with prolonged systemic glucocorticoid therapy and it appears to be dose-related (e.g., 20 milligrams of Prednisone taken orally for several years). Children are more frequently affected with this adverse effect than are adults.

State Trait Anger Expression Inventory2

There is evidence that, in some individuals, attention can be substantially impaired following traumatic brain injury, and the attentional dysfunction may affect driving skill. Recent research suggests that the attentional deficit causes impairment in the driver's ability to cope with time pressure.63 In terms of assessment, some evidence suggests that the Useful Field of View (UFOV), a measure of visual information processing, is a good predictor of vehicle crash risk in older adults. Recent research suggests that traumatic brain injury survivors have higher UFOV scores than young adults, which indicates a greater functional loss of peripheral vision in these individuals. Previous studies in older adults have shown that people with UFOV deficits are more likely to experience vehicle crashes.64,65 Further recent research suggests that virtual reality testing may provide an innovative medium for direct evaluation of basic cognitive function such as divided attention and its impact on...

West Nile Virus Choroiditis

Almost 80 of patients have posterior segment involvement, which is symptomatic in one-third of the patients. There can be a decrease of visual acuity, blurred vision and floaters. Posterior lesions consist of a typical multifocal bilateral choroiditis associated in all cases with a mild vitreous inflammatory reac-tion.The lesions, circular in shape, vary in number from less than 20 to more than 50 per eye. Chorioretinal lesions involve the midzone and or periphery, more prominently in the temporal and the superonasal quadrants as well as the posterior pole. Lesion size ranges from 100 mm to 1,500 mm, with most of the lesions measuring 200-500 mm. Linear clustering of chorioretinal lesions gives the typical pearls on a string aspect of this choroiditis (Fig. 15.6). Active chorioretinal lesions appear as deep, creamy lesions on ophthalmoscopy, with early hypofluorescence and late staining on fluores-cein angiography. Resolved chorioretinal lesions are partially atrophic and partially...

Accommodation Convergen ce Reaction

The eyeball is formed by three layers the sclera, choroid, and retina. The shape of the lens is modified for near and far vision by the ciliary muscle during the accommodation reflex. The sclera is the external layer and continues anteriorly as the cornea, which is transparent and allows light to enter the eye. The intermediate choroid layer is highly vascularized and pigmented. Anteriorly, the choroid layer forms the ciliary body and iris. The retina contains the photoreceptive layer of rods (for night vision and dim light) and cones (for color vision and high visual acuity).

Alternative Approaches

The observation that apoptosis may be manipulated by growth factors suggested an alternative therapeutic approach. The first indication that this may be viable was the demonstration that injection of basic fibroblast growth factor (bFGF) into the eye resulted in long-term survival of photoreceptors in the RCS rat (19). A potential disadvantage of bFGF is its lack of specificity since it influences many cell types. For instance in the rabbit, it can cause cataract and proliferative vitreoretinopathy (20). Neurotrophins, including brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF) and neurotrophin 4 5 (NT4 5) appear to be more attractive since they have a relatively specific influence on neural tissue (21). They are present in the CNS, and play important roles in neural development, differentiation and survival (21). Another important neurotrophic factor is the ciliary neurotrophic factor (CNTF) that is closely related to the interleukin 6 (IL-6) (22). There is an...

The influence of wine consumption on agerelated macular degeneration

Over the past several decades, attention has focused on the negative health consequences of alcohol. In addition to ocular anomalies among children with fetal alcohol syndrome, epidemiological studies indicate that chronic alcoholism is associated with a higher risk of cataract, keratitis and colour vision deficiencies. Not until the past few decades have we begun to explore the dichotomy of the health effect of alcohol. Many studies have attributed any beneficial effect of alcohol to red wine. Specifically, the last decade has witnessed a significant increase in our understanding of the health benefit of moderate wine consumption.

Oral Tolerance Induction

The various treatment strategies discussed above have one major feature in common they generally suppress the immune system, but not only the autoaggressive immune response. Furthermore, the pharmaceutical and even some biological agents are burdened with severe side effects, which might even accumulate with duration of treatment. Although most of the side effects are dose dependent and can be reduced by combining different therapeutic agents, the side effects will limit efficiency of therapy in most patients, often resulting in loss of visual acuity for the sake of the patients' safety. It is therefore important to develop highly specific therapies, such as the induction of antigen specific mucosal tolerance. In this case the antigen which is attacked by the immune system is applied orally, and in that manner induces regulatory cells downregulating the autoaggressive immune response.

HLApeptide B27PD as Oral Tolerogen

In all patients, visual acuity and or intraocular inflammation improved during the peptide treatment. This allowed reducing corticosteroid therapy in all patients within 2-6 weeks, resulting in an average steroid dose reduction from 10.4 mg (in the year prior to study entry) to 3.1 mg daily within the year after study entry. At the same time visual acuity increased slightly. Extensive in vitro testing of peripheral blood lymphocytes revealed that immune responses to mitogens (PHA, phytohaemagglutinin) and recall antigens (tetanus toxoid, PPD (purified protein derivative of M. tuberculosis) were not altered by peptide treatment, indicating that tolerance induction does not cause a generalized immunosuppression. During the follow-up of 4 years, four patients were successfully retreated with oral peptide. The average visual acuity of all patients remained stable with reduced concomitant corticosteroid therapy 76 .

Cone and Cone Rod Dystrophies

Common symptoms in cone dystrophy include photophobia, loss of visual acuity, color vision, and central visual fields. Electro-diagnostic tests are used to distinguish cone, cone-rod, and macular dystrophies. Simplex cases are most commonly reported followed by autosomal dominant inheritance, and autosomal recessive X-linked forms are also described. Genetic studies, to date, have shown that autosomal dominant cone and cone-rod dystrophies are genetically heterogeneous with 13 different genomic regions so far reported. Four genes have been described in cone and cone-rod dystrophies and include peripherin ftDS (52,53) GUCA1A associated with autosomal dominant cone dystrophy (76), GUCY2D associated with cone-rod dystrophy (77), and CRX associated with autosomal dominant cone-rod dystrophy (69).

The diabetes care team

Whether an individual with diabetes is cared for principally by a general practice team or by a hospital diabetes specialist team, it is now widely recognised that care is best provided by groups of health-care professionals with their own particular skills, working closely together. The teams include a consultant physician, diabetes specialist nurse, dietitian, chiropodist, general practitioner and practice nurse. They can also call upon the skills of a psychologist, ophthalmologist, nephrologist, neurologist, vascular and orthopaedic surgeons, obstetricians, midwifes and other specialists as necessary.

Thrombosis Prevention

Aspirin therapy has been shown to be safe in patients with diabetes, does not promote the progression of ophthalmic disease, and ophthalmological studies have not demonstrated any association between aspirin use and worsening of retinopathy. In fact, some studies have shown a benefit of aspirin in reducing the rate of microaneurysms in the early stages of diabetic retinopathy.

Perioperative Immunosuppression

No valid data exist that demonstrate that perioperative control of inflammation reduces the risk of postoperative complications from PPV such as the development of hypotony or CME. Extrapolation from cataract surgery in uveitis patients suggests that surgical results in patients undergoing elective PPV may be better if the inflammation is well controlled. Immuno-suppressive treatment seemed to permit safe intraocular lens (IOL) implantation in selected JIA-uveitis children (five patients) 4 , a disorder in which IOLs are ordinarily contraindicat-ed. However, profound foreign body reactions around implanted materials are generally not primary concerns in PPV surgery.

Intravitreal Corticosteroids

Although randomized studies are still lacking, clinical experience indicates that macular oedema usually resolves, often with dramatic improvements in vision, within 4-6 weeks of injection. Cataract development and pressure elevations, which usually respond to medical therapy, may occur. Finally, injection of the commercial preparation has been associated with a sterile endophthalmitis, which could markedly confuse the postoperative picture. Although intravitreal triamcinolone appears to be capable of providing rapid improvement in vision, its use should be limited to selected cases until more is known about its effect in uveitis patients undergoing PPV.

Gyrate Atrophy of the Choroid and Retina

Gyrate atrophy (GA) is a rare autosomal recessive disorder characterized by elevated levels of serum ornithine (105) caused by reduced activity of ornithine aminotransferase (OAT), a mitochondrial matrix enzyme (106). It is supposed that high levels of circulating ornithine levels damage tissues, including the eye. Patients with GA usually have myopia and night blindness during the first decade of life, although phenotypic variation exists. Progressive visual field constriction with central visual loss leads to blindness by the fifth or sixth decade of life. The fundal appearance shows sharply demarcated circular regions of chorioretinal dystrophy in the midperiphery that become confluent and extend anteriorly and posteriorly (107) (see Fig. 5).

Laboratory and Diagnostic Studies

Laboratory and diagnostic studies should be conducted as part of the initial evaluation to assess the patient's risk or presence of comorbidities. Such laboratory studies should include a fasting lipid profile, fasting insulin and glucose, and liver function tests. Should the history and physical examination suggest the presence of pseudotumor, a head CT scan should be ordered and consultation with a pediatric ophthalmologist arranged. Orthopedic complaints should lead to the use of relevant X-ray studies such as hip films to assess for slipped capital femoral epiphyses, and knee films to assess for the presence of Blount's disease. A sleep study should be ordered for patients with a history of apnea or snoring. An echocardiogram is important in patients whose degree of obesity may be causing cor pulmonale. Pulmonary function testing is indicated particularly for patients who complain of respiratory symptoms or shortness of breath with exercise. Indirect calorimetry is helpful in...

Murine models of ocular toxoplasmosis

A congenital model of ocular toxoplasmosis has been reported in which infected dams are inoculated during gestation (Hay et al., 1984). Unfortunately, a wide range of clinical disease occurred in this model. Murine congenital toxoplasmosis differs significantly from human disease. In the murine model there is significant opaque cataract formation, even with lens autolysis. This can be seen by examination using a 35-diopter lens, and documented with a Zeiss operating microscope (Dutton et al., 1986a). Even though ME49 strain infection of mice is a reliable model for Toxoplasma cysts in the brain, it is unusual to find evidence of intraocular toxoplasmosis even with PCR amplification. Antibodies in the same model against interferon-y, TNFa, or CD4 and CD8 cells result in frequent demonstration of parasite in association with more severe ocular lesions (Gazzinelli et al., 1994).