Randomised clinical study: comparison of acceptability, patient tolerance, cardiac stress and endoscopic views in transnasal and transoral endoscopy under local anaesthetic.

BACKGROUND: Transnasal endoscopy (TNE) with ultrathin endoscopes has been advocated as an attractive alternative, for diagnostic upper endoscopy. AIM: To assess tolerability, acceptability and quality of TNE, in comparison with standard upper endoscopy (SOGD, standard oesophago-gastro-duodenoscopy) under local anaesthetic. METHODS: We prospectively recruited 157 patients (83 females/74 males) mean age 57 years. The Fujinon EG530N (5.9 mm) and EG530WR (9.4 mm) endoscopes were used. The endoscopist and all patients completed detailed questionnaires regarding tolerability, acceptance and quality of endoscopy using standard visual analogue scales (VAS). Oxygen saturation (SaO2 ), heart rate (HR) and systolic blood pressure (SBP) were recorded. Quality of biopsies was evaluated. RESULTS: Analysis included 161 procedures (TNE:79, SOGD:82) with duodenal intubation achieved in all patients. VAS scores for patient comfort were significantly better in the TNE group (7.3 vs. 5.3 respectively, P < 0.001). Twenty patients with previous experience of standard endoscopy were randomised to TNE and 19 of them (95.5%) preferred the TNE. Gagging was significantly less in the TNE group (0.12 vs. 3.41 respectively, P < 0.001). Cardiovascular stress was significantly less in the TNE group irrespective of the degree of gagging or comfort. TNE biopsies were smaller, but adequate for definitive diagnosis, similarly to standard endoscopy. CONCLUSIONS: Transnasal endoscopy is superior to SOGD in terms of comfort and patient acceptance with significantly less cardiovascular stress. TNE can routinely be used as alternative to SOGD under local anaesthetic, for diagnosis and should be preferentially offered in cardiorespiratory compromised patients.

Improved survival of patients presenting with acute variceal bleeding. Prognostic indicators of short- and long-term mortality.

BACKGROUND AND AIM: Variceal bleeding is a severe complication of portal hypertension with a mortality rate between 30% and 60% in previous studies. During the last two decades the treatment of these patients has been improved. The aim of this study was to investigate the clinical outcome of patients after an episode of acute variceal bleeding and to identify risk factors for early and late mortality in these patients. MATERIALS AND METHODS: All patients with acute variceal bleeding hospitalised at two large hospitals between January 1, 1999 and June 30, 2004, were retrospectively enrolled in this study. After discharge, patients were followed until death or study closure date, on June 30, 2005. Bleeding related mortality, 6-week, 1-year and overall mortality were evaluated as well as factors related to early and late mortality. RESULTS: One hundred and forty one patients were included (114 men, 27 women) with a mean age of 60.5+/-13.5 years. In hospital, 6-week, 1-year and overall mortality were 12.1%, 18.4%, 32.6% and 48.2%, respectively. The mean length of hospitalisation was 11.4+/-9 days (1-55) and the mean packed red blood cell requirement was 3.9+/-3.7 (0-25). The rate of recurrent bleeding was 10.7% during initial hospitalisation. Being Child-Pugh C (p=0.003) and shock on admission (p=0.037) were independent predictors of 6-week mortality, while being Child-Pugh C (p=0.028), presence of hepatocellular carcinoma or other neoplasia (p=0.04) and partial thromboplastin time (p=0.021) during the initial admission were independent predictors for 1-year mortality. Mortality was not affected by the presence of active bleeding and/or white nipple at emergency endoscopy. Also presence of infection was not an adverse factor of clinical outcome in our patients. CONCLUSIONS: In conclusion, the clinical outcome of patients with acute variceal bleeding is better in comparison with previous studies. The severity of liver failure as well as the presence of neoplasia mainly affects the survival.

Adjuvant chemotherapy in colorectal cancer.

UNLABELLED: Our aim was to study the three-fold response to treatment, survival rates and toxicity. MATERIALS AND METHODS: We review 76 patients (median age 66.2 years) affected with the disease. All received adjuvant chemotherapy, while 13 with rectal cancer were subjected to radiation too. Patients were staged after Duke's classification. RESULTS: Recurrence was noted in 15 patients, 3 at stage B and 12 at stage C; median recurrence-free interval was 18.9 months. Patients without relapse had a median disease-free period of 35.9 months. Median overall survival was 35.21 months. The 5-year survival mark have surpassed 14 patients (3 with recurrent disease): 8 at stage B and 6 at stage C. Ten have died; median survival in these patients was 30.5 months. No patients suffered from severe bone marrow toxicity; mucositis and diarrhoea grade III/IV was noted in 10 patients.

[Carcinoma-associated retinopathy in breast carcinoma and carcinoid tumor]. / Karzinomassoziierte Retinopathie (CAR) bei Mammakarzinom und Karzinoid.

BACKGROUND: Carcinoma-associated retinopathy (CAR) is a rare paraneoplastic syndrome characterized by diffuse retinal photoreceptor degeneration in the presence of an epithelial tumor. We report on three patients, who developed paraneoplastic retinopathy in the presence of breast carcinoma and a cervical carcinoid tumor. MATERIALS AND METHODS: In addition to biomicroscopic, psychophysical, electrophysiological and angiographic examinations, serum samples were obtained for immunohistochemical staining of human retina. RESULTS: Ring-shaped visual field defects with statokinetic dissociation and abnormal rod and cone responses were found. Immunohistochemical findings included reactions at the level of the inner segments of the photoreceptors, the outer nuclear layer and the outer plexiform layer in absence of anti-recoverin antibodies. CONCLUSIONS: CAR should be considered in the differential diagnosis of visual loss in presence of tumors other than small-cell carcinoma of the lung. The presence of antiretinal antibodies is compatible with a tumor-induced immune response to epitopes shared by both the tumor and retinal tissue. Apparently, various retinal proteins may function as autoantigens.

[Skin electrodes for electroretinography in unsedated children]. / Hautelektroden-ERG bei unsedierten Kindern.

Contact lens electrode ERG is not well tolerated by children. So far, skin electrode ERG has suffered from a weakly defined geometrical relationship to the sources of ERG potentials. Because of the cuplike electric ocular field distribution, skin electrodes were placed: (1) in the middle of the lower eyelid (in order to be positioned in close proximity to the anterior apex of the cornea, which belongs to the electropositive inner surface of the cup); (2) 20 mm laterally to the temporal canthus (in proximity to the cup's electronegative outer surface). (3) Grounding was achieved by attaching a third skin electrode in the forehead midline. Instead of complete dark adaptation, adaptive illumination of 0.1 cd.m-2 was used to avoid frightening the children. After 10 min of adaptation, the examination started. Feeling safe on mother's lap, the little patient looked into a frosted glass screen (about 75 degrees of visual angle, depicting Mickey Mouse) on which a series of strobe flashes was delivered along the lines of the ISCEV ERG Standard: (1) blue flashes: filter no. 625 (Röhm and Haas); repetition rate 0.1 Hz; stimulus strength of white flashes 1.5 cd.m-2 s; (2) red flashes: filter no. S502 (Röhm and Haas); repetition rate 1 Hz; stimulus strength of white flashes 21.75 cd.m-2.s; (3) weak white flashes: stimulus strength 1.5 cd.m-2.s; repetition rate 0.3 Hz; (4) strong white flashes: stimulus strength 11.25 cd.m-2.s; repetition rate 0.3 Hz; (5) white flicker flashes: stimulus strength 1.5 cd.m-2.s; frequency 10, 30, 60 Hz. Recording of single stimulus responses turned out to be feasible; however, to achieve the best results, between 8 and 32 ERG responses were averaged. To illustrate the benefits of skin electrode ERGs in practice, the results of some cases are presented and discussed with respect to clinical findings.

[Improving contrast sensitivity by cut-off filters in high adaptation luminance levels in retinitis pigmentosa]. / Verbesserung der Kontrastempfindlichkeit durch Kantenfilter bei hoher Adaptationsleuchtdichte bei Retinitis pigmentosa.

BACKGROUND: Contrast requirements in patients suffering from retinitis pigmentosa (RP) exceed those of healthy subjects. So far, studies examining contrast sensitivity have been performed at luminance levels of several 100 cd/m2. However, to simulate as closely as possible outdoor levels of luminance, several 1000 cd/m2 are necessary. PATIENTS AND METHODS: We used the Vistech contrast sensitivity charts at a standard high luminance of 5500 cd/m2. Contrast sensitivity was evaluated in 20 healthy subjects (visual acuity 1.10 +/- 0.15) and 25 patients with RP (visual acuity 0.50 +/- 0.29) with and without commercially available cut-off spectacle filters (Zeiss F 80, Zeiss F 90 and Rodenstock L 660. RESULTS: Patients with retinitis pigmentosa showed an increase of contrast sensitivity with all three cut-off filters. This was statistically significant at a spatial frequency of 1.5 cycl/deg (P < 0.027), but not for higher frequencies of 6-18 cycl/deg (P < 0.5). The healthy volunteers did not show any increase in contrast sensitivity values with cut-off filters. CONCLUSION: Evaluating contrast sensitivity at high levels of luminance is useful to identify patients who benefit from cut-off filters. All RP patients subjectively preferred to wear cut-off filters. A statistically proven beneficial effect of cut-off glasses could be found for low spatial frequencies. An individual fitting of the various types of cut-off filters is inevitable.

[Sleep modifies anticholinergic mydriasis]. / Schlaf beeinträchtigt die anticholinerge Mydriasis.

In sleep, the eyelids are closed and the pupils narrow. The pupil width indicates alertness and, if it is narrow, sleepiness. The deeper the sleep, the narrower the pupil: miosis during drowsiness, sleep, sedation and general anesthesia relies on reduced inhibition of the oculomotor nucleus and, even more, on reduced sympathetic tone (it is as sympatholysis that accounts for the miosis exerted by the famous "cocktail lytique" onto an iris whose sphincter is weakened from briskly elevated IOP in angle-closure glaucoma). For whatever reason a lack of sympathetic tone occurs, a poor response to anticholinergic mydriatics will be the consequence. This communication is concerned with children who received tropicamide, cyclopentolate or atropine for diagnostic pupil dilation and cycloplegia but, during subsequent sleep, exhibited an unsatisfactory mydriatic response that could be overcome by additional administration of phenylephrine. Thus, parasympatholytic mydriasis can be proven to be a function of the sympathetic tone. The pupil shrinks during deep sleep even after atropine. If the conditions of deep sleep, sedation or general anesthesia are present and mydriasis needs to be maintained, an additional administration of a sympathomimetic compound is mandatory.

[Coats syndrome in retinitis pigmentosa. Clinical aspects and therapeutic possibilities]. / Coats-Syndrom bei Retinitis pigmentosa. Klinik und therapeutische Möglichkeiten.

Coats disease itself is a rather rare condition, whereas Coats syndrome has been observed in about 1.2-4.9% of all retinitis pigmentosa (RP) patients. The spectrum of clinical presentations and our therapeutic experience are illustrated with reference to case reports of three patients with clinically and electrophysiologically verified RP and Coats syndrome. As in classic Coats disease, Coats-like changes with RP are defined by aneurysmatic and teleangiectatic vessels and intra- and subretinal lipid deposits leading to exudative retinal detachment. Both entities differ with regard to age of onset, gender, bilaterality and location of the retinal changes. The reports published up to now show that there is no consensus concerning the success of the different treatments of Coats syndrome associated with RP. Laser therapy, cryocoagulation, diathermy and buckling procedures have been suggested for treatment of this complex. As in the therapy of Coats disease, our results confirm that the outcome of laser therapy depends on early detection of Coats-type vascular abnormalities and early initiation of the treatment. Therefore, thorough fundus examination should be regularly performed in all RP patients.

[Cerebral tuberous sclerosis and Coats disease]. / Tuberöse Hirnsklerose und Morbus Coats.

A 10-year-old boy with known tuberous sclerosis since early childhood suffered from unilateral Coats' disease. Initially his parents noticed a divergent squint. On examination, well-advanced Coats' disease involving almost the entire retina including the macula was found. Visual acuity had decreased to 20/300. Intrascleral diathermy was successfully performed, and after painful secondary glaucoma, cryotherapy of the ciliary body became necessary. Coats' disease has been reported in a number of genetic diseases, most of them quite variable in their clinical manifestations. To the best of our knowledge this is the first description of Coats' disease associated with tuberous sclerosis, which is known to be of genetic origin. Although in Coats' disease no genetic predisposition has been proven to date, the growing list of genetic diseases associated with Coats' disease should be considered in patients presenting with this retinopathy.

[Hand-held pupillometer for evaluating pupillary light reflex in general practice and at the bedside]. / Handpupillometer zur Prüfung der Pupillenlichtreflexe in der Praxis und am Krankenbett.

Owing to the sophisticated equipment currently required for the investigation of pupillary behavior, pupillographic procedures are still the preserve of a few specialized laboratories. To allow pupillographic measurements under ophthalmological office conditions, we designed a portable pupillometer that can also be used for bedside examinations. Following a defined light stimulus, the prototype presented in this paper records a direct pupillary light reflex on the basis of infrared reflex photometry. The latency of the pupillary reflex and the pupillary constriction time are determined and shown on a digital display.

Panretinal photocoagulation in diabetic retinopathy: argon versus dye laser coagulation.

The range of wavelengths used in ophthalmic photocoagulation treatment has been greatly enlarged by the development of the dye laser. To investigate the efficacy and possible side effects of orange dye laser light in the treatment of diabetic retinopathy, we performed a prospective, controlled clinical study comparing argon blue-green and orange dye laser light. In 14 patients with diabetic retinopathy of equal severity in both eyes one eye was randomly assigned to either blue-green argon (488 and 514.5 nm) or orange dye (600 nm) panretinal laser treatment. The total coagulated area was the same in both eyes. Subjective parameters (visual acuity, perimetry, color vision) as well as objective functions (electroretinography, electro-oculography) and the clinical course were studied preoperatively and then postoperatively over a period of 6 months. Dye laser coagulation proved as effective and safe as blue-green argon laser coagulation in the panretinal treatment of diabetic retinopathy. No significant differences in postoperative retinal function were detected. However, orange laser coagulation proved significantly more painful than blue-green argon laser treatment (P = 0.002).

[Acute necrotizing retinitis with amotio retinae. Surgical and medicamentous antiviral therapy]. / Akute nekrotisierende Retinitis mit Amotio retinae. Operative und medikamentöse antivirale Therapie.

This report pertains to the case of a 25-year-old patient suffering from acute necrotizing retinitis (ANR syndrome). Initially, one eye revealed clinical signs of diffuse chorioretinitis accompanied by perivasculitis and heavy keratic precipitates, papillitis, and vitreous infiltrates. After initial improvement under antiphlogistic therapy, however, necrotizing retinitis developed, associated with peripapillar hemorrhages, multiple peripheral retinal holes and eventually complete retinal detachment. The subsequently performed retinal detachment surgery, completed with vitrectomy, cerclage and silicone oil tamponade, was successful. At the same time, the patient was put on systemic therapy based on acyclovir. In the literature, similar developments are usually related to HSV and HZV infections. Although in our case a virological diagnostic test did not reveal the presence of any virus, the characteristic symptoms of the ANR syndrome completely disappeared under the above-mentioned therapy. Visual acuity, previously consisting only in light perception, improved to 0.4.

[Terson syndrome. Complicated clinical course]. / Terson-Syndrom. Komplizierte klinische Verläufe.

A report is given on three patients who developed spontaneous subarachnoidal bleeding, together with vitreous hemorrhage (Terson's syndrome). In two patients the vitreous hemorrhage was unilateral and showed spontaneous resorption within 15 months. The third patient presented with bilateral vitreous hemorrhage, which first showed slow spontaneous resorption. Five months later, however, secondary vitreous bleeding occurred. Vitrectomy was therefore performed in both eyes. Post-operatively, both eyes developed focal vitreoretinal reproliferations with retinal tears, which led to retinal detachment that was successfully treated by surgery. Because of these observations we can make the following suggestions: in patients presenting with unilateral vitreous hemorrhage one should first watch the spontaneous resorption of the hemorrhage. If there is delayed blood resorption in bilateral vitreous hemorrhage and at the beginning of the hemorrhage, a pars plana vitrectomy should be performed. In one patient an additional ocular symptom peripheral paresis of the facial nerve; a second patient presented with paresis of the oculomotor nerve. Both resolved spontaneously within 15 months.

Function of the diabetic retina after panretinal argon laser photocoagulation. Influence of the intensity of the coagulation spots.

To investigate the influence of the intensity of coagulation spots on retinal function and the clinical course after panretinal argon laser photocoagulation in diabetic retinopathy, we conducted a prospective study in 24 eyes of 12 diabetics. One eye was treated with moderate spots (average: 300 mW), the fellow eye was coagulated with intense spots (average: 600 mW). The spot size was identical in both eyes. Subjective parameters (visual acuity, perimetry), as well as objective functions (ERG, EOG) and the clinical course, were studied preoperatively and on a regular base with a follow-up of 12 months. Visual acuity and fundus findings deteriorated less often in eyes coagulated with intense spots. Visual field loss, however, was more prevalent in eyes treated with intense spots. Early treatment complications only occurred with high-energy coagulation. For this reason, high-energy spots should not be used even though they might be indicated theoretically.

Silicone oil tamponade in the management of severe hemorrhagic detachment of the choroid and ciliary body after surgical trauma.

Eight patients with massive hemorrhagic choroidal and ciliary body detachment after surgical trauma leading to all signs of a beginning phthisis bulbi have been treated by means of silicone oil tamponade in conjunction with multiple subchoroidal drainage and vitrectomy. Almost complete reattachment of the retina and choroid was achieved in all eyes accompanied by improvement of visual function. However, hypotony was persistent in 3 eyes. Two eyes with postoperative hypotony worsened dramatically after silicone oil removal. After silicone refilling both eyes markedly recovered within 6 and 8 weeks.

[Pupillographic perimetry using the "Octopus"]. / Pupillographische Perimetrie mit dem "Octopus".

The Octopus 2000 computerized perimeter (Interzeag, Schlieren, Switzerland) is combined with an infrared videopupillograph (Demel, Haan, FRG) which at the same time records the direct pupil light response and controls fixation. Digital processing of the pupil video image is performed at a rate of 25 cps. A transient oscilloscope display of the pupil surface after each light stimulus covers the subsequent 1000 ms, so that either pupillary light reflexes or the lack of a response can immediately be identified. An additional continuous penwriter printout shows light stimuli, pupil responses and the subject's responses. Thus, potential discrepancies between the pupil response and the subject's response are clearly revealed. The examination conditions slightly deviate from the standard ones used with the Octopus. Stimulus size is analogous to the target Goldmann/V, the stimulus duration 100 ms and the adaptive illumination 1 cd/m2. Pupil fatigue considerably exceeds visual fatigue. Therefore standard Octopus perimetric programs are inconvenient for pupilloperimetric purposes. A Sargon-based pupilloperimetric program determines pupillomotor increment thresholds at 12 stimulus locations throughout the visual field (20 degrees nasal, 0 degrees, 20 degrees and 40 degrees temporal/15 degrees above the 0 degrees meridian, 0 degrees meridian and 15 degrees below the 0 degrees meridian) while applying the normal Octopus strategy of threshold calculation. Instead of the patient's subjective responses, the examiner's assessment of pupil responses provides the basis for threshold determination by the Octopus program. The subjects are unaware of the mode of examination. Their rating of "seen" or "not seen" ist displayed together with the pupil responses, thus providing a hard copy as proof of malingering or of appropriate cooperation.

Histopathology findings following retinal tack implantation.

For the first time this report describes the histopathological findings 2 months after retinal-tack implantation in a human eye. A stainless-steel tack was implanted to seal a small retinal tear during vitrectomy because of severe proliferative diabetic retinopathy in a 38-year-old man. By gross examination the enucleated eye showed a total retinal detachment except at the site where the tack had been implanted. Histologically a fibrovascular tissue proliferation arising from the choroid had grown into the adjacent retina at the tack site. No inflammatory reaction, pigment epithelium proliferation or glial-cell proliferation attributable to the tack were observed.

Function of the diabetic retina after panretinal argon laser coagulation.

Panretinal photocoagulation has been demonstrated to have a beneficial effect on the natural history of diabetic retinopathy. However, it is associated with detectable loss of retinal function. To determine the best coagulation technique we conducted a prospective study in 32 eyes of 16 patients. We investigated retinal function in relation to spot size and scatter density after panretinal laser coagulation. One eye was treated with approximately 400 comparatively large laser spots (0.6-0.8 mm diameter), whereas the fellow eye was coagulated with approximately 1500 small spots (0.2-0.4 mm diameter), so that the total coagulated area was almost the same in both eyes. Subjective parameters (visual acuity, perimetry, dark adaptation, photostress), as well as objective functions (electroretinogram, ERG; electro-oculogram, EOG), were studied preoperatively and then postoperatively over a time span of 6 months. Pronounced impairment of retinal function was detected, which recovered after 3 months on the average. When the pairs of eyes were compared, persistent visual field scotomas as detected by computerized static perimetry, occurred less frequently in eyes subjected to small coagulation spots, although this tendency was not statistically significant.