[Clinical procedures for intraocular lymphomas]. / Klinisches Vorgehen bei intraokulären Lymphomen.

BACKGROUND: The classification of intraocular lymphomas is based on their anatomical location. They are divided into uveal lymphomas with involvement of the choroid, ciliary body or iris and vitreoretinal lymphomas with isolated or combined involvement of the vitreous body and/or retina. Over the last decades it has become increasingly possible to work out the clinical and pathobiological features of the various subtypes, thereby reducing the diagnostic hurdles and creating improved treatment options. OBJECTIVE: A summary of the various types of intraocular lymphoma in terms of clinical features, diagnostics, treatment and prognosis is given as well as recommendations for follow-up care. METHODS: A selective literature search was carried out on the subject of intraocular lymphomas using PubMed and Google Scholar. RESULTS: Intraocular lymphomas affect different structures, so that the symptoms can also be very different. The diagnostic spectrum ranges from typical ocular examination methods to sample biopsies with subsequent cytological, histological and molecular pathological processing. The treatment pillars available are percutaneous irradiation and intravitreal drug administration as local treatment and systemic treatment or a combination of systemic and local treatment. The prognosis depends mainly on the subtype of the lymphoma and the extent of the infestation when the diagnosis is confirmed. Even though some effective treatment options are now available, it has not yet been possible to significantly reduce the mortality rate. CONCLUSION: Many different options are available for the diagnostics and treatment of intraocular lymphomas, which require close interdisciplinary cooperation. The further developments in the field of molecular pathology allow a faster and more accurate diagnosis and could open up new treatment options in the future.

[Proliferative vitreoretinopathy (PVR) minimal: same, same but different. Characteristics and surgical treatment of PVR-associated macular pucker]. / Proliferative Vitreoretinopathie (PVR) minimal: "Same same, but different". Besonderheiten und chirurgische Therapie des PVR-assoziierten Makula-Puckers.

BACKGROUND: Epiretinal membrane formation resulting in a macular pucker is among the typical complications associated with proliferative vitreoretinopathy (PVR) in retinal detachment and has a major impact on the functional outcome after surgical treatment. METHODS: A literature search was carried out in PubMed. RESULTS: Approaches to the surgical treatment of PVR-associated macular pucker include complete membrane removal within the vascular arcades aimed at relieving retinal traction at the posterior pole and peeling of the internal limiting membrane (ILM). As a further option it has been suggested that primary ILM peeling in rhegmatogenous retinal detachment repair may reduce or even prevent postoperative epiretinal membrane formation. In addition, correct timing of surgery is a factor that may contribute to successful treatment. DISCUSSION: Due to the particularly strong adhesion and the frequent occurrence of concurrent retinal detachment, the surgical approach to PVR-associated macular pucker is particularly challenging. As with idiopathic epiretinal membranes, surgical removal has the potential to improve functional outcomes; however, visual improvement depends largely on whether the macula was involved in the original retinal detachment.

[Real-time optical coherence tomography-assisted high-precision vitreoretinal surgery in the clinical routine]. / Echtzeit-optische Kohärenztomographie-assistierte Hochpräzisionsvitreoretinalchirurgie in der klinischen Routine.

The complete integration of spectral domain optical coherence tomography (SD-OCT) into an operating microscope now enables targeted, high-resolution imaging-guided vitreoretinal surgery. This provides real-time visualization of retinal layers, vitreous body and instrument-tissue interactions, which can be used for intraoperative decision making. Compared to conventional surgical microscopes, intraoperative OCT enables a greatly enhanced precision of vitreoretinal surgical maneuvers and is an essential prerequisite for the implementation of real-time guided surgical techniques at the micrometer level.

[Vitrectomy for endophthalmitis : Incubation time and prognosis following intravitreal injection vs. cataract surgery]. / Vitrektomie bei Endophthalmitis : Latenzzeit und Prognose nach IVOM vs. Kataraktchirurgie.

BACKGROUND: Bacterial endophthalmitis is a rare but devastating complication following intraocular surgery. Guidelines on the diagnostics and treatment are based mainly on experience of endophthalmitis treatment following cataract surgery. OBJECTIVE: In this study we analyzed infectious endophthalmitis cases following either intravitreal operative drug injection (IVOM) or cataract surgery for possible differences in the clinical course and prognosis. MATERIAL AND METHODS: All cases of endophthalmitis from January 2013 through December 2017 retrieved from our electronic database were examined and analyzed according to the type of intervention, time elapsed until diagnosis, pathogen detection, postinterventional visual acuity and the presence of comorbidities. RESULTS: A total of 29 cases were included, 11 secondary to IVOM and 18 secondary to cataract surgery. Symptoms for all cases presented at a mean of 6.8 days, with a significant difference between patients following IVOM (5.5 days) and patients following cataract surgery (4.1 days, p < 0.05). Patients with endophthalmitis following cataract surgery had a significantly better visual outcome 1 year after treatment compared to patients with endophthalmitis following IVOM (p < 0.05). The most commonly isolated pathogen was Staphylococcus epidermidis. CONCLUSION: Knowledge of the typical clinical course in the development of endophthalmitis following IVOM or cataract surgery is a critical prerequisite for the timely diagnosis and initiation of adequate treatment measures. Our results point towards a significantly delayed clinical manifestation of endophthalmitis following IVOM, possibly also caused by the anatomical origin of the infection. In an era of increasing numbers of IVOM this clinical observation could be helpful for a careful follow-up control beyond the previous traditional timepoints.

[Parainfectious optic neuritis with macular infiltrate in Neisseria meningitidis B meningitis]. / Parainfektiöse Optikusneuritis mit makulärem Infiltrat bei Neisseria-meningitidis-B-Meningitis.

OBJECTIVE: We report on the case of a young immunocompetent female patient with parainfectious optic neuritis and macular inflitrate due to Neisseria meningitidis B meningitis. METHOD: Case report RESULTS: A 22-year-old female patient was admitted to the emergency department for intensive care treatment with a strong suspicion of meningitis. Clinical and serological parameters were indicative of a bacterial genesis of the meningitis. By analysis of the cerebrospinal fluid (CSF) Neisseria meningitidis type B could be detected. Subjective and objective symptoms could be improved by immediate intravenous administration of antibiotics; however, 1 day before discharge the patient complained of a sudden left-sided, painful loss of vision with extreme photophobia. The ophthalmoscopic examination revealed profound ciliary injection with slight anterior uveitis and papilledema with macular infiltration and diffuse petechiae-like retinal hemorrhage. After exclusion of viral proliferation in the CSF systemic steroid therapy was carried out together with continuation of antibiotic therapy and the eye was treated with local steroids and mydriatics. This resulted in healing of the ocular inflammation and partial recovery of vision. CONCLUSION: The painful loss of vision in this patient is probably due to parainfectious optic neuritis with macular infiltrate from Neisseria meningitidis B meningitis, which is an unusual course. Despite the rarity of this disease the complication of a parainfectious inflammation of the optic nerve should be considered and appropriate steps taken when the corresponding symptoms occur.

[Epstein-Barr virus associated acute retinal necrosis]. / Epstein-Barr-Virus-assoziierte akute retinale Nekrose.

CASE REPORT: This article reports a case of an Epstein-Barr virus (EBV) associated acute retinal necrosis. A 72-year-old male patient presented in the emergency department complaining of progressive loss of vision. During patient management an acute retinal necrosis was suspected and the subsequent diagnostics from a vitreal body biopsy showed positive results only for the EBV genome. OBJECTIVE: The EBV is a rare cause of ocular inflammation. With this report we would like to draw the attention of colleagues to this unusual finding. CONCLUSION: Although EBV screening is not part of the standard diagnostic procedure, its implementation in relevant clinical situations could possibly assist the differentiation between causal relationship and morbidity.

[Unusual IOL Calcification following Vitreoretinal Surgery with Silicone Oil Endotamponade]. / Ungewöhnliche Kalzifikation intraokularer Kunstlinsen nach vitreoretinalem Eingriff mit Silikonölendotamponade.

PURPOSE: Calcification of intraocular lenses (IOL), although nowadays less frequent than in the past, is a well-documented complication that can still necessitate their explantation. Although mostly noted in hydrophilic materials it has been rarely reported in hydrophobic intraocular lenses. We wish to report on two unusual cases of intraocular lense (one hydrophobic and one hydrophilic with hydrophobic surface) calcification following vitrectomy and silicon oil endotamponade. METHODS: In the course of treatment both patients underwent multiple ocular interventions due to re-detachment/persistent macular hole including local rt-PA or triamcinolone injection due to persistent postoperative anterior chamber inflammation/macular oedema. Finally and after thorough patient examination with characteristic visual complaints and difficulty in the retinal assessment the extraction of the calcified lenses was considered necessary. The configuration as well as the elemental analysis of the opacified surface of the IOLs was performed by means of high magnification microscopy, scanning electron microscopy and energy dispersive X-ray spectroscopy (EDX). Intraocular and systemic histories of both patients were summarised. RESULTS: The scanning electron microscopy and EDX analysis demonstrated massive calcium-based deposits on the surface of the hydrophilic and a diffuse vacuolation and calcification consisting of oxygen (O), silicon (Si), magnesium (Mg), aluminium (Al), sulphur (S) and phosphorus (P) on the surface of the hydrophobic IOL. CONCLUSION: The explantation of an IOL due to calcification represents an unusual event. The careful consideration of systemic and ocular factors that promote calcification processes can help reduce the incidence of calcification. Despite all efforts in material production and risk factor analysis, it is not always possible to define or even predict the exact cause of this phenomenon and in the presence of corresponding clinical symptoms IOL exchange remains as the sole option.

[Ocular involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis]. / Okuläre Beteiligung bei Stevens-Johnson-Syndrom und Toxisch epidermaler Nekrolyse.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare severe reactions of skin and mucous membranes. They are considered as a single disease entity with differing severities and are mainly induced by drugs, less frequently by infections. In 50% of the patients ocular complications occur, which can lead to blindness in the absence of immediate ophthalmological treatment. The acute pattern, the unpredictable course and extreme variations in the manifestation of complications require an interdisciplinary treatment. Early diagnosis and initiation of an intensive lubricating and anti-inflammatory surface care are of utmost importance for the best visual outcome. This article is intended to help ophthalmologists towards a better understanding and interpretation of clinical signs of these conditions with the goal to achieve substantial improvements in visual outcome and of course the patient's quality of life.

New insights into hyperglycemia-induced molecular changes in microvascular cells.

Hyperglycemia is the most prevalent characteristic of diabetes and plays a central role in mediating adverse effects on vascular cells during the progression of diabetic vascular complications. In diabetic microangiopathy, hyperglycemia induces biochemical and molecular changes in microvascular cells that ultimately progress to retinal, renal, and neural complications and extends to other complications, including advanced periodontal disease. In this review, we describe changes involving basement membrane thickening, tissue remodeling, gap junctions, inflammation, cytokines, and transcription factors, and their effects on the pathogenesis of diabetic microvascular complications. The majority of the changes described relate to retinal microangiopathy, since ultrastructural, structural, and biochemical alterations have been well-characterized in this tissue.

Dietary supplementation with chickpeas for at least 5 weeks results in small but significant reductions in serum total and low-density lipoprotein cholesterols in adult women and men.

AIM: To compare the effects of a chickpea-supplemented diet and those of a wheat-supplemented diet on human serum lipids and lipoproteins. METHODS: Forty-seven free-living adults participated in a randomized crossover weight maintenance dietary intervention involving two dietary periods, chickpea-supplemented and wheat-supplemented diets, each of at least 5 weeks duration. RESULTS: The serum total cholesterol and low-density lipoprotein cholesterol levels were significantly lower (both p < 0.01) by 3.9 and 4.6%, respectively, after the chickpea-supplemented diet as compared with the wheat-supplemented diet. Protein (0.9% of energy, p = 0.01) and monounsaturated fat (3.3% of total fat, p < 0.001) intakes were slightly but significantly lower and the carbohydrate intake significantly higher (1.7% of energy, p < 0.001) on the chickpea-supplemented diet as compared with the wheat-supplemented diet. Multivariate analyses suggested that the differences in serum lipids were mainly due to small differences in polyunsaturated fatty acid and dietary fibre contents between the two intervention diets. CONCLUSIONS: Inclusion of chickpeas in an intervention diet results in lower serum total and low-density lipoprotein cholesterol levels as compared with a wheat-supplemented diet.

A biochanin-enriched isoflavone from red clover lowers LDL cholesterol in men.

OBJECTIVE: To determine whether the two major isoflavones in red clover differ in their effect on low-density lipoprotein cholesterol (LDL-C). DESIGN: A randomised, placebo-controlled, double-blind trial; two parallel groups taking one of the two isoflavones within which treatment and placebo were administered in a crossover design. SETTING: Free-living volunteers. SUBJECTS: A total of 46 middle-aged men and 34 postmenopausal women. INTERVENTION: Two mixtures of red clover isoflavones enriched in either biochanin (n=40) or formononetin (n=40) were compared. Placebo and active treatment (40 mg/day) were administered for 6 weeks each in a crossover design within the two parallel groups. MAIN OUTCOME MEASURES: Plasma lipids were measured twice at the end of each period. RESULTS: Baseline LDL-C concentrations did not differ significantly between men (n=46) and women (n=34), nor between those randomised to biochanin or formononetin. Interaction between time and treatments, biochanin, formononetin and corresponding placebos (two-way ANOVA) on LDL-C showed a significant effect of biochanin treatment alone. The biochanin effect was confined to men; median LDL-C was 3.61 (3.05-4.14) mmol/l with biochanin and 3.99 (3.16-4.29) mmol/l with the corresponding placebo (RM ANOVA with Dunnett's adjustment P<0.05). The difference between placebo and biochanin effects on LDL-C was 9.5%. No other lipid was affected and women failed to respond significantly to treatment. CONCLUSION: Isolated isoflavones from red clover enriched in biochanin (genistein precursor) but not in formononetin (daidzein precursor), lowered LDL-C in men. This may partly explain the previous failure to demonstrate cholesterol-lowering effects with mixed isoflavones studied predominantly in women. SPONSORSHIP: Novogen Ltd, North Ryde NSW, Australia, provided partial support including provision of tablets and outside monitoring.

Rupture of an aortic anastomotic aneurysm into a ureter.

A case of rupture of a false aneurysm of the distal aorta into the left ureter is reported. The patient presented with purulent hydronephrosis and hematuria. A left aorto-femoral graft had been inserted 3 years earlier, which became infected and was then removed. After 2 years a false distal aortic aneurysm developed, and in the last 6 months recurrent episodes of hematuria have occurred. An aorto-ureteric fistula was confirmed at surgery, and a left nephrostomy was performed with proximal and distal ligation of the ureter and then aneurysmectomy followed by aorto-bifemoral bypass.

Paradoxical embolism. An old but, paradoxically, under-estimated problem.

The theoretical model of paradoxical embolism requires the presence of four parameters, namely, arterial embolism, venous thrombus, abnormal intracardiac communication and right-to-left shunt. Many aspects, however, of this well known entity are under consideration; diagnosis is often difficult to be established and the long term efficacy of preventive measures is undefined. We comment on a case report of recurrent paradoxical embolism with popliteal vein thrombosis and patent foramen ovale, and we briefly review the literature.

Incidence and patterns of iatrogenic arterial injuries. A decade's experience.

OBJECTIVE: To investigate the incidence and patterns of all iatrogenic arterial injuries (IAI) necessitating surgical repair in a ten-year period. DESIGN: Retrospective study. SETTING: Departments of Vascular Surgery a) Athens General Hospital "G. Gennimatas" and b) Red Cross Hospital of Athens, Greece. PATIENTS: Eighty-seven patients underwent surgical repair of an IAI, comprising 36% of the 237 patients treated surgically for various arterial injuries during the same period. RESULTS: Specific injury patterns were implicated in most cases. Cardiac catheterizations were the commonest cause of IAI (n=39). The second commonest source for IAI was the renal units' personnel accountable for 17 false aneurysms, which arose at arteriovenous grafts' puncture sites. Among the surgical specialties orthopaedic surgery was the most common source of IAI (n=13). A less common pattern of IAI was following radical operations for cancer (n=7). The mortality of the series was 4.6% (4/87) and the amputation rate 2.3% (2/87). No death or amputation was associated with IAI following cardiac catheterizations confirming that post-catheterization IAI have a benign prognosis. False aneurysm was the most frequent complication when the cardiac catheterization was via the femoral artery, when the catheterization was via the brachial artery the commonest complication was arterial thrombosis. The two amputations were due to delayed reconstruction of arterial injuries that were not recognised at first sight. CONCLUSION: Common patterns characterize most IAI. Understanding their exact causes is a first step towards prevention or timely repair if the latter is not feasible.

Phenobarbital modifies seizure-related brain injury in the developing brain.

To investigate the potential role of drug therapy in preventing or exacerbating seizure-related brain injury in the prepubescent brain, we administered kainic acid to rats at postnatal day 35. Therapy with daily phenobarbital was started directly before or 1 day after kainic acid was administered, and was continued through postnatal day 153. Rats receiving phenobarbital had therapeutic concentrations during most of the 24-hour dosing period, but also experienced supratherapeutic peak concentrations. The animals were subsequently tested using the water maze (a measure of visuospatial memory), open field (a measure of activity level), and handling tests (a measure of emotionality). The frequency of spontaneous recurrent seizures was monitored during and after phenobarbital therapy. Kainic acid resulted in status epilepticus on postnatal day 35 in all the rats that received it but those receiving phenobarbital first manifested a shorter and less severe status epilepticus as compared to the rats given kainic acid alone. Rats starting phenobarbital immediately before kainic acid was administered did not differ from control rats on behavioral testing and had no subsequent spontaneous recurrent seizures and no histological lesions. Rats receiving kainic acid alone performed significantly poorer than did control rats in the water maze, were more aggressive, had histological lesions, and manifested spontaneous recurrent seizures. As compared to the group treated only with kainic acid, rats receiving kainic acid followed by phenobarbital at postnatal days 36 to 153 manifested similar aggressiveness and histological lesions, similar frequency of spontaneous recurrent seizures after phenobarbital taper, and even greater disturbances in memory, learning, and activity level.(ABSTRACT TRUNCATED AT 250 WORDS)

Age-dependent cognitive and behavioral deficits after kainic acid seizures.

The long-term behavioral and cognitive effects of seizures at different ages were studied using the kainic acid (KA) seizure model. Rats of postnatal (P) ages (in days) 5, 10, 20, 30, and 60 were administered KA intraperitoneally (i.p.), which induced status epilepticus for several hours, or an equivalent volume of saline. Occurrence of spontaneous recurrent seizures (SRS) was then monitored for 3 months by a closed-circuit videotaping system. Rats began behavioral testing on P80; a separate group of rats that received KA on P60 began testing on P120. Behavioral tests included the Morris water maze (visuospatial learning and memory), the open field test (response to a novel environment), and the handling test (emotionality). When tested on P80, KA-treated P5 and P10 rats had no demonstrable deficits on any test as compared with controls. KA-Treated P20 rats differed from controls only on the water maze spatial bias test. KA-Treated P30 rats had deficits in spatial bias, were more active in the open field, and were more aggressive when handled. KA-Treated P60 rats, whether tested on P80 or P120, had deficits in learning platform position and spatial bias in the water maze, were more active in the open field, and were more aggressive when handled. P60 rats with SRS performed poorer in water maze place learning and spatial bias testing, although the number of SRS did not correlate with overall task acquisition. Our findings suggest age-related behavioral and cognitive deficits after KA-induced seizures. Pubescents and adults had alterations in learning, memory, exploratory behavior, and response to handling, whereas younger animals had no obvious behavioral or cognitive deficits.

Effects of kindling on subsequent learning, memory, behavior, and seizure susceptibility.

To determine the long-term effects of seizures on the developing brain we kindled 20-, 40-, and 60-day-old rats to stage 5 seizures and then elicited an additional 15 seizures using the same kindling stimulation. At age 80 days, all animals that reached stage 5 kindling, and their respective age-matched controls, underwent behavioral testing using the Morris water maze, open field test, and handling test. Prior to euthanasia the animals had seizure threshold tested using flurothyl inhalation. No differences were noted in time to platform in the water maze or activity level in the open field test between the kindled rats and controls in any of the three age groups. Rats kindled at age 20 and 40 were more emotional than the controls in the handling test. In the flurothyl inhalation test, rats kindled at 40 and 60 days of age had a shorter latency to all seizures stages than the controls. These results demonstrate that while kindling results in no alteration of learning, memory, or activity level, it does result in altered emotionality and activity level in immature animals, as well as reduced seizure threshold in pubescent and mature rats. The animal model used appears to be an important variable in determining the long-term effects of seizures.