No evidence for increased growth hormone responses to growth hormone-releasing hormone in patients with diabetic retinopathy.

Several studies report increased growth hormone (GH) responses to provocative stimuli in patients with diabetic retinopathy. We studied GH responses to 1 microgram/kg body wt human pancreatic GH-releasing hormone 1-44 (hpGHRH 1-44) in 33 patients with type I diabetes mellitus, 31 patients with type II diabetes mellitus, and 2 control groups (N = 11 and 8). Based on the results of fundoscopy and fluorescein angiography, the diabetic patients were subdivided into patients without diabetic retinopathy, patients with nonproliferative diabetic retinopathy, and patients with proliferative diabetic retinopathy. Growth hormone responses to hpGHRH 1-44 in diabetic patients with proliferative or nonproliferative retinopathy or without retinopathy were not significantly different regardless of the type of diabetes. Remarkably, GH responses to hpGHRH 1-44 in type I diabetic patients without retinopathy were significantly higher than the matched controls. Our data suggest that diabetic retinopathy in type I and in type II diabetes is not associated with increased GH responsiveness to hpGHRH 1-44, whereas in type I diabetes mellitus without diabetic retinopathy, a GH hyperresponsiveness to hpGHRH seems to occur.

Diabetes care in rural area: clinical and metabolic evaluation.

To evaluate the efficacy of conventional diabetes care in a rural area, metabolic control and the presence of late complications were studied in 622 diabetic patients treated by general practitioners beyond the reach of diabetic centers. Seventy-three (12%) of the patients were classified as type I diabetics (age, 38.0 +/- 16.1 yr; duration of diabetes, 12.8 +/- 9.3 yr) and 549 as type II diabetics (age, 67.0 +/- 10.8 yr; duration of diabetes, 7.3 +/- 5.8 yr). Fifty-eight percent of type I diabetic patients administered insulin once daily and 42% twice daily, whereas most (83%) type II diabetics on insulin received only one insulin injection per day. Treatment of type II diabetic patients consisted of sulfonylureas (58%), diet alone (22%), insulin (18%), and biguanides or a combination of sulfonylurea with biguanides (2%). Poor therapeutic efficacy was observed in all patients, and postprandial hyperglycemia (blood glucose greater than 160 mg/dl) was predominant both in type I diabetics (86%) and in type II diabetics on insulin (80%) as well as off insulin (55%). HbA1c above normal (greater than 5.8%) was seen in 96% of type I and in 90 and 73% of type II diabetics with or without insulin therapy, respectively. Accompanying glucosuria was present in type I (73%) and in type II diabetics (on insulin, 71%; off insulin, 33%). Mean prevalence of late diabetic complications was greatest for insulin-treated patients (type I, type II with, and type II without insulin treatment: retinopathy, 41, 56, 22%; proteinuria, 13, 14, 3%; peripheral neuropathy, 21, 51, 12%), whereas macroangiopathy (16, 53, 31%) predominated in type II diabetic patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Platelet aggregation and reversible platelet aggregates in type I-diabetes staged by retinal fluorescein angiography.

In 70 patients with juvenile-onset, insulin-dependent (type I) diabetes and 75 age- and sex-matched controls the reversible platelet aggregates expressed as platelet count ratio (PCR) and the ADP-induced platelet aggregation were studied. Retinal microangiopathy was staged by retinal fluorescein angiography. The mean PCR of the patients (0.82 +/- 0.02) was statistically significantly lower than that of the controls (0.97 +/- 0.01). However, in different stages of retinopathy no significantly different PCR could be observed. ADP-induced platelet aggregation (0.5 and 1.0 micromol/l) exhibited a higher reactivity of diabetic platelets, but with the exception of tangent alpha (see later), the differences were not statistically significant in comparison to the controls. After collagen-induced platelet aggregation (0.5 and 1 microgram/ml) the lag time in diabetics was significantly (p less than 0.001) lower than in the controls, whereas the other quantitative parameters exhibited higher platelet reactivity in general, though not statistically significant. No relationship between PCR and the in vitro induced aggregation was found. The degree of retinopathy had no significant influence on platelet aggregation. In general, the data demonstrate an increase in sensitivity of platelets in juvenile-onset diabetics, whereas no influence of stage of microangiopathy could be detected.

Echography and histological studies in various eye conditions.

A correlation between A-scan echograms recorded clinically in vivo and histological studies of corresponding sections has been made in 42 eyes with intraocular pathological conditions. This study yielded both new and little known acoustic differential criteria for the diagnosis of retinoschisis, funnel-shaped vitreous detachments, serous as well as hemorrhagic retinal and choroidal detachments, intravitreal hemorrhages, and intraocular tumors.

Increased angiotensin-converting enzyme activities in diabetes mellitus: analysis of diabetes type, state of metabolic control and occurrence of diabetic vascular disease.

Serum angiotensin-converting enzyme activities were measured in 41 type 1 diabetics (16.4 +/- 4.0 U/ml), in 40 type 2 diabetics (15.0 +/- 5.2 U/ml) and in 52 controls (13.0 +/- 2.7 U/ml, mean +/- SD). Twenty six (32%) of 81 patients presented with serum angiotensin-converting enzyme activities above the normal range. No relation between serum angiotensin-converting enzyme activities and the presence or lack of diabetic vascular diseases in type 1 and type 2 diabetics could be detected. No significant differences in serum angiotensin-converting enzyme activities were found when comparing various types of diabetic vascular disease (retinopathy, neuropathy, renal failure, arterial vascular disease, diabetic vascular disease, coronary artery disease). However, mean serum angiotensin-converting enzyme activities were significantly increased in diabetics with retinopathy when compared with controls (p less than 0.0005). Correlation between metabolic long term control as determined by measuring glycohaemoglobin (HbA1) concentrations and serum angiotensin-converting enzyme activities could not be established. Serum angiotensin-converting enzyme activities did not show any correlations with duration of diabetes, age or sex of patients. A representative number of diabetics (32%) showed elevated serum angiotensin-converting enzyme activities, but a correlation with diabetic vascular disease, metabolic control or type of disease could not be established.

Atypical cotton-wool spots.

Atypical cotton-wool spots in four selected cases of diabetic retinopathy are discussed. The most striking characteristic distinguishing them from typical cotton-wool spots is their size, which ranges from about 2 to 4 disc diameters. They develop after stenosis or a complete obstruction of a first order arteriole at the point at which it emerges from the parent arterial branch. The size of the lesion corresponds with the size of the affected arteriole. Restoration of local circulation is attempted by neighbouring arterioles and venules, the latter carrying a reversed blood flow. Arterio-venous communications along the border of the infarcted area are a prominent feature, most likely attributable to the necessity of free drainage of the arterial influx. The same haemodynamic principle applies to the coarsening of the adjacent capillary bed. Secondary changes of the bordering venous branches include aneurysm formation and the staining of the venous wall.

In vivo study of cell reactions on poly(methyl methacrylate) intraocular lenses with different surface properties.

PURPOSE: To evaluate the biocompatibility of three poly(methyl methacrylate) (PMMA) intraocular lenses (IOLs) with different surface properties. SETTING: University Eye Clinic, Vienna, Austria. METHODS: Cell reactions on the surfaces of unmodified, heparin-surface-modified (HSM), and surface-passivated (SP) PMMA IOLs were documented in vivo using a Zeiss specular microscope. Risk factors for such reactions were also determined. RESULTS: During the first postoperative days, small round and spindle-shaped cells were found on all IOLs. Cell density was higher in eyes with increased postoperative inflammation. After several days, epithelioid and foreign-body giant cells were seen on some IOLs. Cells appeared significantly less often on the IOLs with hydrophilic surfaces (HSM) than on those with hydrophobic surfaces (unmodified, SP). CONCLUSION: The significantly lower incidence of foreign-body reactions on hydrophilic than on hydrophobic IOL surfaces is consistent with the results of previous studies on hydrogel and silicone IOLs.

[Modern trends in the treatment of diabetic retinopathy (author's transl)]. / Aktuelle Therapie der diabetischen Retinopathie

Adequate control of diabetic patients may not only delay the appearance of diabetic retinopathy, but may, moreover, effect the regression of fundus changes at the pre-retinopathic stage and in cases of commencing non-proliferative retinopathy. Medical treatment is based on the achievement of a decrease in vascular permeability and a lowering of the blood lipid level; a diet enriched with phosphates may influence retinal hypoxia by increasing the 2,3 diphosphoglycerate level in the erythrocytes, thereby leading to an improved free oxygen supply to the tissue. Complete medical and dietetic compensation of hyper-permeability of the retinal capillaries, of the intraretinal exudation of lipoproteins, and of retinal hypoxia belong still today to utopia; hence, conservative treatment is only of auxiliary character. Hypophysectomy has largely been abandoned in view of the mutilation involved and the poor results of this procedure. The most effective active treatment is photocoagulation. The best results are obtained by a combination of generalized unselective coagulation of the peripheral retina by means of a xenon coagulator and the selective elimination of progressive vascular changes seen in the fluorescein angiogram with argon laser.

[Ophthalmosurgical treatment possibilities in diabetic retinopathy]. / Ophthalmochirurgische Behandlungsmöglichkeiten der diabetischen Retinopathie.

On my being appointed to the Chair of Ophthalmology at the oldest university eye department in the world, the importance of ophthalmosurgery and research in the field of diabetic retinopathy at the 1st Department of Ophthalmology at the University of Vienna is presented against the background of a historical review of this department from its inception to the present day, in homage to my predecessors. The currently valid concept of the pathogenesis of diabetic retinopathy is outlined. The most effective treatment techniques in diabetic retinopathy, namely photocoagulation and vitrectomy or membranectomy, are described in detail with particular regard to the indications, success rates and complications.

[Relationship between loss of sight and mortality in diabetics with retinopathy (a retrospective study over the terminal 5 years) (author's transl)]. / Zusammenhang zwischen Erblindung und Mortalität bei Diabetikern mit Retinopathie (Eine retrospektive Studie über die diabetische Retinopathie der letzten 5 Lebensjahre).

1642 diabetics with retinopathy were controlled at half-yearly intervals over 4 to 10 years (6 years on average) using fundus photography, fluoresceinangiography and measurement of visual acuity. 83 of these patients died and the data documented in 43 patients over a mean period of 5.2 years prior to death allowed a retrospective evaluation of the clinical findings and therapeutic results. 27 patients had undergone bilateral and 16 unilateral photocoagulation at the beginning of the observation period. 9 patients were blind already at the outset. Of 13 patients who became blind during the observation period 10 had not undergone photocoagulation of the affected eye. The time span between blindness and death was shorter (1.5 years) in the 3 patients (5 eyes) who had undergone photocoagulation than in the untreated diabetics (4.3 years). All 23 patients in whom the initial visual acuity was maintained had undergone photocoagulation. Presence of florid diabetic retinopathy or nephropathy adversely influenced the results of photocoagulation.

[The fate of corneal infiltrations in cases of epidemic keratoconjunctivitis. A follow-up study over two and a half years (author's transl)]. / Das Schicksal der Hornhautinfiltrate bei Keratoconjunctivitis epidemica. Eine Verlaufsstudie über 2 1/2 Jahre

34 out of 72 patients (47.2%) with epidemic keratoconjunctivitis due to an infection with the adeno-virus type 8 still showed, on average, corneal opacities after 2.3 years. The gamma2-test proved the statistical significance of the correlation between the prevention of persistent corneal changes and the abstention from topical treatment with corticosteroids in the acute phase of the disease. Yet, steroids mitigate the subjective discomfort, delay the development of keratitis by several days, or even prevent its manifestation as long as corticosteroids are applied. However, in one third of the cases, the keratitis recurs as soon as topical treatment with corticosteroids is stopped. Recurrent attacks of keratitis may flare up over years and the visual acuity may decrease to 6/12 causing transient incapability of working.

[Regression of florid proliferative diabetic retinopathy through achievement of normoglycaemic over five months by means of a portable insulin-dosage apparatus (author's transl)]. / Rüchbildung einer floriden proliferativen diabetischen Retinopathie durch 5 Monate lang dauernde Normoglykämie mittels eines tragbaren Insulindosiergeräts.

A portable insulin-infusion device (Siemens-Erlangen) was used by 24-year-old juvenile onset-type diabetic woman for a period of 5 months in order to achieve normoglycaemic conditions. The patient suffered from rapidly deteriorating florid proliferative retinopathy and was practically blind. Kidney function was serioudly impaired and severe neuropathy also existed. Insulin was infused through a polyethylene catheter inserted through the subclavian vein into a central vein. A continuous basal rate which was varied from day to night was infused with additional supplementary rectangular profiles of insulin at meals. Blood glucose was self-monitored with strip test apparatus in order to adjust insulin dosage to diet. HbA1 decreased from 16% during the pre-therapy phase to 8% (= normal range) at the end of the last phase. MBG decreased from 238 during the pre-therapy phase (6 24 hr profiles at 5 to 7 time points) to 97 during the latter phase (daily profiles from day 103 to day 150). After 3 weeks of this treatment the retinal bleeding had disappeared. During further treatment regression of the massive vascular proliferation was observed with fluorescein angiography, and perfusion of the retina improved. Vision also improved, so that the patient has now been able to resume her work as a bank employee. Albuminuria decreased and the neuropathic symptoms also disappeared. The originally planned hypophysectomy was, therefore, considered to be unnecessary.

[Use of neodym-YAG-lasers in ophthalmology]. / Neodym-YAG-Laser-Anwendung in der Ophthalmologie.

Structures within the eye bulb diminishing visual acuity can be cut by means of neodymium-YAG-laser without surgical opening of the globe. The First Eye Department has had the first instrument of this kind in Vienna at its disposal since the summer of 1984. Up to now it has been used for posterior capsulotomy, iridotomy, opening pupillary membranes and for cutting vitreous membranes in 84 operations altogether. The advantages of neodymium-YAG-laser are minimal psychological and physical stress for the patient and the possibility of out-patient surgery. A possible transient increase in the eye pressure and endothelial cell loss are disadvantages. Our experiences with the Lasertek Neodymium-YAG-laser model 135 are reported.

[Analysis of the progressive phases of diabetic retinopathy. Prevention and treatment by photocoagulation (author's transl)]. / Analyse der progressiven Schübe bei diabetischer Retinopathie. Prophylaxe und Therapie mittels Liehtkoagulation

An attempt has been made to clarify various unresolved problems concerning the pathogenesis, course and treatment of diabetic retinopathy (d.r.) on the basis of an analysis of 2320 fluorescein angiograms performed on 150 patients at intervals of 1 week to 6 months during the period January 1967 to April 1975. The characteristic changes of diabetic angiopathy are already visible in the angiogram before the ophthalmoscopic and biomicroscopic features of d.r. become manifest (preretinopathic stage). Like in the later stages of d.r., hyperpermeability of the retinal capillaries predominates in certain patients, whilst stenosis and obstruction of the precapillaries and arterioles prevail in the remaining patients. Hyperpermeability frequently causes a decrease in, or a failure of perfusion of the retinal capillaries due to compression by the swollen perivascular tissue. D.r. is characterised by phasic development. In cases of primary exudative angiopathy an increase in the capillary hyperpermeability can precede phases of progression. Cases of primary occlusive angiopathy display a jerky type of involvement of larger and larger retinal vessels. An additional exudative component accelerates progression of the angiopathy. Large zones without visible capillaries or multiple small areas with deficient capillarisation, IRMAs and shunt vessels herald the imminent onset of the proliferative stage (preproliferative stage). The primary exudative types show slow evolution, whilst the primary occlusive types show rapid, phasic progression...

[Fluorescence angiography as a basis for successful prophylactic and therapeutic light coagulation for diabetic retinopathy (author's transl)]. / Die Fluoreszenzangiogaphie als Grundlage einer erfolgreichen prophylaktischen und therapeutischen Lichtkoagulation bei diabetischer Retinopathie.

The fluorescence angiogramme served as a basis for the plan of treatment and as a criterion of treatment success in 192 patients with diabetic retinopathy who underwent xenon-light coagulation between January 1971 and October 1972. In 64 patients this success could be statistically evaluated comparing the untreated partner eye according to the exact Fisher-test. The rate of success of light coagulation showed itself to be statistically highly significant (p less than 0.01%) with regard to retinal morphology and haemodynamics, but with regard to visual acuity only statistically barely significant (p less than 5%). For the influencing of the capillary occlusion process with light coagulation no statistical significance (p = 25.19%) was found, and for the influencing of the capillary permeation disturbances with light coagulation a slight statistical significancing of the capillary permeation disturbances with light coagulation a slight statistical significnace (p less than 5%) was calculated. For avoiding or hindering present or threatened new vessel formation with light coagulation we calculated a statistical significance of p less than 1%.

[The usefulness of echography in retinal surgery (author's transl)]. / Die Bedeutung der Echographie für die Ablatiochirurgie.

Upon utilization of echography one certainly will not be able to detect retinal defects; however, other parameters of retinal detachment which by means of solely optical examination techniques may remain undiagnosed can be evaluated successfully. This concerns not only the diagnosis of retinal detachment alone but also the measurement of the height of the detachment including its possible variations, the accuracy of this method being up to 0.1 mm. This will also apply to the distinction of serous, haemorrhagic and solid detachment of the choroid, the amount of liquefaction of a subchorioidal haemorrhage as well as the assessment of the relationships between vitreous membranes and retinal detachment: this applies especially to cases with hazy media and decreased visibility of the fundus. Accordingly clinical echography may be successfully applied, prior to retinal surgery, during the operation and during the postoperative follow-up.

[Pseudophakic keratoplasty]. / Pseudophake Keratoplastik.

The author reports on 12 unselected consecutive penetrating keratoplasties performed for pseudophakic bullous keratopathy, in which the intraocular lens was retained. The visual results achieved were significantly better than those in aphakic eyes.

Combined vitrectomy and scleral resection in the therapy of massive epiretinal fibrous membranes due to diabetic retinopathy.

Between December 1981 and June 1984 scleral resection was performed in 35 patients suffering from end-stage proliferative diabetic retinopathy with traction retinal detachment involving the macula. In all cases, vitrectomy, membranectomy, segmentation, and delamination proved to be insufficient to mobilize the "shrunken" retina. In 22 cases (63%), retinal detachment was at least partially flattened in the area of the posterior pole of the eye. Visual acuity thus achieved ranged between 6/24 and 1/60, corresponding to an improvement of visual acuity compared with the preoperative situation in about one-third of the cases successfully treated (8 eyes).

[Peripheral fluorescence angiography in diabetic retinopathy]. / Das periphere Fluoreszenzangiogramm bei diabetischer Retinopathie.

Using the CANON CG 6 60 Z wide-angle fundus camera, fluorescein angiographic examinations of the fundus periphery were performed on 90 diabetic patients presenting with exudative diabetic maculopathy. The peripheral angiogram demonstrates that perimacular hyperpermeability - the main cause of diabetic maculopathy - is preceded by extensive disturbances of capillary perfusion in the midperiphery.