Clinical outcome using a modified treat-and-extend protocol for neovascular age-related macular degeneration.

AIM: To compare outcome between patients treated using a modified treat-and-extend (mT&E) protocol and patients treated using a conventional T&E protocol. METHODS: A retrospective cohort study of two groups of treatment-naïve neovascular age-related macular degeneration patients within a single centre were evaluated. One group treated using the conventional T&E protocol, with visual acuity, dilated fundus examination (DFE) and optical coherence tomography (OCT) performed at each visit. The second group treated using the mT&E protocol in which visual acuity and DFE were performed only every three visits. The main outcome measures were time spent per clinical visit, visual and anatomical outcomes measured for 36 months. RESULTS: The T&E and mT&E groups included 135 eyes in 116 patients and 119 eyes in 94 patients, respectively, with similar baseline characteristics. At 36 months, the number of injections administered (7.9±2.9 vs 8.1±2.3 injections, respectively; p=0.55), the percentage of eyes that gained ≥15 Early Treatment for Diabetic Retinopathy Study (ETDRS) letters (23% vs 25.2%, respectively; p=0.39) and the percentage of eyes that lost ≥15 ETDRS letters (21.5% vs 17.7%; p=0.43, respectively) were similar between the T&E and mT&E groups. However, waiting and contact time were reduced during the OCT-only visits compared with the full visits, with an average of 41 min saved per patient encounter. CONCLUSIONS: Both protocols yielded similar visual and anatomical outcomes. However, the mT&E protocol reduced the number of full visits, with considerably less time spent at the clinic.

Aflibercept as a Second Line Therapy for Neovascular Age Related Macular Degeneration in Israel (ASLI) study.

PurposeThe purpose of this study is to evaluate an early switch to aflibecept in eyes with neovascular age-related macular degeneration (nvAMD) showing partial or lack of response for initial therapy with bevacizumab.MethodsThe Aflibercept as a Second Line Therapy for Neovascular Age Related Macular Degeneration in Israel (ASLI) was a prospective, multicenter, single-arm clinical trial. Eyes with nvAMD having incomplete response to 3-9 prior bevacizumab injections were recruited. Three monthly intravitreal aflibercept (2 mg) injections were administered, followed by two bi-monthly injections and a final examination at week 28. An optional injection was allowed at week 20.ResultsForty-seven eyes of 46 patients (mean±SD age 76±8 years) were recruited. The mean number of prior bevacizumab injections was 5.5±2.9. The mean visual acuity improved from 60.3±10 ETDRS letters at baseline to 63.1±15 letters at week 28 (P=0.02, paired t-test). The central subfield thickness (CST) reduced from 409±127 micron at baseline to 330±110 microns at week 4 (P=0.0002; paired t-test), and 277±70 microns at week 28 (P=0.00002; paired t-test). Twenty-two eyes had three to five prior bevacizumab injections (mean 5.1±0.7), and 25 eyes had six to nine prior injections (7.32±1.2). Both groups had reduced CST from baseline to week 28 (P=0.0004 and P=0.0007; paired t-test, respectively). Thirty-five (75%) eyes required the optional additional aflibercept injection at week 20.ConclusionsThe ASLI study demonstrated improved BCVA and reduced CST following an early switch to aflibercept therapy in eyes with prior incomplete response to initial therapy with three to nine bevacizumab injections.

Neural pathways mediating basal and stress-induced secretion of luteinizing hormone, follicle-stimulating hormone, and testosterone in the rat.

Adult male rats, intact or bearing complete, anterior, or posterior hypothalamic deafferentations (CHD, AHD, or PHD, respectively) or bilateral medial forebrain bundle (MFB) lesions, were acutely exposed to visual, audiogenic, or thermal stress. Two to 30 min after stress onset, the rats were decapitated, and trunk blood was collected from serum LH, FSH, and testosterone (T) determinations. While basal serum LH levels were found to be normal in all experimental groups, FSH levels were reduced in CHD and AHD rats, and serum T concentrations were found to be 3-fold greater than control values in the AHD group. In intact animals, exposure to all modalities caused significant elevations in serum levels of both LH and T, with no effect on FSH secretion. In the CHD and AHD groups, the LH and T responses were eliminated, with the exception of the T response to heat exposure, which persisted in CHD animals. In the PHD group, the LH and T responses persisted and were, in fact, potentiated. Bilateral medial forebrain bundle lesions inhibited the LH and T responses to audiogenic and thermal, but not to visual, stimulation. These data demonstrate that 1) basal FHS, but not LH, secretion is dependent upon extrahypothalamic afferents to the medial basal hypothalamus; 2) acute neurogenic stress stimulates LH and T, but not FSH, secretion; and 3) central nervous system sites, rostral to the medial basal hypothalamus, mediate the stress-induced elevations in LH release.

Site and mode of action of indomethacin on the hypothalamo-hypophyseal-adrenal axis: a temporal study in intact, hypothalamic-deafferentated, and hypothalamic-lesioned male rats.

Adult male rats were given single sc injections of indomethacin (IM; 5 mg/100 g BW) and sacrificed 2-24 h later. IM effects upon serum ACTH and corticosterone (CS) levels, rectal temperature, and hypothalamic and adenohypophyseal prostaglandin E2 (PGE2) and cAMP contents were observed. Rectal temperature was normal for 5-10 h post injection and later decreased by approximately 2.5 C. Both hypothalamic and adenohypophyseal PGE2 concentrations were reduced from 2-24 h after IM administration; no changes in cAMP content were observed. Serum ACTH and CS levels were elevated 4- and 6-fold, respectively, over the entire period observed. In animals with complete hypothalamic deafferentations, the ACTH and CS responses to IM were as marked as they were in intact rats. In rats with hypothalamic lesions in which the ACTH and CS responses to ether stress were attenuated, marked ACTH and CS secretory responses to IM were seen. It is concluded: 1) that the main site of action of systemically administered IM on the hypothalamohypophyseal-adrenal axis, is within the adenohypophysis; 2) that this effect is mediated by PGE2, and cAMP is not involved; and 3) that central nervous system PGs may be involved in the maintenance of basal body temperature in the rat.

Day-to-day variations in serum levels of follicle-stimulating hormone and luteinizing hormone in homosexual males.

Levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone in sera of eight homosexual males and a matched control group were determined every second day during one month. Significant day-to-day variations in serum levels of FSH and a reversed LH area/FSH area ratio among homosexuals were found. There were no significant differences between homosexuals and controls in relation to the average levels of the tested hormones nor the average area and variance of LH and testosterone. It is suggested that a single blood sample for each subject is not enough for hormonal evaluation of homosexuals. It is suggested that the present findings may point to some defect in the gonadotropin regulation in male homosexuals.

Solitary intracranial chloroma in a patient with chronic granulocytic leukemia.

A rare case of solitary CNS chloroma in a patient with chronic granulocytic leukemia (CGL) is described. This appears to be the first reported case of intracranial chloroma in CGL without systemic blastic crisis.

Hippocampal cell nuclear binding of corticosterone following 5,7-dihydroxytryptamine.

Adult male rats were injected into the lateral brain ventricle with 5,7-dihydroxytryptamine (5,7-DHT). They were adrenalectomized 5-7 days later and, following an additional 24 h, the specific in vitro [3H]corticosterone binding capacity of dorsal hippocampal slices was determined by estimation of uptake of radioactivity by the nuclear fraction. Specific corticosterone (CS) binding was reduced by 50-70% in the neurotoxin-treated as compared to vehicle-injected animals. Brain serotonin and 5-hydroxyindoleacetic acid concentrations were depleted by 50-70% in the 5,7-DHT-injected rats. These results suggest that the maintenance of normal dorsal hippocampal CS binding capacity is dependent upon the integrity of endogenous brain serotoninergic neuronal systems.

Disseminated echinococcosis with repeated anaphylactic shock. Treated with mebendazole.

A 46-year-old man, who was twice operated on for echinococcosis and who suffered from recurrent angioneurotic edema, was hospitalized with anaphylactic shock. Chest x-ray examination showed round lesions in the lungs; Casoni, immunofluorescence and hemagglutination tests for echinococcosis were strongly positive. With a diagnosis of disseminated echinococcosis, drug treatment with mebenzadole was given for 29 weeks (the last 22 weeks a dose of 1,200 mg daily). No side effects were observed, allergic manifestations disappeared, and the round lesions were noticeably reduced. The titer of hemagglutination fell gradually, and IgE concentration initially increased and later fell. Mebendazole is proposed as a drug of choice in the cure of disseminated hydatidosis; it may both alter the indication for operation and considerably improve the prognosis.

Retinitis pigmentosa associated with Fuchs' heterochromic uveitis.

OBJECTIVE: To investigate whether the combination of Fuchs' heterochromic uveitis (FHU) and retinitis pigmentosa (RP) in the same patient is coincidental or represents a true association. METHODS: We have examined the frequency of FHU in 338 patients with RP and in 1984 patients who were seen in our primary care ophthalmic clinic because of reasons other than RP. RESULTS: Of 338 patients with RP, 4 (1.2%) had the typical findings of FHU. Three of them had Usher syndrome type II, and 1 had RP simplex. By contrast, only 1 patient in the control group had FHU (5%), and the difference in the frequency of FHU between the 2 groups was significant (P=.002, Fisher exact test). CONCLUSIONS: Fuchs' heterochromic uveitis is associated with RP. Since autoimmune phenomena have been previously described in patients with RP, it is conceivable that RP predisposes to the development of FHU. Arch Ophthalmol. 2000;118:800-802

Corticotrophin and corticosterone secretory patterns following acute neurogenic stress, in intact and in variously hypothalamic deafferented male rats.

Adult male rats, intact (N) or bearing complete (CHD), anterior (AHD), or posterior (PHD) hypothalamic deafferentations, were acutely exposed to either visual or audiogenic stimulation. At 2, 4, 10 or 30 min following the onset of stress exposure the animals were decapitated and trunk blood was collected for ACTH (RIA) and corticosterone (CS, CBG) determinations. Basal serum concentrations of both hormones were elevated in CHD and AHD, but not in PHD animals as compared to N animals. In N rats, exposure to both stresses resulted in elevated serum ACTH and CS concentrations, with the ACTH response to audiogenic but not visual stimulation being biphasic. In CHD animals, serum ACTH concentrations decreased, and those of CS were unchanged following stress exposure. While audiogenic stimulation caused elevation in serum levels of both hormones in AHD rats, the normal ACTH and CS response to visual stimulation were completely abolished by anterior hypothalamic deafferentation. In PHD animals, no ACTH response to either of the stress exposures was apparent; in spite of this, partial CS responses were elicited. These data thus describe the temporal aspects of the ACTH and CS secretory responses to different neurogenic stresses, and provide insight into the neural pathways mediating these responses.

Neural pathways mediating the prolactin secretory response to acute neurogenic stress in the male rat.

Adult male rats, intact (N) or bearing complete, anterior or posterior hypothalamic deafferentations (CHD, AHD or PHD, respectively), or bilateral medial forebrain bundle (MFB) lesions, were acutely exposed to visual or audiogenic stimulation. At 2, 4, 10 or 30 min following stress onset the animals were decapitated and trunk blood was collected for prolactin (PRL) determinations. Basal serum PRL levels were found to be similar in all groups. In N animals, exposure to both modalities resulted in rapid and marked PRL secretory responses. These responses were totally abolished in the CDH group. In AHD rats, no significant elevation in serum PRL concentration was found upon stress exposure. In PHD animals, the PRL secretory responses were only slightly attenuated when compared with the N group. In MFB-lesioned rats, a marked elevation in serum PRL concentrations was recorded following visual stimulation; contrary thereto, the PRL secretory response following audiogenic stress was markedly attenuated. These data (1) describe the temporal aspects of the PRL secretory response to acute exposure to neurogenic stresses in the male rat, and (2) demonstrate that these PRL responses are elicited via a neural pathway impinging upon the medial basal hypothalamus from the rostral direction.

Deafferentation reduces the hypothalamic cell nuclear binding of corticosterone.

Hypothalamic or hippocampal slices and adenohypophyseal lobes taken from adrenalectomized male rats either intact or with complete hypothalamic deafferentation (CHD) were incubated in Krebs-Ringer bicarbonate buffer in the presence of either 10-50 nM [3H]corticosterone or [3H]dexamethasone with or without 500-fold excess of unlabeled steroid for 15-60 min. The cell nuclear binding in the hypothalamic slices from the CHD rats, was markedly reduced by approximately 50% but remained unchanged in the hippocampi and in the pituitaries. These results suggest that brain sites outside the mediobasal hypothalamus are important for the regulation of corticosterone binding in the hypothalamus.

Effects of naloxone on basal and stress-induced ACTH and corticosterone secretion in the male rat--site and mechanism of action.

The acute effects of naloxone upon basal and stress-induced secretion of ACTH and corticosterone (CS) in the adult male rat were investigated. Forty-five minutes subsequent to naloxone injection (5 mg/kg body wt, i.p.), basal serum levels of ACTH (by radioimmunoassay) and of CS (by corticosterone-binding globulin) were more than doubled, as compared to vehicle-treated animals. Upon exposure to either photic or audiogenic stress, the ACTH and CS secretory responses were greater in the naloxone-injected groups. In animals with complete hypothalamic deafferentation basal serum ACTH concentrations were significantly greater than in intact controls (2-fold), and naloxone elicited a further doubling of this parameter. In dexamethasone-pretreated rats (50 micrograms/animal, 4 h prior to naloxone), naloxone had no effect upon ACTH and CS secretion. This study demonstrates: (1) that acute naloxone administration leads to hypersecretion of ACTH, as well as of CS, in the adult male rat; and (2) that its effect is due to an action within the hypothalamo-hypophyseal unit. The data also suggest that these naloxone effects are not mediated by glucocorticoid hormones.

A temporal study of post-adrenalectomy increase in ACTH secretion in the rat: effect of various hypothalamic deafferentations.

Adult male rats, intact (N) or with complete (CHD), anterior (AHD), or posterior (PHD) hypothalamic deafferentations were bilaterally adrenalectomized. At 3, 6, 12 and 20 days post-adrenalectomy they were decapitated and trunk blood was collected for ACTH determinations. In N rats, ACTH markedly elevated up to 850 pg/ml. A similar ACTH response was found in PHD rats but the values were lower by approximately 20%. In contrast, in either AHD or CHD rats, ACTH responses were markedly attenuated and reached a plateau of about 350 pg/ml. These data suggest that: (1) neural inputs entering the medio-basal hypothalamus (MBH) from both the caudal and rostral directions are important for obtaining maximal ACTH responses following adrenalectomy; (2) at least part of this ACTH response is mediated by sites inside the MBH or in the pituitary.

PRL and ACTH secretion following acute heat exposure, in intact and in hypothalamic deafferentated male rats.

Adult male rats, intact or bearing complete, anterior or posterior hypothalamic deafferentiations (CHD, AHD AND PHD, respectively) were acutely exposed to environmental temperature of 36 degrees C, and serum PRL and ACTH concentrations were determined by RIA. In intact animals, heat exposure resulted in elevated serum PRL and ACTH levels. None of the deafferentations affected basal serum PRL concentrations, whereas those of ACTH were elevated in both CHD and AHD, but not in PHD groups, as compared to intact controls. The PRL heat response was completely absent in CHD, attenuated in AHD, and delayed in PHD animals, and the ACTH heat response was absent in all three groups. These results demonstrate (1) that acute exposure to elevated environmental temperature stimulates secretion of PRL and of ACTH; (2) that this stimulation is carried out by diverse neural pathways; and, (3) that hypothalamic modulation of the secretion of PRL and ACTH is effected by independent mechanisms.

ACTH and corticosterone secretion following 2-deoxyglucose administration in intact and in hypothalamic deafferentated male rats.

Adult male rats were given a single i.p. injection of 2-deoxyglucose (2-DG, 100-400 mg/kg b. wt). The animals were decapitated 1-4 h later and trunk blood was collected for ACTH, corticosterone (CS) and glucose determinations. Serum ACTH and CS were markedly elevated when compared with saline-treated animals; these elevations were correlated with given doses of 2-DG so that with the higher dose, an approximately 6-fold increase in serum levels of both hormones was observed. Injection of 2-DG up to 200 mg/kg did not change serum glucose levels; injection of 400 mg/kg of 2-DG increased serum glucose by approximately 2-fold. A time course study showed that levels of serum ACTH, CS and glucose were maximal 1 h after 2-DG administration and returned to basal values 3 h later. Injection of 2-DG to animals with complete hypothalamic deafferentation failed to induce any change in serum ACTH, CS or glucose. This study demonstrates that: (1) 2-DG can stimulate the hypothalamo-hypophyseal-adrenal (HHA) axis as measured by ACTH and CS; this effect is not related to blood glucose levels; (2) the HHA response to 2-DG is mediated by sites outside the mediobasal hypothalamus.

Laser pointer maculopathy.

PURPOSE: To report a case of macular damage from a laser pointer. METHOD: Case report. A 19-year-old woman had an acute reduction of visual acuity in the right eye after deliberately staring into a commercial class 2 laser pointer for approximately 10 seconds. RESULTS: The patient's best-corrected visual acuity was RE: 20/40, and she had two small pericentral scotomata, as well as a hypopigmented ring-shaped lesion in the fovea. Within 8 weeks, her visual acuity improved to 20/20 and visual field returned to normal, but a subjective relative decrease in brightness of objects viewed by the right eye was apparent. Retinal pigment epithelial abnormality persisted. CONCLUSIONS: Commercial laser pointers, commonly used for teaching and entertainment purposes, may cause notable macular damage if abused. Morphologically, this may manifest as foveal retinal pigment epithelial disturbance.

The role of the medial forebrain bundle in the mediation of the hypothalamic-hypophyseal-adrenal responses to acute neurogenic stress.

Adult male rats, intact (N) or bearing bilateral lesions in the medial forebrain bundle (MFB), were acutely exposed to visual, audiogenic, or thermal stress, during the following which serum ACTH and corticosterone (CS) levels were determined. The marked elevations in serum concentrations of both ACTH and CS which occurred in intact animals following photic stimulation were absent in MFB rats. The normal ACTH and CS responses to audiogenic stress were slightly delayed and attenuated, respectively, in the operated group, whereas the responses of both hormones to exposure to elevated environmental temperature were partially blocked in lesioned, as compared to intact, animals. These results demonstrate that the MFB is involved in mediating the ACTH, as well as the CS secretory responses to acute stress exposure. More specifically, the role of the MFB, vís-à-vis the hypothalamo-hypophyseal-adrenal axis, appears to be in the transmission of sensory input from rostral brain areas posteriorly.

Post-brachytherapy initial tumour regression rate correlates with metastatic spread in posterior uveal melanoma.

AIM: To confirm the prognostic value of post-brachytherapy initial tumour regression rate in posterior uveal melanoma. METHODS: A prospective, comparative, observational cohort study was carried out on 147 eyes (147 patients) with choroidal melanoma (mean age 61 years) treated with Ru-106 brachytherapy. OBSERVATION PROCEDURE: Patients were followed clinically and ultrasonically every 6.7 (SD 0.3) months (1001 examinations). On average each patient was examined 5.8 times (mean follow up 9.6 (3.7) years). The echographic parameters included tumour base size, height, internal reflectivity, regularity, vascularity, and extrascleral extension. The clinical follow up included ocular examination and periodic metastatic screening (liver function tests and liver imaging). Main outcome measures were risk of liver metastasis in correlation with the post-brachytherapy initial tumour regression rate. RESULTS: At brachytherapy the mean tumour height was 5.2 mm (range 2.2-11.8 mm). After brachytherapy 142 tumours (96.6%) responded by a decrease in height. The initial height regression rate was 6.1% (0.8%) per month in patients who later developed metastasis v 4.3% (0.4%) per month in those who did not. Tumours higher than 6 mm, tumours with an internal reflectivity smaller than 50%, and tumours with an initial rate of height regression larger than 0.7 mm/month (10% per month) had higher 5 year melanoma related mortality. Kaplan-Meier survival analysis and the multivariate Cox proportional hazards model showed a significant role for tumour height and initial tumour regression rate on patients' survival. CONCLUSION: This study confirms that post-brachytherapy initial tumour regression rate has a prognostic value.

Cone and rod dysfunction in the NARP syndrome.

AIMS: Description of the ophthalmic manifestations of the NARP (neuropathy, ataxia, retinitis pigmentosa) syndrome that is associated with a point mutation in position 8993 of the mitochondrial DNA (mtDNA). METHODS: A mother and her two children, all carrying the 8993 mtDNA mutation, were examined. Two had manifestations of the NARP syndrome. A complete ocular and systemic examination was performed on all three patients. RESULTS: The clinical examination, electroretinogram, and visual fields revealed a typical cone-rod dystrophy in the son, and a typical cone dystrophy in the daughter. The mother had no ocular manifestations of the disease. CONCLUSIONS: NARP is a recently described, maternally inherited mitochondrial syndrome in which a retinal dystrophy, among other abnormalities, is related to a mutation of the mtDNA at nucleotide 8993. This study demonstrates the great variability of the ocular manifestations in the NARP syndrome. It also indicates that the retinal dystrophy in at least some NARP patients affects primarily the cones.