An objective tool to measure the effect of botulinum toxin in blepharospasm and hemifacial spasm.

BACKGROUND AND PURPOSE: It is challenging to assess patients with blepharospasm (BSP) and hemifacial spasm (HFS) as these patients exhibit a wide range of amplitudes of eyelid movements. In order to quantify these movements, a mathematical algorithm, i.e. Fast Fourier Transform, can be employed to convert the signal from the time domain to the frequency domain. The result of this quantification represents the energy generated during the eyelid movements. In order to objectively assess the therapeutic effects of botulinum toxin (BoNT) in these patients, we evaluated the energy generated by the upper eyelid during spontaneous eyelid movements before and after treatment. METHODS: A total of 39 patients with BSP and HFS were evaluated before and 30 days after receiving onabotulinum toxin A injections. A high-speed camera and micro light-emitting diodes were used to register the spontaneous eyelid movements. The result of the quantification obtained using Fast Fourier Transform permitted assessment of the activity associated with the eyelid movements. RESULTS: We studied 78 eyelids. The total energy generated during spontaneous eyelid movements was significantly reduced after treatment in the patients with BSP (P = 0.0018) and on the affected side in the patients with HFS (P = 0.0058). CONCLUSIONS: The assessment of the energy generated by the upper eyelid during spontaneous eyelid movements enabled us to measure the therapeutic effects of BoNT in patients with these conditions. The use of this system could enable customized and fine adjustments to BoNT doses based on each patient's needs.

IL-10 and TGF-beta immunoregulatory cytokines rather than natural regulatory T cells are associated with the resolution phase of Vogt-Koyanagi-Harada (VKH) syndrome.

The pro-inflammatory cytokines play a critical role in the initiation and propagation of ocular autoimmune diseases. Regulation of these cytokines is generally mediated by the immunoregulatory cytokine such as IL-10 or TGF-beta. In this study, we investigated the immunoregulatory cytokine profile and frequency of natural regulatory T cells (nTregs) in patients with Vogt-Koyanagi-Harada (VKH). We obtained the peripheral blood mononuclear cells (PBMC) from patients with VKH and healthy controls. The cytokine profile from supernatants of PBMC cultured with or without phytohaemagglutinin (PHA) was measured by ELISA, the percentage of CD4(+) Foxp3(+) and CD25(high)Foxp3(+) T regulatory cells were analysed by flow cytometry, and the transcriptional level of Foxp3 expression was analysed by real-time quantitative PCR. The immunoregulatory cytokines, TGF-beta and IL-10, increased in patients with VKH in the inactive stage of the disease. We observed no significant difference in the CD4(+) Foxp3(+) and CD25(high)Foxp3(+) T cells as well as no reduction in FOXP3 mRNA expression in the patients with VKH when compared to healthy controls. We showed in our work, an increase in IFN-gamma secretion by PBMC of patients with VKH in the active stage of the disease when compared to healthy controls and patients in the inactive stage. Our data suggest that IL-10 and TGF-beta cytokines, rather than nTregs are associated with the resolution phase of the disease and may have a more relevant role in controlling this disease.

Dose-dependent in vitro inhibition of rabbit corneal matrix metalloproteinases by an extract of Pothomorphe umbellata after alkali injury.

The in vitro ability of Pothomorphe umbellata ethanolic crude extract to inhibit matrix metalloproteinase (MMP) in normal cornea and in cornea after alkali injury was demonstrated. Corneas of albino rabbits were injured with 1 N NaOH for 20 s. After 48 h the corneas were excised, homogenized and analyzed for MMP-9 (92 kDa), pro-MMP-2 (72 kDa) and MMP-2 (67 kDa) activity by gelatin zymography. The activity was also measured in untreated corneas. After electrophoresis of 20 microg protein, gels were incubated with 50, 100, or 250 microg/mL lyophilized hydroethanolic (1:1) root crude extract of P. umbellata standardized for 4-nerolidylcatechol (7.09%). The activity of the enzymes was compared with that of untreated gel. At 48 h after injury, the activity of all MMPs was increased compared with untreated eyes. When the gels were incubated with P. umbellata extract the activity of MMP-2, pro-MMP-2 and MMP-9 decreased in a dose-dependent manner. MMP-9 activity decreased by approximately 50% after incubation with 50 microg/mL and was completely abolished at 100 and 250 microg/mL of the extract. After incubation with 50 microg/mL the activity of pro-MMP-2 and MMP-2 also decreased by 50%. The activity of pro-MMP-2 was almost completely abolished after incubation with 250 microg/mL of the extract. For MMP-2 the incubation with 100 or 250 microg/mL of the extract of P. umbellata promoted a 10-fold decrease in activity. In conclusion, P. umbellata root crude extract can be useful as an alternative therapy to control MMP activity after corneal injury.

[Ocular manifestations of Zika virus: What we do and do not know]. / Manifestations oculaires du virus Zika : où en sommes-nous ?

Zika virus (ZIKV) disease outbreak, which was declared by the end of 2015 in Brazil, has become the largest one to date. Being reported in the Americas and in certain islands of the Pacific, it has the potential to spread worldwide. Although ZIKV infections are mostly self-limiting and/or asymptomatic in the healthy adult, they are responsible for devastating congenital neurologic malformations ZIKV (mainly microcephaly) when contracted during the first months of pregnancy. Ocular manifestations during the acute adult infection include conjunctivitis and more rarely ocular inflammation. Congenital infection is associated with chorioretinal atrophy pigment mottling of the retina retinal vasculature abnormalities and optic nerve atrophy. Therefore, complete ophthalmological evaluation is recommended for suspected congenital infections.

Colour vision defects in asymptomatic carriers of the Leber's hereditary optic neuropathy (LHON) mtDNA 11778 mutation from a large Brazilian LHON pedigree: a case-control study.

AIMS: To determine if asymptomatic carriers from a previously identified large pedigree of the Leber's hereditary optic neuropathy (LHON) 11778 mtDNA mutation have colour vision deficits. METHODS: As part of a comprehensive analysis of over 200 members of a large Brazilian LHON pedigree spanning seven generations, colour vision tests were obtained from 91 members. Colour vision was tested one eye at a time using the Farnsworth-Munsell 100 (FM-100) hue colour vision test. The test was administered under uniform conditions, taking into account: ambient light levels, daylight colour temperature of 6700 kelvin, and neutral uniform background. Tests were scored using the FM-100 MS-Excel computer scoring program. Defects were determined and categorised as tritan, deutan, or protan. Categorisation of each dyschromatopsia was based on review of demonstrated axis computer generated plots and age adjusted error scores which coincided with Verriest 95% confidence intervals. Only the axis with the greatest magnitude error score was used to classify the defect. 55 of the 91 test subjects were LHON mtDNA 11778 J haplotype mutation carriers, proved by mtDNA analysis. The remaining 36 subjects were age matched non-blood relatives (off pedigree), who served as controls. RESULTS: 27 of 55 carriers (49.10%) were shown to have colour vision defects in one or both eyes. 13 of the 27 (48%) abnormal tests in the carrier group were tritan defects and the remaining 14 (52%) were deutan defects. Nine of the 27 (33%) abnormals in the carrier group were identified as having bilateral defects. Six of these were deutan, and the remaining three were tritan dyschromatopsias. Only six of the 36 (16.66%) age matched controls were found to have any type of dyschromatopsia. Five (83.3%) of these were deutan defects. The remaining one was a tritan defect. The difference between the two groups using a chi(2) test with one degree of freedom was statistically significant with a p value less that 0.001. CONCLUSIONS: Until now, LHON has always been characterised by a sudden, devastating vision loss. Asymptomatic carriers, those without vision loss, were considered unaffected by the disease. It now appears that asymptomatic carriers of the LHON mutation are affected by colour vision defects and may manifest other subtle, yet chronic, changes.

Intravenous administration of recombinant human macrophage colony-stimulating factor to patients with metastatic cancer: a phase I study.

PURPOSE: Recombinant human macrophage colony-stimulating factor (M-CSF) has been shown to stimulate specifically macrophage lineage differentiation in vitro and to induce cells capable of antitumor activity alone or in combination with an antibody. The administration of M-CSF to mice has demonstrated antitumor therapeutic effects in vivo. Therefore, a phase I trial of M-CSF administration to patients with metastatic cancer was undertaken. PATIENTS AND METHODS: M-CSF was given by intermittent intravenous bolus infusion every 8 hours for 7 days; the treatment cycle was repeated once after a week of rest. Cohorts of three patients underwent dose escalation from 10 to 100,000 micrograms/m2/d; 23 patients received 27 courses of M-CSF administration. All patients had metastatic solid tumors refractory to conventional therapy, including renal cell carcinoma (RCC) (nine), melanoma (seven), and colorectal carcinoma (seven). RESULTS: Treatment-related toxicity was minimal; five patients developed transient signs of ocular or periorbital inflammation, with iridocyclitis as the most severe manifestation. At the highest doses, platelet counts decreased with therapy (but remained > 100,000/mm3) and the absolute monocyte count increased during the course of therapy. Only at 30,000 and 100,000 micrograms/m2/d was treatment limited because of toxicity (iritis and malaise). Pharmacokinetic studies demonstrated up to a 1,000-fold increase in circulating serum M-CSF after bolus infusion; half-life varied from 1 to 6 hours. Complete regression of mediastinal adenopathy and multiple pulmonary metastases were observed in one patient with RCC. CONCLUSION: Recombinant M-CSF can be administered safely to patients with metastatic cancer at doses that demonstrate biologic activity.

Cigarette toxicity triggers Leber's hereditary optic neuropathy by affecting mtDNA copy number, oxidative phosphorylation and ROS detoxification pathways.

Leber's hereditary optic neuropathy (LHON), the most frequent mitochondrial disease, is associated with mitochondrial DNA (mtDNA) point mutations affecting Complex I subunits, usually homoplasmic. This blinding disorder is characterized by incomplete penetrance, possibly related to several genetic modifying factors. We recently reported that increased mitochondrial biogenesis in unaffected mutation carriers is a compensatory mechanism, which reduces penetrance. Also, environmental factors such as cigarette smoking have been implicated as disease triggers. To investigate this issue further, we first assessed the relationship between cigarette smoke and mtDNA copy number in blood cells from large cohorts of LHON families, finding that smoking was significantly associated with the lowest mtDNA content in affected individuals. To unwrap the mechanism of tobacco toxicity in LHON, we exposed fibroblasts from affected individuals, unaffected mutation carriers and controls to cigarette smoke condensate (CSC). CSC decreased mtDNA copy number in all cells; moreover, it caused significant reduction of ATP level only in mutated cells including carriers. This implies that the bioenergetic compensation in carriers is hampered by exposure to smoke derivatives. We also observed that in untreated cells the level of carbonylated proteins was highest in affected individuals, whereas the level of several detoxifying enzymes was highest in carriers. Thus, carriers are particularly successful in reactive oxygen species (ROS) scavenging capacity. After CSC exposure, the amount of detoxifying enzymes increased in all cells, but carbonylated proteins increased only in LHON mutant cells, mostly from affected individuals. All considered, it appears that exposure to smoke derivatives has a more deleterious effect in affected individuals, whereas carriers are the most efficient in mitigating ROS rather than recovering bioenergetics. Therefore, the identification of genetic modifiers that modulate LHON penetrance must take into account also the exposure to environmental triggers such as tobacco smoke.

Experimental guinea pig ocular infection by Salmonella typhimurium.

The clinical, microbiologic, and cytologic features of the guinea pig model of keratoconjunctivitis with enterobacteria, Salmonella typhimurium were elucidated. Guinea pig eyes were instilled with S. typhimurium and the eyes were studied by biomicroscopy, culture, cytology, pathology, and electron microscopy. All animals developed moderate to severe conjunctivitis that was present in 18% of the animals on day 1. It became more intense, appearing in all of the eyes on day 10 and disappeared before day 30. The cultures for S. typhimurium were almost all positive on days 1 and 2, declined steadily to 10% on day 10, and were negative after that. A coarse, epithelial punctate keratitis was present in more than 90% of the infected eyes at some time during the experiment. The keratitis had a biphasic clinical course. The first peak correlated with the maximum culture results, but during the second peak only 10% of the cultures were positive. Electron microscopy of the cornea showed the S. typhimurium at the epithelial surface within surface epithelial cells during the early phases of infection. The later phase keratitis, with negative culture results, resembles the keratitis of Reiter's syndrome.

Epidemiological study of eye injuries in Brazilian children.

A year-long follow-up study of 146 eye injuries in children up to 15 years of age was carried out in two emergency hospitals of a southern Brazilian city. These injuries represent approximately 65% of the total number of patients seeking ophthalmic care at emergency hospitals within this city. Patients were followed up for at least four months after injury; visual results as well as epidemiological factors were analyzed. Based on these findings, children in the 0- to 5-year-old group were at greatest risk, regardless of sex; among children older than 5 years, eye injuries were more frequent in boys. Generally, the child takes part in the accident as an active participant, and adequate adult supervision decreases the number of these accidents. Analysis of the relationship between socioeconomic levels of the parents and severity of eye injuries revealed that severe eye injuries were more frequent in lower socioeconomic strata. In severe eye injuries 35.1% of the children ended with visual acuity under 20/200 in the affected eye, which corresponds to 9% of all studied eye injuries.

T and B lymphocytes in the aqueous humor of patients with uveitis.

Sixteen patients with different types of uveitis (ocular toxoplasmosis, chronic cyclitis, Vogt-Koyanagi-Harada syndrome, Behçet's syndrome, ocular herpes, and a probable nematode) had the aqueous humor withdrawn and had the number of T, B, and null lymphocytes assessed. T and B lymphocytes were identified by rosette formation with sheep erythrocytes and with human erythrocytes sensitized with IgM antibody and complement or zymosan-C3 complexes, respectively. A much higher number of T lymphocytes than B lymphocytes was observed in all cases. The results were not influenced by treatment with steroids or immunosuppressive drugs for local, periocular, or systemic effects.

Immunohistochemistry of the inflammatory response in Propionibacterium acnes endophthalmitis.

Specimens were obtained from two patients with culture-proven Propionibacterium acnes endophthalmitis who had undergone vitrectomy. Wright's and Giemsa stains were performed using cytospin preparations of the dilute vitreous and revealed a predominance of polymorphonuclear leukocytes (80% to 90%). The remaining inflammatory cells in the vitreous were mostly macrophages (10% to 15%); very few lymphocytes were present (less than 5%). Immunohistochemical studies using monoclonal antibodies confirmed the paucity of lymphocytes. Most lymphocytes were CD4+ helper/inducer T cells. Almost no CD8+ suppressor/cytotoxic T lymphocytes or B lymphocytes were found. The inflammatory response in these two patients is most characteristic of acute inflammation and consistent with an underlying bacterial infection, despite a clinical picture of persistent, low-grade inflammation. Infection with P acnes has been shown to inhibit CD8+ T cells and may play a role in the persistent inflammation in cases of P acnes endophthalmitis.

Differentiation of Toxoplasma gondii from closely related coccidia by riboprint analysis and a surface antigen gene polymerase chain reaction.

The tachyzoite of the human pathogen Toxoplasma gondii is morphologically indistinguishable from the proliferative stages of some other zoonotic coccidia, including Sarcocystis. To determine the identity of such coccidia obtained from human tissues and other sources, we compared riboprints (through restriction enzyme analysis of the polymerase chain reaction [PCR]-amplified small subunit rRNA gene) of the following protozoa: the RH and ts-4 strains of T. gondii, lines OH3 and S11, which are two recently isolated T. gondii-like parasites from Brazil, Neospora caninum, Sarcocystis species, and the malarial parasite Plasmodium berghei. In addition, the protozoan genomes were examined by PCR for homologs of surface antigen genes of T. gondii, and by Southern hybridization to the heterologous rRNA gene probe pSM 389. Strains OH3, S11, ts-4, and RH shared identical riboprints, and OH3, S11, and ts-4 have p22 and p30 surface antigen gene structures similar to RH. In contrast, riboprints for N. caninum and T. gondii differ with respect to Dde 1 sites, and moreover, their genomes vary significantly from one another at both the p22 and p30 gene loci. The riboprints of Sarcocystis and P. berghei differ markedly from T. gondii and N. caninum and from each other. Bam HI pSM 389 restriction fragment length polymorphisms differentiate ts-4 from RH, OH3, and S11. Our results confirm that OH3 and S11 are indeed T. gondii, but that N. caninum and T. gondii are likely to be separate species, thereby resolving previous uncertainties concerning the identity of these parasites. Together, the variation in riboprints and surface antigen gene structure reflects the phylogenetic diversity among these coccidia, and in addition, confirms the value of riboprinting in the identification of apicomplexan parasites such as T. gondii.

Presumed ocular and central nervous system tuberculosis in a patient with the acquired immunodeficiency syndrome.

PURPOSE: To elucidate a case of tuberculous choroiditis in a patient with the acquired immunodeficiency syndrome (AIDS). METHODS: We treated a 35-year-old woman who had AIDS with neurologic involvement caused by Mycobacterium tuberculosis. She developed a yellow-white chorioretinal infiltrate with indistinct borders and mild vitreitis in the right eye, probably caused by this pathogen. RESULTS: The patient's visual acuity improved in the right eye with healing of the ocular lesion and her neurologic condition improved after specific therapy with isoniazid, rifampin, and ethambutol. CONCLUSION: Tuberculosis must be considered in the differential diagnosis of posterior uveitis and choroiditis in AIDS patients.

Squamous cell carcinoma of the conjunctiva in a patient with the acquired immunodeficiency syndrome.

PURPOSE: To alert ophthalmologists to the possibility of human immunodeficiency virus (HIV) infection in individuals with conjunctival squamous cell carcinoma. METHODS: We treated a 24-year-old patient with the acquired immunodeficiency syndrome who developed a limbal mass. The mass was excised and examined by routine histologic and immunohistochemical methods. RESULTS: The histopathologic examination disclosed infiltrating squamous cell carcinoma with features of spindle cell carcinoma. Frequent abnormal mitotic figures were present in this neoplasia. CONCLUSIONS: Squamous cell carcinoma with histologic features of aggressive behavior in a young individual should alert physicians to the possibility of HIV infection. Such patients may require frequent follow-up examination, even after complete excision of the tumor.

Antihelminthic drugs in diffuse unilateral subacute neuroretinitis.

PURPOSE: To evaluate the efficacy of ivermectin and thiabendazole in confirmed cases of diffuse unilateral subacute neuroretinitis. METHODS: Two patients with diffuse unilateral subacute neuroretinitis were treated with anthelminthic drugs. The first patient was treated with ivermectin and the second, with thiabendazole. RESULTS: The worms were still mobile after treatment with ivermectin or thiabendazole. With the application of photocoagulation, the organisms were destroyed, and the patients' vision improved. CONCLUSION: In these two patients, ivermectin and thiabendazole were not effective in treating confirmed diffuse unilateral subacute neuroretinitis.

Indomethacin and the corneal immune response.

To study the effect of treating rabbits with a locally administered noncorticosteroid anti-inflammatory drug, we gave 26 rabbits unilateral subconjunctival injections of 15 mg of indomethacin suspension daily for 16 days, starting one day before the intracorneal injection of the same eye with bovine gamma globulin. We graded the eyes clinically and killed groups of rabbits on postimmunization days 6, 9, 12, and 15. We determined the number of antibody-forming cells in the homolateral cervical lymph nodes, corneas, and uveal tracts and tested the sera, aqueous humor, and vitreous humor for antibodies. Indomethacin-treated eyes showed significantly less inflammatory response, and an insignificantly greater number of antibody-forming cells, than the controls.

Fuchs' heterochromic cyclitis and ocular toxoplasmosis.

Ocular toxoplasmosis and Fuchs' heterochromic cyclitis are well-defined diseases that have completely different clinical courses. We studied 13 patients (seven men and six women, ranging in age from 18 to 73 years) who had Fuchs' heterochromic cyclitis and the focal necrotizing chorioretinal lesions characteristic of ocular toxoplasmosis. The reason for this association is still unknown, as is the pathogenesis of Fuchs' heterochromic cyclitis. None of the patients had ciliary injection or posterior synechiae, but 11 of the 13 (84.6%) had keratic precipitates, anterior chamber reaction, and cataracts. Six patients (38.4%) had iris transillumination, two (15.3%) had glaucoma, and four (30.7%) had lesions in the fellow eyes.

Resolution of microsporidial keratoconjunctivitis in an AIDS patient treated with highly active antiretroviral therapy.

PURPOSE: To report the outcome of microsporidial keratoconjunctivitis in a patient with acquired immunodeficiency syndrome (AIDS) after highly active antiretroviral therapy without any specific treatment for microsporidiosis. METHODS: Case report. A 42-year-old woman diagnosed with AIDS and severe immunodepression (CD4+ of 9 cells/mm(3) and viral load of 460,000/mm(3)), antiretroviral naive, presented with cerebral toxoplasmosis and microsporidial keratoconjunctivitis in the right eye documented by conjunctival scraping and electron microscopy. RESULTS: The patient was treated with a combination of indinavir, stavudine, and lamivudine, besides sulfadiazine and pyrimethamine. No specific treatment for the microsporidial keratoconjunctivitis was attempted. One month later, the keratoconjunctivitis had disappeared. CONCLUSION: This case suggests that microsporidial keratoconjunctivitis in the setting of AIDS and severe immunodepression can be effectively managed with highly active antiretroviral therapy alone.

Intraocular inflammatory reactions without focal necrotizing retinochoroiditis in patients with acquired systemic toxoplasmosis.

PURPOSE: To describe the occurrence of intraocular inflammatory reactions as the sole ophthalmic manifestation of acquired systemic toxoplasmosis. METHODS: Review of medical records for 10 patients with uveitis and evidence of recent Toxoplasma gondii infection. RESULTS: Patient ages ranged from 3 to 51 years. Ocular symptoms were present in each of eight adult patients. Inflammation was unilateral in nine patients; it manifested as vitreous humor cells and haze (10 patients), anterior chamber cells (seven patients), and retinal vasculitis (seven patients). No patient had necrotizing retinochoroiditis upon initial examination. Inflammation resolved in each of nine patients who had follow-up examinations. Foci of retinitis or inactive retinochoroidal scars were seen in four of these nine patients during follow-up examinations, at intervals of 2.0 weeks to 2.5 years after initial examination. CONCLUSIONS: Retinal vasculitis and associated inflammatory reactions may be the only ophthalmic disorder during the early stages of a newly acquired T. gondii infection. Later development of retinitis or scars consistent with toxoplasmic retinochoroiditis in the same eyes suggests that the initial, isolated inflammation may be caused by the presence of parasites in retinal tissue. These cases may have implications for understanding the original source of retinal infection in patients who have recurrent toxoplasmic retinochoroiditis and for treatment of newly acquired T gondii infection.

Exophiala jeanselmei causing late endophthalmitis after cataract surgery.

PURPOSE: To report two cases of late endophthalmitis caused by Exophiala jeanselmei after cataract surgery. METHODS: Case reports, including clinical evaluation, direct examination, and culture of the aqueous humor. RESULTS: In each case, samples from the anterior chamber had positive growth of yeasts with toruloid hyphae and pseudohyphae. Intravitreal and anterior chamber amphotericin B were used in both cases. Apparent clinical resolution was achieved, but after 3 months in one case and 6 months in the other the infection recurred more aggressively, with severe endophthalmitis leading to ocular atrophy. CONCLUSION: E. jeanselmei causes a severe intraocular infection and isolation, and identification of the agent ensures proper diagnosis and treatment. After clinical resolution of the infection, careful and long-term follow-up is recommended to promptly detect relapse and immediately reintroduce treatment.