[Shock-induced ischemic optic neuropathy]. / Shockgeïnduceerde ischemische opticusneuropathie.

BACKGROUND: Shock can lead to ischemic injury of organs. Ischemic injury of the optic nerve may even cause blindness. CASE DESCRIPTION: A 61-year-old female patient was admitted to ICU with septic shock. When recovering, she was only able to determine the difference between light and dark; before admission her vision was good. Ophthalmologic examination revealed slow pupillary reflexes and pale, atrophic optic discs. The diagnosis of bilateral shock-induced ischemic optic neuropathy was made. The patient was permanently blind and traumatised by her experiences during her hospital stay when her blindness was not yet recognised. CONCLUSION: Blindness caused by ischemic optic neuropathy is a rare and severe complication of shock that is usually irreversible. Early recognition is important in order to allow appropriate communication with, and approach of the patient to prevent traumatic experiences and promote rehabilitation.

Morphometric analysis of Bruch's membrane, the choriocapillaris, and the choroid in aging.

PURPOSE: To quantify changes in choriocapillary density and in thickness of Bruch's membrane, the choriocapillaris, and the choroid in 95 unpaired, histologically normal human maculae aged 6 to 100 years and in 25 maculae with advanced age-related macular degeneration. METHODS: Light microscopic, computer-aided, morphometric quantitative analysis. RESULTS: In ten decades, Bruch's membrane thickness increased by 135%, from 2.0 to 4.7 microns; the choriocapillary density decreased by 45%; the diameter of the choriocapillaris decreased by 34%, from 9.8 to 6.5 microns; and the choroidal thickness decreased by 57%, from 193.5 to 84 microns in normal maculae. In maculae with basal laminar deposit, geographic atrophy, or disciform scarring, the density of the choriocapillaris was 63%, 54%, and 43% of normal and the choriocapillary diameter was 81%, 73%, and 75% of normal, respectively. Choroidal thickness remained unchanged. CONCLUSIONS: Thickness of Bruch's membrane was only related to age (rs = 0.63) and not to age-related atrophy of the choriocapillaris. Age was also the strongest factor related to choriocapillary density (rs = -0.58). In advanced stages of age-related macular degeneration, the decrease in choriocapillary density and diameter was significantly larger than in normal maculae, but the thickness of the choroid and Bruch's membrane was the same. The latter was significantly thinner (81% of normal) in disciform scarring.

Changing views on open-angle glaucoma: definitions and prevalences--The Rotterdam Study.

PURPOSE: To create a quantitative basis for diagnostic criteria for open-angle glaucoma (OAG), to propose an epidemiologic definition for OAG based on these, and to determine the prevalence of OAG in a general white population. METHODS: Of the 7983 subjects 55 years of age or older participating in the population-based Rotterdam Study, 6756 subjects participated in the ophthalmic part of this study (6281 subjects living independently and 475 in nursing homes). The criteria for the diagnosis of OAG were based on ophthalmoscopic and semiautomated Imagenet estimations of the optic disc such as vertical cup-to-disc ratio (VCDR), minimal width of neural rim, or asymmetry in VCDR between both eyes, and visual field testing with kinetic Goldmann perimetry. All criteria for the diagnosis of OAG were assessed in a masked way independently of each other. RESULTS: Mean VCDR on ophthalmoscopy was 0.3 and with Imagenet 0.49, and the 97.5th percentile for both was 0.7. The prevalence of glaucomatous visual field defects was 1.5%. Overall prevalence of definite OAG in the independently living subjects was 0.8% (95% confidence interval [CI] 0.6, 1.0; 50 cases). Prevalence of OAG in men was double that in women (odds ratio 2.1; 95% CI 1.2, 3.6). Different commonly used criteria for diagnosis of OAG resulted in prevalence figures ranging from 0.1% to 1.2%. CONCLUSIONS: The overall prevalence of OAG in the present study was comparable to most population-based studies. However, prevalence figures differed by a factor of 12 when their criteria for OAG were applied to this population. A definition for definite OAG is proposed: a glaucomatous optic neuropathy in eyes with open angles in the absence of history or signs of secondary glaucoma characterized by glaucomatous changes based on the 97.5 percentile for this population together with glaucomatous visual field loss. In the absence of the latter or of a visual field test, it is proposed to speak of probable OAG based on the 99.5th or possible OAG based on the 97.5th percentiles of glaucomatous disc changes for a population under study.

Genetic risk of primary open-angle glaucoma. Population-based familial aggregation study.

OBJECTIVES: To study familial aggregation of primary open-angle glaucoma in a general population and to determine the absolute and relative risks for first-degree relatives. METHODS: First-degree relatives of patients with glaucoma (n = 48) and control subjects (n = 155) from the population-based Rotterdam Study underwent a standardized examination, including perimetry. MAIN OUTCOME MEASURES: Intraocular pressure, vertical cup-disc ratio; and the presence of glaucoma, defined as a visual field defect with a cup-disc ratio of 0.7 or higher or asymmetry of 0.3 or higher between both eyes. RESULTS: The prevalence of glaucoma was 10.4% in siblings of patients, 1.1% in offspring of patients, 0.7% in siblings of controls, and 0% in offspring of controls. Life-time risk of elevated intraocular pressure in relatives of patients vs relatives of controls was 42.5% vs 6.7%, of enlarged cup-disc ratio was 62.2% vs 16.6%, and of glaucoma was 22.0% vs 2.3%, yielding a risk ratio for glaucoma of 9.2 (95% confidence interval = 1.2-73.9). The population-attributable risk of glaucoma was 16.4%. CONCLUSIONS: In a general population, relatives of patients with glaucoma have a strongly increased risk of glaucoma. Enlarged cup-disc ratio, not intraocular pressure, was the earliest and most prominent feature of familial aggregation. Further studies are needed to disentangle the genetic components of the increased familial risk.

Prevalence and causes of visual field loss in the elderly and associations with impairment in daily functioning: the Rotterdam Study.

OBJECTIVES: To determine the prevalence and causes of visual field loss (VFL) and the association between VFL and indicators of impairment in daily functioning. DESIGN: Population-based cohort study. SETTING: Suburb of Rotterdam, the Netherlands. PARTICIPANTS: Community-dwelling elderly residents (n = 6250). MAIN OUTCOME MEASURE: Visual field loss on suprathreshold static, Goldmann kinetic perimetry, or both. METHODS: Suprathreshold testing of the central visual field was performed on both eyes and repeated if results were abnormal or unreliable. Goldmann perimetry was performed to confirm defects. Causes were determined using ophthalmologic and neurologic examination data and medical records. Impairment was assessed using data from interviews and medical records on disability in daily life, falling, and fractures. RESULTS: The overall prevalence of VFL was 5.6% (3.0% in those aged 55-64 years to 17.0% in those > or =85 years); glaucoma was the leading cause in all age groups. Before age 75 years, other optic nerve diseases and stroke ranked second and third, respectively, as did age-related macular degeneration and retinal vascular occlusive disease, respectively, after this age. Also, after adjustment for visual acuity, VFL was associated with disability, diminished enjoyment of reading and watching television, and a higher risk of incident falling. Risk of incident hip fracture was not increased. CONCLUSIONS: Visual field loss is present in 1 of every 20 community-dwelling elderly people and is associated with impaired daily functioning. Glaucoma is the leading cause in all age groups. Other high-ranking causes, some of which are partly preventable, vary by age.

Epidermal participation in post-burn hypertrophic scar development.

The reconstruction of epidermal architecture over time in normotrophic and hypertrophic scars in untransplanted, spontaneously healed partial-thickness burns has scarcely been studied, unlike the regeneration of epidermal grafts used to cover burn wounds and the regeneration of the dermis during hypertrophic scarring. The expression of markers of epidermal proliferation, differentiation and activation in normotrophic and hypertrophic scars in spontaneously healed partial-thickness burns was assessed and compared with the expression of these markers in normal control skin of healthy persons to determine whether hypertrophic scarring is associated with abnormalities in the phenotype of keratinocytes. Punch biopsies were taken both of partial-thickness burns after re-epithelialisation and of matched unburned skin. At 4 and 7 months post-burn, biopsies were taken of normotrophic and hypertrophic scars that had developed in these wounds. The biopsies were analysed using immunostaining for markers of keratinocyte proliferation, differentiation and activation (keratins 5, 10, 16 and 17, filaggrin, transglutaminase and CD36). We observed a higher expression of markers for proliferation, differentiation and activation in the epidermis of scars at 1 month post-burn than in normal control skin of healthy persons. There was a striking difference between normotrophic and hypertrophic scars at 4 months post-burn. Keratinocytes in hypertrophic scars displayed a higher level of proliferation, differentiation and activation than did normotrophic scars. At 7 months post-burn all keratinocyte proliferation and differentiation markers showed normal expression, but the activation marker CD36 remained upregulated in both normotrophic and hypertrophic scars. Surprisingly, in matched unburned skin of burn patients, a state of hyperactivation was observed at 1 month. Our results suggest that keratinocytes may be involved in the pathogenesis of hypertrophic scarring.

Cup-to-disc ratio: ophthalmoscopy versus automated measurement in a general population: The Rotterdam Study.

OBJECTIVE: To determine the correlations between ophthalmoscopic estimations and the measurements with a semiautomated image-analysis device of the vertical cup-to-disc ratio (VCDR) in the human optic disc. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: All subjects 55 years of age and older from the population-based sample of 6777 ophthalmologically examined subjects from The Rotterdam Study of whom gradable optic disc transparencies of at least 1 eye and ophthalmoscopic data of the same eye were available. MAIN OUTCOME MEASURES: Ophthalmoscopic assessment of the VCDR and semiautomated measurement of the VCDR. METHODS: Indirect and direct ophthalmoscopy were performed in mydriasis to assess the VCDR. Optic disc transparencies made with a simultaneous stereoscopic telecentric fundus camera were analyzed with a semiautomated measurement system (Topcon Imagenet). RESULTS: In 5143 subjects, the mean ophthalmoscopic VCDR was 0.30 (standard error [SE], 0.0021; range, 0.00, 1.00) compared with a semiautomatically measured VCDR of 0.49 (SE, 0.0019; range, 0.04, 0.86; difference, 0.19; P < 0.0001). The overall correlation between both methods was moderate (correlation coefficient, 0.61; SE, 0.11) and lower in small optic discs. Semiautomated optic disc measurements correctly identified 76% of the glaucoma cases (as defined using visual field data and ophthalmoscopic data about the optic disc). CONCLUSION: Semiautomated measurements of the VCDR are larger than the ophthalmoscopic VCDR estimate with a moderate correlation. The interobserver variability using Imagenet was smaller compared with the ophthalmoscopic assessments, and Imagenet was better standardized, which is important for epidemiologic surveys and follow-up studies.

Determinants of optic disc characteristics in a general population: The Rotterdam Study.

OBJECTIVE: To determine whether age, gender, height, and refractive error are associated with optic disc morphology in a general elderly population. DESIGN: Population-based, cross-sectional study. PARTICIPANTS: A total of 5114 subjects 55 years of age or older participated in this study, representing 76% of a population-based sample of 6777 ophthalmologically examined white patients from a geographically well-defined suburb in Rotterdam, The Netherlands. MAIN OUTCOME MEASURES: Disc area, neural rim area, cup area, vertical and horizontal cup-to-disc ratios, and parapapillary atrophy. METHODS: Disc characteristics were measured on stereoscopic simultaneous optic disc transparencies using an image analyzer. The presence and location of parapapillary atrophy, differentiated into zones alpha and beta, were assessed from disc transparencies of both eyes in a random sample of 894 persons. Subjects with open-angle glaucoma were excluded. RESULTS: The mean disc area was 2.42 mm2 (standard deviation [SD], 0.47), mean neural rim area was 1.85 mm2 (SD, 0.39), mean cup area was 0.57 mm2 (SD, 0.34), mean vertical cup-to-disc ratio was 0.49 (SD, 0.14), and mean horizontal cup-to-disc ratio was 0.40 (SD, 0.14). Age was not a determinant of any disc characteristic. Disc and rim areas were 3.2% (P < 0.0005; 95% confidence interval [CI], 2.7%-3.7%) and 4.3% (P < 0.0005; 95% CI, 3.5%-4.6%) larger in men than in women. For each diopter increase toward myopia, the disc area increased by 0.033 mm2 (P < 0.0005; 95% CI, 0.027-0.038) and neural rim area by 0.029 mm2 (P < 0.0005; 95% CI, 0.025-0.034). The disc area increased by 0.02 mm2 (P = 0.02; 95% CI, 0.005,0.05) for each 10-cm increase in height. The prevalence of zone alpha slightly decreased by 0.4% per 10 years of age (P = 0.035; 95% CI, 0.03%-0.8%), whereas the prevalence of zone beta increased by 1.3% (P = 0.0003; 95% CI, 0.57%-1.9%) for each diopter increase toward myopia. CONCLUSIONS: In a general population, statistically normal discs may vary twofold in disc area and threefold in rim area. Age is not associated with any disc characteristic, whereas disc area and neural rim area are slightly larger in men than in women. Refractive error is weakly related to disc area and neural rim area. Height is weakly related to disc area in persons of medium height. The prevalence of zone beta is higher in myopic eyes.

Is open-angle glaucoma associated with early menopause? The Rotterdam Study.

The authors examined the association between age at menopause and open-angle glaucoma among women aged > or = 55 years in the population-based Rotterdam Study (1990--1993). Information on age and type of menopause was obtained by interview. Subjects (n = 3,078) were stratified into three categories according to age at menopause: <45 years, 45--49 years, and > or = 50 years, with the last group serving as the reference group. Diagnosis of open-angle glaucoma was based on the presence of a glaucomatous visual field defect and glaucomatous optic neuropathy. Open-angle glaucoma was diagnosed in 78 women with a natural menopause and 15 women with an artificial menopause. In the category of natural menopause, women who went through menopause before reaching the age of 45 years had a higher risk of open-angle glaucoma than the reference group (odds ratio = 2.6; 95% confidence interval: 1.5, 4.8), after adjustment for age and use of hormone replacement therapy. Among women who went through menopause between the ages of 45 and 49 years, the odds ratio was 1.1 (95% confidence interval: 0.7, 2.0). These findings suggest that early menopause is associated with a higher risk of open-angle glaucoma.