Influence of cycloplegia with topical cyclopentolate on higher-order aberrations in myopic children.

PURPOSE: To investigate the influence of cycloplegia with topical cyclopentolate on wavefront aberrations in myopic children. DESIGN: This is a prospective, comparative study. METHODS: Twenty-eight myopic children with a mean age of 7.25 ± 2.55 were enrolled in this study. We evaluated refraction and wavefront aberrations before and after cycloplegia with 1% cyclopentolate hydrochloride. Ocular and corneal aberrations were simultaneously measured and compared with each other. Individual Zernike components were also analyzed up to the sixth order. All these parameters were compared before and after cycloplegia. RESULTS: Ocular higher-order aberrations (HOAs) significantly increased after cycloplegia (P=0.012 for spherical-like and P=0.015 for total HOAs). Corneal HOAs did not change after cycloplegia. When corneal and ocular HOAs were compared, the ocular HOAs were significantly smaller than the corneal HOAs in spherical-like aberrations (P<0.001) and total HOAs (P=0.006). As for individual Zernike components, ocular aberration generally showed smaller or equivalent values in comparison with corneal aberration. In addition, each Zernike component showed a large standard deviation. CONCLUSIONS: Internal optics compensates for corneal HOAs in myopic children, and paralysis of tonic accommodation with cyclopentolate considerably affects ocular HOAs. However, inter-individual variation in each Zernike component is quite large in myopic children.

Time course of changes in ocular wavefront aberration after administration of eye ointment.

PURPOSE: To investigate the influence of an eye ointment on ocular aberration. DESIGN: Prospective, comparative study. METHODS: In 10 normal volunteers, ocular aberration was assessed before and 5, 30 min, 1, 2, 3, 6, and 12 h after administration of ofloxacin eye ointment. Ocular aberration was sequentially measured over a period of 10 s, and the root mean square (RMS) of the second-, third-, fourth-, and total higher-order aberrations (HOAs) were determined. From the sequential changes in total HOAs during 10 s, the fluctuation index (FI) and stability index (SI) were calculated. The obtained data were compared with those of another 17 normal volunteers who received timolol maleate gel-forming ophthalmic solution. RESULTS: No significant changes in second-order RMS were observed after administration of the ointment. HOAs such as third-, fourth-, and total higher-order RMS significantly changed during the study period (P<0.05, repeated-measures analysis of variance). The RMS of each HOA component significantly increased 5 min after administration compared with the baseline values (P<0.05, Dunnett test). FI also increased significantly 5 min after administration (P<0.05), but SI did not change significantly. When compared with the results of the gel-forming solution group, HOAs and FI showed significantly higher values at several time points during 6 h after application (P<0.05, Mann-Whitney U-test). CONCLUSIONS: Administration of eye ointment significantly degrades optical quality of the eye by increasing and oscillating HOAs. These changes were more pronounced than those after instillation of gel-forming ophthalmic solution for at least several hours.

Vision-related quality of life and visual function in patients undergoing vitrectomy, gas tamponade and cataract surgery for macular hole.

AIM: To evaluate the relationship between vision-related quality of life (VR-QOL) and visual function in patients undergoing vitrectomy, gas tamponade and cataract surgery for macular hole (MH). METHODS: The 25-item National Eye Institute Visual Function Questionnaire (VFQ-25) was self-administered by 32 patients with MH (age 66.2 (SD 5.4) years) preoperatively and at 3 months postoperatively. Clinical data were collected, including logarithm of minimum angle of resolution (logMAR) best corrected visual acuity (BCVA), severity of metamorphopsia and letter contrast sensitivity. The severity of metamorphopsia was evaluated by the M-Charts. MH index was measured using optical coherence tomography. The presence and severity of cataract were graded using the Lens Opacities Classification System III reference standards. Multiple regression analysis was performed to investigate the relationship between various explanatory variables and VFQ-25 questionnaire scores. Explanatory variables tested were the severity of metamorphopsia, visual acuity, letter contrast sensitivity, MH index and grade of cataract. RESULTS: Vitrectomy for MH significantly improved VFQ-25 composite score as well as subscale scores, including general vision, near activities, distance activities, social functioning, mental health and dependency (p<0.05, Wilcoxon signed-rank test). Multiple regression analysis revealed that, both preoperatively and postoperatively, the severity of metamorphopsia had a significant correlation with VFQ-25 composite score (p<0.05), whereas other explanatory variables did not. In addition, changes in the severity of metamorphopsia was the single variable that was significantly related to changes in VFQ-25 composite score (p<0.01). CONCLUSION: Vitrectomy for MH significantly improved VR-QOL. The severity of metamorphopsia was significantly associated with both preoperative and postoperative VR-QOL.

Immunohistochemical localisation of D-beta-aspartic acid in pingueculae.

BACKGROUND: D-beta-aspartic acid residues, which are biologically uncommon, have been reported to accumulate in various proteins of the living body with age. In the present study, D-beta-aspartic acid-containing proteins were found to be localised in pingueculae, which represent one of the most prominent age-related ocular changes. METHODS: Surgical specimens of conjunctivae with or without pingueculae were obtained from eight patients. Immunohistochemical localisation of D-beta-aspartic acid-containing proteins was performed using a polyclonal antibody against D-beta-aspartic acid-containing peptides. RESULTS: Strong immunoreactivity to D-beta-aspartic acid-containing peptides was detected in the subepithelial amorphous materials of all surgical specimens with pingueculae. In contrast, no immunoreactivity to D-beta-aspartic acid-containing peptides was detected in the specimens without pingueculae. CONCLUSIONS: Pingueculae are thought to be aggregates of proteins that contain D-beta-aspartic acid residues. It is known that the conversion of L- to D-aspartyl residues is accelerated by ultraviolet irradiation. In addition, D-beta-aspartic acid-containing proteins, in general, tend to aggregate with each other and accumulate in the tissues. These facts indicate that ultraviolet irradiation-induced racemisation of aspartic acid is closely related to the development of pingueculae.

Sprouty4 negatively regulates protein kinase C activation by inhibiting phosphatidylinositol 4,5-biphosphate hydrolysis.

Sproutys have been shown to negatively regulate growth factor-induced extracellular signal-regulated kinase (ERK) activation, and suggested to be an anti-oncogene. However, molecular mechanism of the suppression has not yet been clarified completely. Sprouty4 inhibits vascular endothelial growth factor (VEGF)-A-induced ERK activation, but not VEGF-C-induced ERK activation. It has been shown that VEGF-A-mediated ERK activation is strongly dependent on protein kinase C (PKC), whereas that by VEGF-C is dependent on Ras. This suggests that Sprouty4 inhibits the PKC pathway more specifically than the Ras pathway. In this study, we confirmed that Sprouty4 suppressed various signals downstream of PKC, such as phosphorylation of MARCKS and protein kinase D (PKD), as well as PKC-dependent nuclear factor (NF)-kappaB activation. Furthermore, Sprouty4 suppressed upstream signals of PKC, such as Ca(2+) mobilization, phosphatidylinositol 4,5-biphosphate (PIP(2)) breakdown and inositol 1,4,5-triphosphate (IP(3)) production in response to VEGF-A. Those effects were dependent on the C-terminal cysteine-rich region, but not on the N-terminal region of Sprouty4, which is critical for the suppression of fibroblast growth factor (FGF)-mediated ERK activation. Sprouty4 overexpression or deletion of the Sprouty4 gene did not affect phospholipase C (PLC) gamma-1 activation, which is an enzyme that catalyzes PIP(2) hydrolysis. Moreover, Sprouty4 inhibited not only VEGF-A-mediated PIP(2) hydrolysis but also inhibited the lysophosphatidic acid (LPA)-induced PIP(2) breakdown that is catalyzed by PLC beta/epsilon activated by G-protein coupled receptor (GPCR). Taken together, Sprouty4 has broader suppression activity for various stimuli than previously thought; it may function as an inhibitor for various types of PLC-dependent signaling as well as for ERK activation.

Recovery of corneal irregular astigmatism, ocular higher-order aberrations, and contrast sensitivity after discontinuation of overnight orthokeratology.

AIMS: To examine prospectively the recovery of various parameters after discontinuation of overnight orthokeratology. METHODS: Seventeen subjects undergoing orthokeratology for 12 months were examined. Refraction, corneal topography, wavefront aberrometry, a visual acuity test and a contrast sensitivity test were performed at baseline, 12 months after commencement of the procedure, and 1 week and 1 month after discontinuation of the treatment. Asymmetry and higher-order irregularity components were calculated using a Fourier analysis of the corneal topography data. Contrast sensitivity was assessed at four spatial frequencies, and the area under the log contrast sensitivity function (AULCSF) was calculated. RESULTS: Orthokeratology significantly reduced manifest refraction (p<0.0001, Dunnett test) and significantly improved uncorrected visual acuity (UCVA) at 12 months after commencement of the procedure (p<0.0001). Asymmetry and higher-order irregularity components increased significantly (p<0.0001, p = 0.0032, respectively), and third- and fourth-order aberrations also increased significantly (p<0.0001). The treatment resulted in significant decreases in AULCSF (p = 0.0004). After discontinuing lens wear, all parameters, such as refraction, UCVA, asymmetry, higher-order irregularity, third-order aberration, fourth-order aberration and AULCSF, returned to the baseline level at 1 week. CONCLUSION: This study confirmed that the effect of orthokeratology is completely reversible in light of optical quality of the eye and quality of vision as well as refraction and visual acuity.

Higher-order wavefront aberration and letter-contrast sensitivity in keratoconus.

AIMS: To evaluate the relation between higher-order aberration of the eye and contrast sensitivity function in eyes with keratoconus. METHODS: In 22 eyes of 14 patients with keratoconus (age 30.5+/-8.4 years, means+/-SD) and 26 eyes of 13 normal controls (age 29.2+/-6.7 years), ocular higher-order wavefront aberration for a 6-mm pupil was measured with the Hartmann-Schack aberrometer (KR-9000 PW, Topcon). The root mean square (RMS) of third- and fourth-order Zernike coefficients was used to represent higher-order aberrations. The letter-contrast sensitivity was examined using the CSV-1000LV contrast chart (Vector Vision). RESULTS: In the keratoconus group, the letter-contrast sensitivity showed significant correlation with third-order (Spearman's correlation coefficient r=-0.736, P<0.001) and fourth-order aberrations (r=-0.464, P<0.05). There was borderline correlation between log MAR BSCVA and third-order (r=0.413, P=0.070) and fourth-order aberrations (r=0.394, P=0.086). In the normal group, the letter-contrast sensitivity had no significant correlation with third-order (r=-0.170, P=0.411) and fourth-order aberrations (r=-0.088, P=0.673), and log MAR best spectacle-corrected visual acuity (BSCVA) showed no correlation with third-order (r=0.063, P=0.762) and fourth-order aberrations (r=-0.282, P=0.165). CONCLUSIONS: In eyes with keratoconus, there is significant correlation between contrast sensitivity and ocular higher-order wavefront aberrations.

Changes in higher-order aberrations after scleral buckling surgery for rhegmatogenous retinal detachment.

PURPOSE: To evaluate changes in higher-order aberrations (HOAs) after scleral buckling surgery for the treatment of rhegmatogenous retinal detachment (RD). DESIGN: Prospective observational comparative case series. PARTICIPANTS: The study included 67 eyes of 67 rhegmatogenous RD patients undergoing scleral buckling surgery, and the fellow normal eyes comprised the control group. Twenty-seven eyes were treated with the segmental buckling procedure and 40 eyes received the encircling buckling procedure alone. METHODS: Hartmann-Shack wavefront analysis was performed at 2 weeks, 1 month, and 3 months postoperatively. MAIN OUTCOME MEASURE: Time course of changes in HOAs. RESULTS: Scleral buckling surgery significantly increased HOAs at 2 weeks (P<0.0001), 1 month (P<0.0005), and 3 months (P<0.05) postoperatively as compared with the control group. At 3 months postoperatively, the HOAs were significantly lower in the encircling group than in the segmental buckling group (P<0.05). The vertical coma (Zernike Z(3)(-1)) became negative (significantly lower than zero, P<0.01) in patients who received segmental buckling in the upper quadrant. The ocular HOAs and logarithm of the minimum angle of resolution best-corrected visual acuity significantly correlated at 3 months postoperatively (third-order root mean square [RMS]: r = 0.445, P<0.0005; fourth-order RMS: r = 0.489, P<0.0001). CONCLUSIONS: Scleral buckling surgery significantly increased HOAs. The segmental buckling procedure increased the HOAs to a greater extent and for a longer duration than the encircling procedure. The direction of coma aberration corresponded to the location of the segmental buckle. The increase in HOAs can be one of the factors responsible for visual disturbances after scleral buckling surgery.

Changes in corneal topography after 25-gauge transconjunctival sutureless vitrectomy versus after 20-gauge standard vitrectomy.

PURPOSE: To evaluate the changes in regular and irregular corneal astigmatism after 25-gauge transconjunctival sutureless vitrectomy and 20-gauge standard vitrectomy. DESIGN: Prospective observational comparative case series. PARTICIPANTS: Thirty-two eyes of 32 patients undergoing 25-gauge transconjunctival sutureless vitrectomy and 25 eyes of 24 patients undergoing 20-gauge standard vitrectomy. METHODS: Corneal topography was obtained preoperatively and at 2 weeks and 1 month postoperatively. MAIN OUTCOME MEASURES: The dioptric data of the central 3-mm zone of the cornea were decomposed using Fourier harmonic analysis into spherical power, regular astigmatism, asymmetry, and higher-order irregularity. RESULTS: None of the 4 Fourier indices changed throughout the observation period in the 25-gauge group. In the 20-gauge group, regular astigmatism, asymmetry, and higher-order irregularity were increased significantly at 2 weeks after vitrectomy (P<0.05, Wilcoxon signed-ranks test) and returned to preoperative levels by 1 month. The spherical power in the 20-gauge group did not change after surgery. For regular astigmatism, asymmetry, and higher-order irregularity, the 20-gauge group showed significantly greater surgically induced changes than the 25-gauge group (P<0.05, Mann-Whitney U test). CONCLUSIONS: Twenty-five-gauge transconjunctival sutureless vitrectomy does not induce significant changes in corneal topography and exerts little influence on the optical quality of the cornea.

Retention and removal of a new viscous dispersive ophthalmic viscosurgical device during cataract surgery in animal eyes.

AIMS: To assess the retention and removal properties of a new viscous dispersive ophthalmic viscosurgical device (OVD), DisCoVisc, in comparison with those of cohesive (Provisc), dispersive (Viscoat), and viscoadaptive (Healon5) OVDs. METHODS: In 20 porcine eyes, cataract surgery was simulated using one of the four OVDs which were stained with fluorescein for better visualisation. Three parameters were measured. Firstly, the presence/absence of OVDs in the chamber at the completion of phacoemulsification was recorded. Secondly, the time until the OVDs were completely removed from the anterior chamber using the phaco needle was measured. Thirdly, after intraocular lens (IOL) implantation, the time needed to completely remove the OVDs from the chamber with irrigation/aspiration tip was recorded. RESULTS: At the completion of phacoemulsification, the OVDs retained in 0% (0/5) for Provisc, 80% (4/5) for Healon5, 100% (5/5) for DisCoVisc, and 100% (5/5) for Viscoat. The retention of OVDs during phacoemulsification was greatest with Viscoat followed by, in descending order, DisCoVisc, Healon5, and Provisc. The removal of OVDs after IOL implantation took longest with Viscoat followed by Healon5, DisCoVisc, and Provisc. CONCLUSION: The viscous dispersive DisCoVisc showed excellent retention during phacoemulsification, while its removal after IOL implantation was very easy. When compared with the viscoadaptive Healon5, DisCoVisc was retained better in the chamber and was easier to remove. These features of DisCoVisc should be highly advantageous when considering covering the entire cataract surgery procedure with a single OVD.

Importance of early repair of isolated abdominal aortic dissecting aneurysm.

BACKGROUND: Since the available information on isolated abdominal aortic dissecting aneurysm (AADA) is mainly related to case reports or reports of small groups of patients, its natural history remains undetermined and there is no agreement on its optimal management. The purpose of this study is to define the features and pattern of development of this unusual entity as well as to propose criteria for treatment based on our own experience and previously published data. PATIENTS AND METHODS: We retrospectively evaluated the history of 6 patients diagnosed with AADA. The patients were 5 males and 1 female. The mean age was 71 +/- 8 years (range: 61-80 years), and the mean aneurysm diameter was 54 +/- 14 mm (range: 35-70 mm). All of these patients were hypertensive (100%). History of cerebrovascular accident, ischemic heart disease, peripheral arterial disease, or diabetes mellitus was present in 1 patient, respectively. Two patients developed mycotic AADA. RESULTS: Emergency operations had been performed in 3 cases, and scheduled surgical reconstruction in the remaining 3 cases. Operation consisted of aneurysmectomy and graft replacement of the diseased aortic segment in all cases. One patient treated in an emergency setting died subsequently of multisystem organ failure, but the others did well. CONCLUSION: Symptomatic patients or patients at good risk should undergo surgical repair earlier than in the case of abdominal aortic aneurysm without dissection (AAA). Dissection in addition to an AAA will further increase the weakness of the aortic wall and the possibility of aortic rupture will become higher.

Comparison of corneal thickness measurements using Orbscan II, non-contact specular microscopy, and ultrasonic pachymetry in eyes after laser in situ keratomileusis.

AIMS: To compare central corneal thickness measurements of three pachymetry devices in eyes after laser in situ keratomileusis (LASIK). METHODS: Central corneal thickness was measured in 203 eyes after myopic LASIK. Orbscan II scanning slit topography (Bausch & Lomb), SP-2000P non-contact specular microscopy (Topcon), and ultrasonic pachymetry (Tomey) were used in this sequence. RESULTS: Three devices gave significantly different corneal thickness readings (p<0.0001, repeated measure analysis of variance). The measurements of Orbscan II (445.6 (SD 60.0) microm) were significantly smaller than those of noncontact specular microscopy (467.9 (SD 40.2) micro m; p<0.0001, Tukey multiple comparison) and ultrasonic pachymetry (478.8 (SD 41.9) microm; p<0.0001). The value obtained with SP-2000P non-contact specular microscopy was significantly smaller than that taken with ultrasonic pachymetry (p<0.001). There were significant linear correlations between scanning slit topography and non-contact specular microscopy (Pearson's correlation coefficient r = 0.912, p<0.0001), non-contact specular microscopy and ultrasonic pachymetry (r = 0.968, p<0.0001), and ultrasonic pachymetry and scanning slit topography (r = 0.933, p<0.0001). CONCLUSION: In post-LASIK eyes, Orbscan II scanning slit topography significantly underestimated corneal thickness. Non-contact specular microscopy gave smaller thickness readings than ultrasonic pachymetry, but these two units showed an excellent linear correlation.

[Assessment of saphenous vein grafts flow by Doppler echocardiography].

In an effort to evaluate flow characteristics of the saphenous vein grafts (SVG) after coronary artery bypass grafting, we performed duplex scanning of SVG which were anastomosed to the left anterior descending artery in 12 patients, and compared those indexes with 34 internal thoracic artery grafts (ITAG). The SVG were observed with a 7.5 MHz duplex scanner through the anterior intercostal space. The diameter of the vessel, systolic peak velocity, and diastolic peak velocity were recorded in both groups, and systolic flow volume, diastolic flow volume, and velocity ratio were calculated. The systolic and diastolic peak velocity of SVG were predominantly lower than ITAG. No difference in the diameter and flow ratio could not be demonstrated between 2 groups. The flow volume of SVG were also predominantly lower than that of ITAG throughout cardiac cycle. This study reveals that advanced stenotic change were caused in the SVG group and suggest the occurrence of vein grafts disease long after coronary artery bypass grafting.

Mirror image myopic anisometropia in two pairs of monozygotic twins.

Two sets of monozygotic twins with mirror image myopic anisometropia are reported. The first set were two boys aged 1 year 8 months. There was a right eye myopic anisometropia in one twin, and a left eye myopic anisometropia in the other. The differences in refractive power between both eyes were 11.6 and 7.6 dpt, respectively (spherical equivalent). The second set were two 6-year-old boys. The right eye had myopic anisometropia in one twin, while the left eye was affected in the other. The differences in refractive power between both eyes were 6.5 and 3.7 dpt, respectively (spherical equivalent). Exotropia was recognized in 3 cases. Previously only two sets of monozygotic twins with mirror image myopic anisometropia have been reported. Monozygotic twins with mirror image myopic anisometropia are extremely rare.

Genistein, a soybean isoflavone, inhibits inward rectifier K(+) channels in rat osteoclasts.

Genistein, a soybean-derived isoflavone with an inhibitory effect on protein tyrosine kinases (PTKs), has been shown to suppress osteoclastic bone resorption. To clarify the mechanisms underlying this action, we investigated the effects of genistein on inward rectifier K(+) current (I(Kir)) in rat osteoclasts by using the whole-cell patch-clamp technique. Extracellularly applied genistein inhibited I(Kir) in a concentration-dependent manner. Physiologically attainable concentrations of genistein inhibited I(Kir). IC(50) values obtained 5 and 10 min after the application of genistein were 54 and 27 microM, respectively. The removal of genistein partially restored the current. Daidzein, an isoflavone without PTK-inhibiting activity, also showed a weak inhibitory effect on I(Kir), but genistin had no effect. Other PTK inhibitors, tyrphostin A25, tyrphostin B42, and tyrphostin B46, inhibited I(Kir), whereas herbimycin A and lavendustin A were without effect. The inactive tyrphostin, A1, showed a similar inhibitory effect as tyrphostin A25. The tyrosine phosphatase inhibitor, orthovanadate, did not affect the inhibitory potency of genistein on I(Kir). The inhibitory action of genistein was unaffected by changing intracellular Ca(2+) concentration ([Ca(2+)]i) or by pretreatment of the cell with GDPbetaS, Rp-cAMPS, okadaic acid, or staurosporine. Therefore the inhibition of I(Kir) by genistein does not depend on PTK inhibition, involvement of changes in [Ca(2+)]i, or secondary interaction with protein kinase A or protein kinase C. Genistein-induced inhibition of I(Kir) would cause membrane depolarization, elevation of [Ca(2+)]i, and inhibition of osteoclastic bone resorption.

[Assessment of left internal thoracic artery graft by exercise Doppler echocardiography].

Doppler echocardiography has several advantages such as frequent use, noninvasive approach, and physiological evaluation. Supine bicycle exercise testing was conducted for 30 patients undergoing CABG with LITA to LAD. Doppler echocardiography studies were performed before and after exercise to observe the change. On the basis of the angiographic data, patients were divided into two groups: 27 patients with a patent LITA graft, 3 patients with mildly stenosed LITA graft. In the patients who had patent grafts, diastolic flow velocity were increased higher than systolic after exercise. In the stenotic group, the flow pattern was changed to further systolic one. Doppler echocardiography during exercise is thought to be a reliable method to assess the LITA flow.

Defect in human myocardial long-chain fatty acid uptake is caused by FAT/CD36 mutations.

Because of the importance of long-chain fatty acids (LCFAs) as a myocardial energy substrate, myocardial LCFA metabolism has been of particular interest for the understanding of cardiac pathophysiology. Recently, by using radiolabeled LCFA analogues, myocardial LCFA metabolism has been clinically evaluated, which revealed a total defect of myocardial LCFA accumulation in a small number of subjects. The mechanism for the cellular LCFA uptake process is still disputable, but recent results suggest that fatty acid translocase (FAT)/CD36 is a transporter in the heart. In the present study, we analyzed mutations and protein expression of the FAT/CD36 gene in 47 patients who showed total lack of the accumulation of a radiolabeled LCFA analogue in the heart. All the patients carried two mutations in the FAT/CD36 gene, and expression of the FAT/CD36 protein was not detected on either platelet or monocyte membranes. Our results showed the link between mutations of the FAT/CD36 gene and a defect in the accumulation of LCFAs in the human heart.

Factors associated with increased aqueous flare in psoriasis.

PURPOSE: To evaluate the changes in aqueous flare in psoriasis patients and to identify the factors that influence the level of aqueous flare. METHODS: We examined the 68 eyes of 34 psoriasis patients and the 68 eyes of 34 healthy subjects with a laser flare-cell meter. Complete dermatologic and ophthalmic examinations were performed on the psoriasis patients. RESULTS: Flare was significantly higher in psoriasis patients than in normal controls (P <.000l). The factors that increased flare significantly were age and Psoriasis Area and Severity Index. Flare was not significantly associated with sex, psoriasis type, duration of disease, and cyclosporin therapy. A flare increase was significantly correlated with serum total protein and immunoglobulin (Ig) A, but not with albumin, IgG, and IgM. CONCLUSIONS: Psoriasis patients, even without ocular symptoms, had slight damage to the blood-aqueous barrier. Multiple linear regression analysis showed that flare had the strongest correlation with the severity of psoriasis.

[A case of lateral origin of the left internal mammary artery].

A 66 years old men, with left anterior descending coronary artery (LAD) stenosis and aortic valve stenosis, underwent coronary artery bypass grafting (CABG) to LAD with left internal mammary artery (LIMA) and aortic valve replacement. His postoperative course was uneventful. But, postoperative angiogram showed that his patent LIMA graft was originated from much lateral side of the left subclavian artery. Internal mammary artery is considered the most ideal graft for CABG, but its' anomality is not well known. We present this rare case with the anomalous origin of LIMA.

Refractive changes in diabetic patients during intensive glycaemic control.

AIMS: To evaluate the clinical course and the characteristics of transient refractive error occurring during intensive glycaemic control of severe hyperglycaemia. METHODS: 28 eyes of patients with persistent diabetes were included in this prospective study. During the observation period, patients underwent general ophthalmological examination and A-mode scan ultrasonography was performed at each examination-at days 1, 3, and 7, and then once every week or every other week until recovery of hyperopia. RESULTS: A transient hyperopic change occurred in all patients receiving improved control after hyperglycaemia. Hyperopic change developed a mean of 3.4 (SD 2. 0) days after the onset of treatment, and reached a peak at 10.3 (6. 1) days, where the maximum hyperopic change in an eye was 1.47 (0. 87) D (range 0.50-3.75 D). Recovery of the previous refraction occurred between 14 and 84 days after the initial assessment. There was a positive correlation between the magnitude of the maximum hyperopic change and (1) the plasma glucose concentration on admission (p<0.01), (2) the HbA(1c) level on admission (p<0.005), (3) the daily rate of plasma glucose reduction over the first 7 days of treatment (p<0.001), (4) the number of days required for hyperopia to reach its peak (p<0.001), and (5) the number of days required for the development and resolution of hyperopic changes (p<0.0001). There was a negative correlation between the maximum hyperopic change of an eye and baseline value of refraction (p<0.01). During transient hyperopia, no significant changes were observed in the radius of the anterior corneal curvature, axial length, lens thickness, or depth of anterior chamber. CONCLUSIONS: The degree of transient hyperopia associated with rapid correction of hyperglycaemia is highly dependent on the rate of reduction of the plasma glucose level. A reduction of refractive index in intraocular tissues, especially in lens, appears to be responsible for this hyperopic change.