Psychosomatic aspects in patients with central serous chorioretinopathy.

AIMS: Patients with central serous chorioretinopathy were tested for psychosomatic symptoms and social support at the onset of their ailments; their personality profiles were also tested. METHODS: 24 consecutive outpatients at the department of ophthalmology, Freiburg University Hospital, Freiburg, Germany, presenting with central serous chorioretinopathy filled in the following standardised questionnaires: Symptom Checklist 90-R (SCL 90-R), Symptom List, Questionnaire on Social Support, and Sixteen Personality Factor Questionnaire. RESULTS: The sample (n=24) included 22 male patients with an average age of 44.1 years. Three quarters of the patients have children and live with their families; three quarters are white collar workers or self employed; one quarter are skilled blue collar workers. 12 patients were suffering from the ailment for the first time; 12 patients were undergoing a relapse. Mean visus of the affected eye was 0.8. The Symptom List yielded an inconspicuous total score for psychosomatic symptoms. In the SCL 90-R, nine out of 24 patients (37%) evinced elevated psychic stress. The total value of the questionnaire on social support showed good social support. In the Sixteen Personality Factor Questionnaire, the patients showed heightened emotional instability and insecurity as well as flexibility and spontaneity. CONCLUSION: The sociodemographic data confirm that central serous chorioretinopathy is predominantly an ailment of middle aged, socially well integrated men. This study suggests elevated psychic stress a few weeks after the onset of the ailment. The personality factors in the patients with central serous chorioretinopathy found in this study have to be verified with other populations. These results did not clearly show that psychosocial factors have a definite role in the aetiology of central serous chorioretinopathy. In order to make any clear assertions about this matter, further longitudinal studies on the progression of psychosocial parameters with larger patient samples would be indispensable.

A randomised prospective study of treatment of non-ischaemic central retinal vein occlusion by isovolaemic haemodilution.

In a randomised study 25 patients over 50 years of age with non-ischaemic central retinal vein occlusion (CRVO) were assigned to either a treatment (14 patients, isovolaemic haemodilution) or a control group (11 patients, no treatment). After three months eight eyes in patients with haemodilution improved, whereas none of the untreated eyes had better visual acuity (p less than 0.01). Thirteen haemodiluted and 11 control patients could be observed for one year. Six eyes of the haemodiluted patients retained a better visual acuity, whereas no improvements had occurred in the control group (p less than 0.025). In fluorescein angiography the lowering of the packed cell volume to 35-32% accelerated the time of maximal venous filling (tmvf) from 17.4 (SEM 1.4) s to 11.4 (SEM 0.9) s (p less than 0.005). In patients with non-ischaemic CRVO without treatment the passage time did not change. The shortened tmvf reflects a higher blood velocity. Thus isovolaemic haemodilution improves the visual prognosis in non-ischaemic CRVO probably by inducing a higher blood fluidity, which results in higher blood velocity, at least in areas of compromised retinal microcirculation.

Haemorheological parameters in patients with retinal artery occlusion and anterior ischaemic optic neuropathy.

The haemorheological parameters haematocrit (Hct), plasma viscosity (PV), red cell aggregation (RCA), red cell filterability (RCF), apparent whole blood viscosity (WBV), and fibrinogen were measured in 31 patients with retinal artery occlusion (RAO), 25 patients with anterior ischaemic optic neuropathy (AION), and 19 patients with giant cell arteritis (GCA). The patient groups were compared with controls of same age and similar prevalence of cardiovascular risk factors. Patients with RAO and AION have a significantly decreased RCF in comparison with controls. All other parameters showed no differences. Patients with GCA had significantly decreased Hct and RCF and increased PV and fibrinogen. After 2 weeks of systemic treatment with high dose steroids in patients with GCA the plasma viscosity had returned to normal and was even lower than in controls, and the Hct and fibrinogen had reached normal levels.

Effect of isovolaemic haemodilution on visual outcome in branch retinal vein occlusion.

AIMS: To assess the efficacy of isovolaemic haemodilution therapy (IHT) in the treatment of patients with branch retinal vein occlusion (BRVO). METHODS: Patients presenting with BRVO between 1 July 1991 and 31 August 1993 were eligible for inclusion and randomised into treatment and control groups. Patients randomised to receive IHT were treated for 6 weeks with venesection and volume replacement using hydroxyethylstarch, a plasma expander. The target haematocrit was 35%. Follow up was for 1 year. RESULTS: The baseline visual acuity of the two groups was similar at 0.74 and 0.75 logMAR units (Snellen 6/36), for the IHT and control groups, respectively. At 6 weeks, visual acuity in the IHT group had improved by 0.20 logMAR units (2 lines on the Bailey-Lovie chart) (p = 0.0001). Vision was unchanged in the control group. At 1 year, the IHT group exhibited an improvement of 0.43 logMAR units. By comparison, the improvement in the control group at 1 year was significantly less at 0.17 logMAR units (p = 0.03). The final visual acuity in the IHT and control groups was 0.30 (Snellen 6/12) and 0.60 (Snellen 6/24) logMAR units, respectively. CONCLUSIONS: The results support the theory that IHT has a positive effect on the visual outcome in patients with BRVO.

Haemorheological changes in patients with retinal vein occlusion after isovolaemic haemodilution.

In 83 patients with central retinal vein occlusion and branch vein occlusion we measured the haematocrit (HCT), plasma viscosity (PV), red cell aggregation (RCA), red cell filterability (RCF) and apparent whole blood viscosity (WBV). A control group (n = 41) was matched for sex, age, and cardiovascular risk factors. Measurements were performed before and after treatment with isovolaemic haemodilution (IHD). We found no significant differences between patients with retinal vein occlusion (RVO) and control subjects in haematocrit, plasma viscosity, red cell aggregation, and red cell filterability and no increased whole blood viscosity in the patient group. Patients with ischaemic retinal vein occlusion and non-ischaemic retinal vein occlusion did not show different haemorheological parameters either. After treatment with haemodilution, only the haematocrit and whole blood viscosity were significantly decreased, and there were no changes in plasma viscosity, red cell aggregation or red cell filterability.

Statewide survey of laboratories performing Mycobacterium tuberculosis testing in Minnesota.

Rapid and accurate laboratory detection and identification of Mycobacterium tuberculosis, particularly multidrug-resistant strains, is critical to both public health control measures and patient management. The authors surveyed microbiology laboratories to evaluate whether their methods met national guidelines. As needed, laboratories received individualized recommendations for improvement. The laboratories were resurveyed a year later to assess changes in methods. Current guidelines recommend fluorochrome acid-fast smears, broth cultures, identification by nucleic acid probe or BACTEC-NAP, and BACTEC primary susceptibility panels, which should include pyrazinamide. Of 27 laboratories performing acid-fast smears, 15 used fluorochrome methods. Six of 16 laboratories performing mycobacterial cultures used broth media. Of six laboratories performing species identification, five used nucleic acid probes or BACTEC-NAP. Of five laboratories evaluating drug sensitivity, two used BACTEC and two included pyrazinamide in their protocols. Overall, 24 (89%) laboratories needed improvements; a year later, 16 (67%) of those had altered their methods or made definite plans to do so. Survey results suggest that health departments can facilitate improvements in laboratory testing for pathogens of public health importance.

[Unilateral blindness in neurosyphilis]. / Einseitige Erblindung bei Neurolues.

A 55 year-old patient developed loss of vision in his right eye over a period of a few weeks with the clinical finding of uveitis and papillaedema. Subsequently, also the left eye was affected by a marked deterioration of vision. The neurological findings were normal. The laboratory findings showed a marked elevation of the ESR (> 100 mm within the first hour) and protein electrophoreses showed changes suggestive of chronic inflammation. Analysis of the cerebrospinal fluid revealed a lymphocytic meningitis with 180/3 cells; the positive serological and liquor findings for TPHA and FTA led to the definite diagnosis of neurosyphilis. Treatment intravenously with 3 x 4 million units penicillin G daily for a fortnight proved curative. Vision of the left eye recovered fully, but the ophthalmological changes in the right eye were irreversible. This case shows that even today the differential diagnosis of syphilis must be considered with loss of vision of doubtful aetiology and uveitis.

Retinal blood flow in diabetic retinopathy.

OBJECTIVES: (a) To report on the basic parameters of retinal blood flow in a population of diabetic patients with and without retinopathy and non-diabetic controls; (b) to formulate a haemodynamic model for the pathogenesis of diabetic retinopathy from this and other studies. DESIGN: Laser-Doppler velocimetry and computerised image analysis to determine retinal blood flow in a large cross sectional study. SETTING: Diabetic retinopathy outpatient clinic. SUBJECTS: 24 non-diabetic controls and 76 diabetic subjects were studied (63 patients with insulin dependent diabetes, 13 with non-insulin dependent diabetes). Of the diabetic subjects, 12 had no diabetic retinopathy, 27 had background retinopathy, 13 had pre-proliferative retinopathy, 12 had proliferative retinopathy, and 12 had had pan-retinal photocoagulation for proliferative retinopathy. MAIN OUTCOME MEASURES: Retinal blood flow (microliters/min) and conductance (rate of flow per unit of perfusion pressure). RESULTS: In comparison with non-diabetic controls (9.52 microliters/min) and diabetic patients with no diabetic retinopathy (9.12 microliters/min) retinal blood flow was significantly increased in all grades of untreated diabetic retinopathy (background 12.13 microliters/min, pre-proliferative 15.27 microliters/min, proliferative 13.88 microliters/min). There was a significant decrease in flow after pan-retinal photocoagulation in comparison with all the other groups studied (4.48 microliters/min). Conductance of the retinal circulation was higher in the untreated diabetic retinopathy groups. These results were independent of age, sex, type of diabetes, duration of diabetes, glycated haemoglobin concentration, blood glucose concentration, blood pressure, and intraocular pressure. CONCLUSIONS: Retinal blood flow is significantly increased in diabetic retinopathy in comparison with non-diabetic controls and diabetic subjects with no retinopathy. This has implications for controlling hypertension and hyperglycaemia as a strategy in reducing morbidity from diabetic retinopathy.

A refined technique of transscleral suture fixation of posterior chamber lenses developed for cases of complicated cataract surgery with vitreous loss.

Described is a new technique of transscleral suture fixation of posterior chamber intraocular lenses (PC-IOLs) designed to simplify the procedure in cases of complicated cataract surgery with vitreous loss. Sling-sutures are hooked to both haptics of the PC-IOL and the transscleral sutures are buried in scleral tissue without scleral flaps. This scleral-slit technique, which has been successfully used in 20 patients, provides a useful alternative, even in destabilized eyes, to techniques that require preparation of scleral flaps.

[Computer controlled analysis of the optic papilla in patients with anterior ischemic optic neuropathy]. / Computergesteuerte Papillenanalyse bei Patienten mit anteriorer ischämischer Optikusneuropathie (AION).

BACKGROUND: In patients with non-arteritic anterior ischaemic optic neuropathy disc parameters have been measured with a largely objective method (Optic Nerve Head Analyzer). We wanted to find out, whether the measurements of different disc parameters allow an assertion of predisposition to AION. METHODS: Measurements have been done with the Optic Nerve Head Analyzer (ONHA). In 25 patients with AION disc area and neuroretinal rim area was measured in the nonaffected fellow eye. The results were compared to those of 19 healthy subjects. In 12 of the 25 patients the disc structure of the AION-eye was measured over time with an average of 4 measurements in 16 months. RESULTS: 1) Disc area and neuroretinal rim area of the AION-eyes do not differ significantly from those of the healthy subjects. 2) Disc area and neuroretinal rim area of the healthy fellow eyes of the AION patients were not significantly different from those of the healthy subjects. 3) Measurements of disc parameters over time did not show significant differences between the parameters of the beginning of AION and after 16 months. CONCLUSIONS: Measurements of disc area and neuroretinal rim area with the Optic Nerve Head Analyzer do not allow assertions of predisposition to AION.

[Isovolemic hemodilution on non-arteritic anterior optic neuropathy. Initial results of a randomized study]. / Isovolämische Hämodilution bei nichtarteriitischer anteriorer Optikusneuropathie. Erste Ergebnisse einer randomisierten Studie.

As there is no generally accepted treatment for non-inflammatory anterior ischemic optic neuropathy, we have started a randomized, controlled clinical trial on isovolemic hemodilution. In this study all patients received a basic treatment of 75 mg of acetylsalicyclic acid daily. Patients were then randomly assigned to either a group without additional therapy or a group with isovolemic hemodilution. Isovolemic hemodilution was carried out over 6 weeks by several blood-letting procedures and replacement of volume by infusion of hydroxyethyl starch solutions (PCV down to 35-32%). So far, 21 patients have fulfilled the inclusion criteria (symptoms less than or equal to 30 days, no medical contraindications, no giant-cell arteritis), and since they matched for age, duration of symptoms, cardiovascular risk factors, they could be observed for at least 3 months. Although only 1 of 10 control patients hat better visual acuity after 3 months; 6 out of 11 hemodiluted patients had better vision after treatment (p = 0.024). These results indicate that isovolemic hemodilution most likely has a beneficial effect on the visual prognosis of patients with anterior ischemic neuropathy.

[Hemorheologic parameters in patients with giant cell arteritis before and after treatment with steroids]. / Hämorheologische Parameter bei Patienten mit Riesenzellarteriitis vor und nach der Behandlung mit Steroiden.

Basic hemorheological parameters like packed cell volume (PCV), plasma viscosity, red cell aggregation, red cell filterability and whole blood viscosity were measured in 18 patients (14 women, aged 75.4 years) with giant cell arteritis before and after treatment with steroids. The patient group was compared to controls (n = 27, age: 69.8 years) with matched age and cardiovascular risc factors. While no changes in red cell aggregation and filterability could be observed plasma viscosity was increased (1.59 +/- 0.14 mm2/s) by about 20%. The typical anemia of patients with giant cell arteritis (PVC: 0.38 +/- 0.05) prevented an increase in whole blood viscosity at high and medium shear rates (6.6 +/- 0.14 cP = mPas at 23/s). After a fortnight of systemic treatment with high doses of steroids the PCV had normalized and plasma viscosity was even lower than in controls. Thus the blood fluidity was improved as shown by a fall in whole blood viscosity (5.5 +/- 0.7 cP = mPas at 23/s). Results showed: (1) increased plasma viscosity probably induced by increased fibrinogen concentration and (2) an improvement in blood fluidity by treatment with steroids. As the plasma viscosity may participate in the deterioration of microcirculation in patients with giant cell arteritis, lowering the fibrinogen may possibly prevent a further decrease in visual acuity during the first few days of steroid treatment.

Effect and compatibility of isovolaemic haemodilution in the treatment of ischaemic and non-ischaemic central retinal vein occlusion.

In a prospective study, 48 eyes with non-ischaemic and 35 with ischaemic central retinal vein occlusion (CRVO) were treated by isovolaemic haemodilution (IHD). Two or more cardiovascular risk factors were present in 42% of patients with non-ischaemic and in 69% of patients with ischaemic CRVO (p less than 0.025). Nevertheless, IHD in no case caused serious cardiovascular complications. Minor problems were short fainting spells in 5% and a general weakness in 16% of the haemodiluted patients. The effect of IHD was measured by determining the time of maximal venous filling (tmvf) in fluorescein angiographies. Lowering the packed cell volume to 32-35% accelerated the tmvf from 18.4 +/- 1.61 to 13.1 +/- 1.0 s (p less than 0.001) in eyes with non-ischaemic CRVO and from 24.5 +/- 1.2 to 14.8 +/- 1.3 s (p less than 0.001) in eyes with ischaemic CRVO. After 3 months, an increase in visual acuity had occurred in 27% of eyes with non-ischaemic CRVO and in 48.5% with ischaemic CRVO. These improvement rates could nearly be maintained after 1 year. 59% of eyes with non-ischaemic and 25% with ischaemic CRVO were able to read (visual acuity greater than or equal to 6/15) after 1 year.

Retinal blood flow in nonischemic central retinal vein occlusion.

OBJECTIVE: The authors studied the changes in retinal blood flow (RBF) and oxygen reactivity in a major temporal vein in patients with central retinal vein occlusion (CRVO). PARTICIPANTS: Eleven patients with nonischemic CRVO approximately 7 weeks from onset of disease. INTERVENTION: Laser Doppler velocimetric measurement of RBF and vessel reactivity to inhaling 60% oxygen. Measurements were performed at baseline and 3 months. RESULTS: Flow velocity in the affected eye had increased significantly by 3 months, from 1.6 +/- 0.4 cm/second to 2.0 +/- 0.4 cm/second (P = 0.02). Retinal blood flow, however, remained unchanged (13.7 +/- 5.8 microl/minute versus 15.0 +/- 6.5 microl/minute). The two comparable RBF values, despite differing velocity values, suggest that the relatively normal baseline value was achieved through higher intravascular pressure at baseline (Bernoulli's principle). This is supported by the fact that oxygen reactivity had improved from 2.1% +/- 3.6% at baseline to 3.8% +/- 3.1% (P = 0.001) at 3 months, which suggests an improved ability to respond to hyperoxia from reduced intravascular pressure. CONCLUSION: Intravascular pressure in CRVO appears to continue to decrease during the first 5 months after the onset of CRVO, indicating continuing reduction in the degree of outflow obstruction during this time.

Vessel diameter changes during the cardiac cycle.

Retinal vessel diameter, which is an important parameter in blood flow measurement, is affected by pulsation during the cardiac cycle and by vasomotion. This project studied these changes by analysing three monochromatic fundus photographs taken in eight arbitrary parts of the cardiac cycle of 10 healthy subjects. It was found that the venous diameter decreased in early systole, increasing thereafter to a maximum level in early diastole and then declined towards end diastole. The maximum change of 4.82% (between early systole and early diastole) (p = 0.03) represents a 9.83% change in volumetric blood flow. The arterial diameter peaked in mid-late systole, increasing by 3.46% (p = 0.01); this represents a blood flow increase of 7.04%. Vasomotion led to changes of 3.71% and 2.61% in arteries and veins respectively. It is concluded that for accurate measurement of retinal blood flow, fundus photographs should be taken synchronised with the electrocardiogram.

Internal limiting membrane ablation in pig eyes with the Er:YAG laser under perfluorodecalin.

PURPOSE: The aim of our study was to evaluate the in vivo feasibility of non-contact Er:YAG laser ablation of the internal limiting membrane (ILM), which is recommended for the treatment of macular holes. METHOD: Vitrectomy was performed in 16 eyes of 15 pigs. After perfluorodecalin filling, it was attempted to remove the ILM using a free-running fiber-guided Er:YAG laser (lambda=2.94 microm, pulse length 250 micros, repetition rate 1.7 Hz, radiant exposure 0.6-2.05 J/cm2). The eyes were enucleated either immediately (11 eyes, group 1) or 2 weeks after laser therapy (5 eyes, group 2). Furthermore, in one additional pig eye the retina was carefully treated with microforceps after vitrectomy to assess the damage produced by conventional techniques of ILM peeling. All eyes were examined histologically. RESULTS: Group 1: Nine eyes could be examined (problems with fixation in two eyes). In four of nine eyes, the ILM was either removed or detached, in one eye there was a superficial retinal hemorrhage, and in four eyes the ILM was still intact. In the latter cases, there was no intraoperative whitening or bleeding and no posterior vitreous detachment was present histologically. Group 2: Four eyes (problems with fixation in one eye) could be examined. The ILM was either removed or detached in three eyes. In one eye there was a superficial retinal hemorrhage. In one eye the ILM was not removed and there had neither been intraoperative whitening or hemorrhage nor histologically visible posterior vitreous detachment. In both groups, the nerve fiber layer in treated areas was thicker than in adjacent untreated retina. In one eye the retina was gently manipulated with microforceps in an attempt to perform ILM peeling. This led to damage to all layers of the retina. CONCLUSIONS: Removal of the ILM by Er:YAG laser is possible in vivo. However, the variability of the laser effects calls for further improvement such as a reliable indicator of ablation depth. In any case, any damage to the retina was lesser than that produced by microforceps.

A national outbreak of Salmonella enteritidis infections from ice cream. The Investigation Team.

BACKGROUND: In September 1994, the Minnesota Department of Health detected an increase in the number of reports of Salmonella enteritidis infections. After a case-control study implicated a nationally distributed brand of ice cream (Schwan's) in the outbreak, the product was recalled and further epidemiologic and microbiologic investigations were conducted. METHODS: We defined an outbreak-associated case of S. enteritidis infection as one in which S. enteritidis was cultured from a person who became ill in September or October 1994. We established national surveillance and surveyed customers of the implicated manufacturer. The steps involved in the manufacture of ice cream associated with cases of S. enteritidis infection were compared with those of products not known to be associated with infection matched for the date of manufacture. Cultures for bacteria were obtained from ice cream samples, the ice cream plant, and tanker trailers that had transported the ice cream base (premix) to the plant. RESULTS: We estimate that S. enteritidis gastroenteritis developed in 224,000 persons in the United States after they ate Schwan's ice cream. The attack rate for consumers was 6.6 percent. Ice cream associated with infection contained a higher percentage of premix that had been transported by tanker that had carried nonpasteurized eggs immediately before (P = 0.02). S. enteritidis was isolated from 8 of 226 ice cream products (3 percent), but not from environmental samples obtained from the ice cream plant (n = 157) or tanker trailers (n = 204). CONCLUSIONS: This nationwide outbreak of salmonellosis was most likely the result of contamination of pasteurized ice cream premix during transport in tanker trailers that had previously carried nonpasteurized liquid eggs containing S. enteritidis. To prevent further outbreaks, food products not destined for repasteurization should be transported in dedicated containers.