Asymmetry indicates more severe and active disease in Graves' orbitopathy: results from a prospective cross-sectional multicentre study.

PURPOSE: Patients with Graves' orbitopathy can present with asymmetric disease. The aim of this study was to identify clinical characteristics that distinguish asymmetric from unilateral and symmetric Graves' orbitopathy. METHODS: This was a multi-centre study of new referrals to 13 European Group on Graves' Orbitopathy (EUGOGO) tertiary centres. New patients presenting over a 4 month period with a diagnosis of Graves' orbitopathy were included. Patient demographics were collected and a clinical examination was performed based on a previously published protocol. Patients were categorized as having asymmetric, symmetric, and unilateral Graves' orbitopathy. The distribution of clinical characteristics among the three groups was documented. RESULTS: The asymmetric group (n = 83), was older than the symmetric (n = 157) group [mean age 50.9 years (SD 13.9) vs 45.8 (SD 13.5), p = 0.019], had a lower female to male ratio than the symmetric and unilateral (n = 29) groups (1.6 vs 5.0 vs 8.7, p < 0.001), had more active disease than the symmetric and unilateral groups [mean linical Activity Score 3.0 (SD 1.6) vs 1.7 (SD 1.7), p < 0.001 vs 1.3 (SD 1.4), p < 0.001] and significantly more severe disease than the symmetric and unilateral groups, as measured by the Total Eye Score [mean 8.8 (SD 6.6) vs 5.3 (SD 4.4), p < 0.001, vs 2.7 (SD 2.1), p < 0.001]. CONCLUSION: Older age, lower female to male ratio, more severe, and more active disease cluster around asymmetric Graves' orbitopathy. Asymmetry appears to be a marker of more severe and more active disease than other presentations. This simple clinical parameter present at first presentation to tertiary centres may be valuable to clinicians who manage such patients.

Does early response to intravenous glucocorticoids predict the final outcome in patients with moderate-to-severe and active Graves' orbitopathy?

PURPOSE: Intravenous glucocorticoids (ivGCs) given as 12-weekly infusions are the first-line treatment for moderate-to-severe and active Graves' orbitopathy (GO), but they are not always effective. In this study, we evaluated whether response at 6 weeks correlated with outcomes at 12 (end of intervention) and 24 (follow-up) weeks, particularly in patients initially unresponsive. METHODS: Our database (Bartalena et al. J Clin Endocrinol Metab 97:4454-4463, 10), comprising 159 patients given three different cumulative doses of methylprednisolone (2.25, 4.98, 7.47 g) was analyzed, pooling data for analyses. Responses at 6 weeks were compared with those at 12 and 24 weeks using three outcomes: overall ophthalmic involvement [composite index (CI)]; quality of life (QoL); Clinical Activity Score (CAS). Responses were classified as "Improved", "Unchanged", "Deteriorated", compared to baseline. RESULTS: Deteriorated patients at 6 weeks for CI (n = 8) remained in the same category at 12 weeks and 7/8 at 24 weeks. Improved patients at 6 weeks for CI (n = 51) remained in the same category in 63% and 53% of cases at 12 and 24 weeks, respectively. Unchanged patients at 6 weeks (n = 100) eventually improved in 28% of cases (CI), 58% (CAS), 32% (QoL). There was no glucocorticoid dose-dependent difference in the influence of early response on later outcomes. CONCLUSIONS: Patients who deteriorate at 6 weeks after ivGCs are unlikely to benefit from continuing ivGCs. Patients unresponsive at 6 weeks still have a significant possibility of improvement later. Accordingly, they may continue ivGC treatment, or, alternatively, possibly stop ivGCs and be switched to a second-line treatment.

Pituitary apoplexy during pregnancy: a rare, but dangerous headache.

Pituitary apoplexy is a rare endocrine emergency that occurs in a small number of patients with a pituitary tumor. It is a clinical syndrome characterized by the sudden onset of headache, nausea, vomiting, visual impairment, and decreased consciousness, caused by hemorrhage and/or infarction of the pituitary gland. Pituitary apoplexy has very rarely been described during pregnancy, when it is potentially life-threatening to both the mother and the fetus, if unrecognized. Only a few cases have been published to date. The review of the existing literature underlines that pituitary apoplexy, although rare, should be borne in mind when a pregnant woman presents with severe headache and visual defects of sudden onset. After initial management, which includes intravenous glucocorticoid therapy, fluid and electrolyte replacement, the final selection of medical or surgical treatment should result from a multidisciplinary approach involving expert specialists, keeping into account both severity of clinical presentation and gestational week.

Interactions between light and vitreous fluid substitutes.

To determine the interactions between light and vitreous fluid substitutes, we studied the absorption and fluorescence properties of the following fluids that are commonly used in vitreoretinal surgery: Ringer's solution, balanced salt citrate-buffered solution, balanced salt bicarbonate-buffered solution, hydroxypropyl methylcellulose ophthalmic solution, hyaluronate sodium, perfluorocarbons, silicone oil, and fluorosilicone oil. The absorption spectra for all the fluids peaked in the UV-C (reference range <280 nm) and UV-B (reference range from 315 to 280 nm) regions of the spectrum, with little or no absorption in the visible region of the spectrum (from 400 to 700 nm). Emission of almost all of the fluids occurred mainly in the 300- to 360-nm region, with fairly low-quantum efficiency. The limited light absorption properties of the fluids calls for caution during transpupillary and intraocular laser photocoagulation to avoid excessive retinal damage, mainly when the laser power is increased during treatment. Transmission of incoherent light (environmental and ophthalmic artificial light) through highly transparent vitreous fluid substitutes may lead in time to dangerous light exposure, particularly in aphakic eyes. The emitted fluorescence in these fluids generates a minimal risk of long-term damage.

Interaction between infrared radiation and vitreous substitutes.

OBJECTIVE: To characterize the interaction between midintrared radiation of cutting lasers used or proposed for vitreoretinal surgery and fluid vitreous substitutes commonly used in vitreoretinal surgery. METHODS: Optical transmittance of vitreous substitutes was measured with a double-beam spectrophotometer. Measurements were performed in a wide spectral range of infrared radiation, including the 2120-nm wavelength of the holmium-YAG laser and the water absorption peaks at 1440, 1930, and 2940 nm. RESULTS: The wavelengths considered have a penetration depth varying from 410 to 1 microns in Ringer's solution, balanced salt citrate-buffered solution, balanced salt bicarbonated-buffered solution, hyaluronate sodium, and hydroxypropyl methylcellulose ophthalmic solution, from 2000 to 13 mm in perfluorocarbon liquid, and from 52 to 2.5 mm in silicone and fluorosilicone oils. CONCLUSIONS: Midinfrared optical radiation exhibits dramatic differences of penetration depth in different vitreous substitutes. High-absorbing liquids should be used mainly with contact laser procedures and could provide a shield for remote structures. Low-absorption vitreous substitutes allow noncontact laser surgical procedures, but they also may cause direct optical damage to remote tissues. The knowledge of wavelength transmittance of vitreous substitutes is necessary to evaluate and optimize the efficacy and safety of cutting laser sources.

Surgical treatments of proliferative vitreoretinopathy.

Four hundred ten eyes with retinal detachment and proliferative vitreoretinopathy underwent closed vitrectomy with membrane peeling, scleral buckling, and intraocular air injection. The retina was reattached in 243 eyes (59.3%). Useful vision was attained in 223 eyes. The preoperative proliferative vitreoretinopathy was clinically graded in six groups of increasing severity (C-1, C-2, C-3, D-1, D-2, D-3). From grades C-2 to D-3, a significant trend related a decreased rate of retinal reattachment with increased severity. However, grade C-1 showed a significantly lower success rate than did grade C-2. Scleral buckling alone may be the treatment of choice in grade C-1 eyes. Grade D-3 eyes had the worst anatomic and functional results. Preoperatively, there was a significant relationship between increasing severity of proliferative vitreoretinopathy and frequency of aphakia, and aphakic eyes showed a significantly lower rate of retinal reattachment than did phakic eyes.

Correlation between optical coherence tomography data and biomicroscopic interpretation of idiopathic macular hole.

PURPOSE: This study was designed to assess the new clinical information given by optical coherence tomography in patients with idiopathic macular hole. METHODS: Sixty-one consecutive eyes of 47 patients with idiopathic macular hole at different stages of development were studied clinically. Patients with myopia, epiretinal macular membrane, and any other ocular disease were excluded. Best-refracted visual acuity and biomicroscopic fundus examination with macular contact lens were performed. Optical coherence tomography was performed through a dilated pupil. The optical coherence tomography findings were correlated with the Gass biomicroscopic classification of idiopathic macular hole. RESULTS: Optical coherence tomography provided different or additional information in 22 of 24 eyes (91.7%) biomicroscopically classified in stages 1-A and stage 1-B, according to the Gass macular hole classification, and in seven of 37 eyes (18.9%) biomicroscopically classified in stages 2, 3, and 4. The main difference from Gass biomicroscopic classification was a macular pseudocyst instead of a foveolar detachment in the first stages. The main additional optical coherence tomography observation, not detected biomicroscopically, was the presence of retinal tissue on the bottom of the macular hole. Optical coherence tomography may be particularly useful in evaluation of early stages in development of idiopathic macular hole. CONCLUSIONS: Compared with classic biomicroscopical observation, optical coherence tomography frequently gives different or additional information on idiopathic macular hole, especially in its early stages. Correct diagnosis and surgical indication of idiopathic macular hole may benefit from optical coherence tomography imaging.

Long-term histopathologic evaluation of human expanded skin.

Forty-two patients operated on by skin expansion have been contacted after a mean time of 25 months from the last surgery. Two biopsies have been taken from the expanded area of each patient. In 12 patients it has been possible to obtain a similar sampling from the opposite, nonexpanded area of the body. The samples underwent optic microscopy and cell kinetic and DNA content investigations. The epidermal structure of the followed-up skin, compared with the skin of the opposite side of the body, looks normal. The mitotic activity of the epidermal cells has returned to the values of preexpanded skin. The dermis shows a low degree of elastosis and zonal fragmentation of elastic fibers. The hypodermis, where the expander capsule was removed during the last surgery, does not show an accentuated fibrosis.

Pharmacological assay of Casearia sylvestris. I: Preventive anti-ulcer activity and toxicity of the leaf crude extract.

An ethanol extract of the leaves of Brazilian Casearia sylvestris, given orally, inhibited gastric secretion in pylorus-ligated rats. At a prophylactic dose of 57.5 mg/kg, the extract showed a reduction of gastric juice more effective than misoprostol (500 micrograms/kg). In reducing hydrochloric acid output, the extract was less effective than misoprostol, cimetidine (32.0 mg/kg) and atropine (5.3 mg/kg). With the extract, the pH of the stomach contents was not significantly different from that of controls. Stress-induced lesions produced by restraint and water immersion were significantly prevented by the extract for all levels of severity when compared with the controls. The extract appeared more effective than misoprostol in suppressing light lesions, was equivalent to cimetidine and misoprostol for moderate lesions, and less effective than cimetidine and misoprostol for severe lesions. Toxicological experiments indicated a low acute toxicity, confirmed by subchronic daily testing. The oral LD50 value of greater than 1840 mg/kg was over 32 times higher than the antiulcerogenic ED50 (57.5 mg/kg).

Pharmacological assay of Cordia verbenacea. III: Oral and topical antiinflammatory activity and gastrotoxicity of a crude leaf extract.

The antiinflammatory effects and gastrotoxicity of a lyophilized 70% ethanol extract of the leaves of Cordia verbenacea were investigated through experimental models in rats and mice. The oral administration of 1.24 mg/kg of the extract significantly inhibited nystatin-induced oedema. Topical application of the extract at a dose of 0.09 mg/ear in mice was clearly more effective than 1.0 mg/ear of naproxen in the reduction of the ear oedema induced by corton oil. At antiinflammatory doses, the extract showed an important protective effect on the gastric mucosa, reducing significantly the number of gastric lesions.

Posterior empty spaces during vitreoretinal surgery.

PURPOSE: To study during vitreoretinal surgery the intravitreal posterior empty spaces caused by different posterior relationships between the retina, posterior hyaloid and posterior vitreous. METHODS: A total of 151 eyes with different vitreoretinal disorders were considered; 97 eyes with retinal detachment (Group I), 54 eyes without retinal detachment (Group II). Intraoperative anatomy was carefully observed. In Group I, intraoperative observations were made with and without the infusion fluid entering the eyes. RESULTS: Different intraoperative posterior empty spaces were found: (i) within the posterior vitreous, (ii) between the detached posterior hyaloid and the retina, (iii) above and below the detached posterior "isolated hyaloid", and (iv) between the more posterior vitreous and the attached posterior hyaloid. The infusion fluid flux may variously change the size and shape of these posterior empty spaces. CONCLUSIONS: Many types of posterior empty spaces were observed intraoperatively. Their correct interpretation was important to well-conducted surgery. Dynamic movements of fluids in the vitreous cavity caused many intraoperative artifacts, making it difficult to understand the empty spaces and the vitreoretinal relationships present before surgery.

Reliability of preoperative ultrasonography evaluation for vitreoretinal surgery.

To evaluate the present level of reliability of common ultrasonography prior to vitreoretinal surgery, we carried out a prospective study to compare preoperative ultrasonography data with direct intraoperative findings. A total of 228 eyes with different vitreoretinal disorders and opaque or clear media were studied. In the group of 187 eyes with tractional retinal detachment (group I), the percentage of agreement between the ultrasonography data and the surgical findings ranged from 77.1% to 92.2%, depending on the pathology. In the group of 41 eyes without retinal detachment (group II), agreement ranged from 90.4% to 100%. The most frequent causes of failure of preoperative ultrasonography were incorrect prediction of macular detachment, partial posterior vitreous detachment, posterior vitreoschisis and vitreoretinal adhesions. The main cause of failure was the presence of multiple complicated echoes in group I, particularly in tractional diabetic retinal detachment. To achieve maximum benefits from ordinary preoperative ultrasonography, the vitreoretinal surgeon must be fully aware of its present level of reliability and general limitations.

OCT images and surgery of juvenile Macular retinoschisis.

We describe three cases of X-linked juvenile retinoschisis confined to the posterior pole of the eye, one of which surgically treated. In the first two cases, in vivo optical coherence tomography (OCT) had revealed a cleavage plane in both nerve fiber and outer retinal layers. In the two similar operated eyes of the third case, postoperative OCT had revealed the disappearance of macular schisis in the eye with good recovery of visual function after surgery. On the contrary, it had revealed a persistent splitting of the retina in the other eye, not clinically visible, which explained the poor recovery of visual function after surgery. In cases with progressive worsening of macular involvement in X-linked juvenile retinoschisis, highly accurate surgery may be considered, and the pre- and postsurgical OCT monitor of these patients is indicated.

Age-related macular degeneration and vitreous hemorrhage.

Age-related macular degeneration led to vitreous hemorrhage (VH) in six eyes of four patients. Macular involvement was bilateral in three patients and fluorescein angiography performed before VH showed extensive subretinal hemorrhage in the macular region in all eyes. We examine the possible causal mechanisms of VH resulting from age-related macular degeneration. Local risk factors, as outlined in our series by fluorescein angiography, are discussed and systemic risk factors are considered. Three out of the six eyes underwent pars plana vitrectomy for removal of intravitreal blood, and had severe inflammatory reactions in the postoperative period. In the three non-operated eyes spontaneous reabsorption of VH was observed at the end of follow-up.

Herpes simplex virus type 2 acute retinal necrosis in an immunocompetent patient.

PURPOSE: To report a case of acute retinal necrosis caused by herpes simplex virus 2 in an otherwise healthy patient. CASE REPORT: A 45-year-old man presented with one month's history of decreased vision in the right eye. He had previously received a course of intravenous gancyclovir because of a clinical suspicion of cytomegalovirus retinitis. The patient's ocular history was remarkable for a similar episode in the left eye thirty years earlier, resulting in important visual impairment. System and laboratory investigations were unremarkable. Ocular examination showed severe anterior granulomatous uveitis, vitreous haze, areas of necrosis and retinal exudates. The anterior chamber tap disclosed the presence of HSV type 2, and oral steroids and acyclovir were instituted. Two weeks after the patient had been discharged, a retinal detachment occurred in the right eye, necessitating surgical repair. The presence of HSV type 2 was confirmed in the vitreous. Visual acuity recovered completely after surgery and the patient was placed on a maintenance dose of oral acyclovir. CONCLUSIONS: HSV type 2 is a rare cause of acute retinal necrosis in healthy patients. Bilateral involvement can occur in the fellow eye, even with a long delay. Acute retinal necrosis is a severe ocular inflammatory syndrome associated with a very poor visual outcome. It is caused by VZV, HSV type 1 and, less commonly, by HSV type 2. The disease can affect healthy patients and cause bilateral involvement in the fellow eye, even with a long delay.

Optical coherence tomography in idiopathic epiretinal macular membrane surgery.

PURPOSE: To evaluate the usefulness of Optical Coherence Tomography (OCT) images for surgical indication, intraoperative management and postoperative outcome of patients with idiopathic epiretinal macular membrane (IEMM). METHODS: 28 selected eyes underwent surgery for removal of IEMM. The patients' mean age was 57.3 years. The macular region and the IEMMs were studied before and after surgery using OCT, slit-lamp biomicroscopy and fundus photography. The mean postoperative follow-up was 6.2 months (range 1.3-14). RESULTS: Preoperatively, in 12 of the 28 eyes (42.9%) only the OCT images revealed IEMM partially separated from the macula, with tractional focal point(s) of attachment to the macular region. In the other 16 eyes (57.1%) in which IEMMs were totally adherent to the macular region, the membranes were barely visible by OCT in 13 eyes and not visible in three. Intraoperatively, the surgeon was guided in the peeling procedures. A significant correlation (p < 0.001) was found between visual acuity and macular thickness before surgery and at the end of the postoperative follow-up. CONCLUSIONS: OCT images provide very useful information for the surgical indication, intraoperative management and postoperative outcome of patients with IEMM.

[A case of transareolar mastocele (tuberous breast) following an early lateral thoracotomy]. / Su di un caso di mastocele transareolare (tuberous breast) conseguito a toracotomia laterale precoce.

The paper reports a rare case of breast anomaly, classified as "tuberous breast", which was of a specific nature since it was the result of a lateral thoracotomy performed at the age of 7 days old to esophageal atresia. The paper analyses the possible etiopathogenetic mechanisms. The use of an original reparative technique enable an adequately shaped and protruding breast to be obtained without the use of prosthesis and without leaving additional scars.

[A rare case of breast ectopy associated with partial agenesis of osteo-muscular structures of the thoracic wall. Proposal of an original reparative technique]. / Un raro caso di ectopia mammaria, associato ad agenesia parziale delle strutture osteomuscolari della parete toracica. Proposta di una metodica riparativa originale.

The Authors report a case of chest wall malformation characterized by costal defect (6th and 7th ribs), hypoplasia of the serratus and pectoralis major muscles, left mammary ectopy and mucoviscidosis. The case is reported because of the very singular malformative association and the originality of the reparative procedure. Appearance has been improved and a good shape and breast projection achieved.

Minimal incision palatopharyngoplasty. A preliminary report.

A new palatopharyngoplasty which allows good muscular reorientation as well as elongation of the soft palate with minimal morbidity and scarring has been developed, and 66 selected patients underwent the procedure during the period September 1989 to March 1993. The most important findings were reduced operative bleeding, good length and mobility of the soft palate, and minimal scarring. A total of seven fistulas (11%) developed. Twenty-three patients (mean age 6 years and 2 months at the time of operation) underwent nasopharyngoscopy and multiview videofluoroscopy; velopharyngeal insufficiency was evident in only four (17%). Dental casts were obtained in 14 patients (mean age at the time of the operation 1 year, 3 months) who were followed up for a maximum period of two years. No postoperative orthodontic treatment was required and the width and harmony of the dental arch were maintained in all cases.

Myofasciocutaneous expansion in the tegumentary rehabilitation of the amputation stump.

In post-traumatic amputations, in particular in leg amputations, the presence of an unstable scar or of ulcerous areas that are difficult to heal in the site of the amputation stump constitutes a repair problem that is not easily solved. In this specific field of reconstruction skin expansion has earned significant agreement, and is even considered to be a safe and reliable method for the surgical rehabilitation of the amputation stump, allowing us to obtain high-quality tegumentary covering, with no excessive thickness, that adapts well to the prosthesis and to the underlying skeleton, and that is characterized by good sensitivity of protection. Tegumentary amplification may, in some cases, also become myocutaneous, allowing us to obtain more tissue thickness for protection in patients submitted to chronic loading that lasts longer and in those with thin teguments, in which traditional expansion could determine excessive narrowing of the tegumentary covering, following atrophy caused by compression of the subcutaneous adipose tissue.