Early and late endophthalmitis following trabeculectomy in a Chinese population.

PURPOSE: To investigate the rate of bleb-related endophthalmitis over 5 years in a Chinese population. METHODS.:Retrospective chart review. RESULTS: Of 988 trabeculectomies performed over 5 years, one case (0.1%) developed early endophthalmitis caused by Morganella morganii, which was rarely reported in the literature. Six cases (0.6%) developed late-onset endophthalmitis. Mitomycin C significantly increased the risk of late-onset endophthalmitis (p=0.0002). CONCLUSIONS: Physicians should weigh the benefits against the risks of mitomycin C application in performing trabeculectomies.

ß-1,4-Galactosyltransferase III suppresses extravillous trophoblast invasion through modifying ß1-integrin glycosylation.

INTRODUCTION: Glycosylation controls diverse protein functions and regulates various cellular phenotypes. Trophoblast invasion is essential for normal placental development. However, the role of glycosylation in human placenta throughout pregnancy is still unclear. The ß-1,4-galactosyltransferase III (B4GALT3) has been found to regulate cancer cell invasion. We therefore investigated the expression of B4GALT3 in placenta and its roles in trophoblast. METHODS: B4GALT3 protein expression was examined by quantitative Western blotting analysis in human placentas. For identification of B4GALT3-positive cells in normal human placenta, immunohistochemistry and immunofluorescence methods were used. To investigate effects of B4GALT3 on extravillous trophoblast (EVT)-like cell and primary EVT cells, we analyzed cell growth, adhesion, migration, and invasion in mock and B4GALT3-transfected cell. RESULTS: B4GALT3 expression significantly increased in third trimester human placenta. Immunostaining revealed that B4GALT3 expressed in placental villous cytotrophoblast, syncytiotrophoblast, and a subpopulation of EVT cells throughout pregnancy. Interestingly, we found increases in the expression level and percentage of B4GALT3-positive cells in third trimester EVT, but not in syncytiotrophoblasts and cytotrophoblasts of placental villi. Overexpression of B4GALT3 in HTR8/SVneo cells and primary trophoblast cells significantly suppressed cell migration. In addition, B4GALT3 suppressed cell invasion, and enhanced cell adhesion to laminin in HTR8/SVneo cells. Notably, we found that B4GALT3 modified glycans on ß1-integrin, suppressed focal adhesion kinase (FAK) signaling, and enhanced ß1-integrin degradation. DISCUSSION: We propose that B4GALT3-mediated glycosylation change not only enhances ß1-integrin binding to laminin, but also attenuates ß1-integrin stability. Our findings suggest that B4GALT3 is a critical regulator for suppressing EVT invasion in the late stages of pregnancy.

Congenital interstitial cell of cajal hyperplasia with neuronal intestinal dysplasia.

Interstitial cells of Cajal (ICCs) are intestinal pacemaker cells that initiate peristalsis in the stomach and intestine, and are considered to be precursors of gastrointestinal stromal tumors (GISTs). We report a 2-year-old girl who suffered from scanty stool passage since birth. On barium enema, the distal colon was rigid with narrow lumen, whereas the proximal colon was dilated and atonic. She received right hemicolectomy and ileostomy. Histopathologically, there was continuous proliferation of spindle cells located between the layers of the muscularis propria throughout the right colon. These spindle cells were positive for c-kit and CD34 but negative for myogenic or neurogenic markers, indicating they are ICCs. No germline or somatic mutation of the juxtamembrane domain of c-kit gene was detected. In addition, the changes of the submucosal plexus fulfilled the histologic criteria of neuronal intestinal dysplasia type B. To our knowledge, this is the first reported case of congenital ICC hyperplasia. Further studies of ICC development may contribute to better understanding of the pathogenesis of this congenital malformation and the tumorigenesis of GIST.

Molecular analysis of mucosa-associated lymphoid tissue (MALT) lymphoma of ocular adnexa.

Lymphomas of mucosa-associated lymphoid tissue (MALT) are a distinct subgroup of extranodal B-cell non-Hodgkin's lymphomas. Most studies have failed to demonstrate the clonal rearrangement of BCL-1, BCL-2 or c-MYC genes for MALT lymphomas. Further, alteration of the p53 gene is rarely demonstrated in low-grade MALT lymphomas, but can be detected in high-grade disease. Lymphomas of the ocular adnexa represent approximately eight percent of all extranodal lymphomas, most of which are MALT lymphomas, but few studies had explored the alterations of BCL-1, BCL-2, c-MYC and p53 genes specifically for ocular MALT lymphomas. We investigated the changes to BCL-1, BCL-2, c-MYC and p53 genes in these lymphomas for Taiwanese patients. Clonal rearrangement for immunoglobulin heavy-chain (IgH), BCL-1, BCL-2, c-MYC and p53 genes was examined for 16 cases of ocular MALT lymphoma. Restriction-length polymorphism and polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) of the DNA, corresponding to exons 5 through 9, followed by DNA sequencing, were utilized to analyze the possible mutations of the p53 gene for these tumors. Thirteen of the cases revealed rearranged IgH genes using Southern blotting or PCR. No rearrangement of BCL-1, BCL-2, c-MYC or p53 genes was discovered, with point mutation of the p53 gene in one case. As for other types of MALT lymphomas, BCL-1, BCL-2 and c-MYC genes are not implicated in the pathogenesis of the ocular sub-group. Although alteration of the p53 gene is rare for low-grade ocular MALT lymphoma, its role in disease progression merits further research.

A new approach to the correction of involutional entropion by pretarsal orbicularis oculi muscle fixation.

A new surgical technique to repair involutional entropion involves fixation of a strip of dissected and displaced pretarsal orbicularis oculi muscle. In 112 patients followed up for an average of 14 months, this technique was successful. The procedure is easy to perform and complications were minimal.

Serratia Marcescens corneal ulcer as a complication of orthokeratology.

PURPOSE: To report a case of Serratia Marcescens corneal ulcer as a complication of orthokeratology treatment. METHODS: Case report. RESULTS: A 9-year-old male who underwent orthokeratology treatment for 6 months suffered from a corneal ulcer. The refractive state of lesion eye was -5.5D/-1.25D x 180 degrees, and visual acuity was hand motion at 30 cm. He wore a retainer lens, rigid gas permeable lens, overnight for 2 months before the corneal ulcer occurred. Ulcer became worse after tobramycin and gentamycin treatment for 2 days. After ciprofloxacin treatment, the ulcer healed and visual acuity recovered to 20/20 with spectacle correction. Cultures of the cornea tissue and contact lens storage solution both grew Serratia Marcescens, which was sensitive to ciprofloxacin. CONCLUSION: Overnight wearing of a rigid contact lens is a risk factor for a corneal ulcer.

Effect of latanoprost 0.005% and brimonidine tartrate 0.2% on pulsatile ocular blood flow in normal tension glaucoma.

AIM: To determine the effect of brimonidine tartrate 0.2% and latanoprost 0.005% on pulsatile ocular blood flow (POBF) in patients with normal tension glaucoma (NTG). METHOD: NTG patients with progressive optic neuropathy, new disc haemorrhage, or field defects that threatened fixation were enrolled into a randomised, investigator masked, crossover study. Group I patients received 4 weeks each of latanoprost, lubricant, and brimonidine, while group II patients received 4 weeks each of brimonidine, lubricant, and latanoprost. Diurnal POBF was measured at baseline and after each 4 week treatment. RESULTS: 25 patients completed the study and had reliable POBF measurement at each visit. There was no significant diurnal change in baseline POBF (p = 0.768). Latanoprost increased POBF by 213 (SD 257) micro l/min (22.8%, p <0.001) while brimonidine increased it by 97 (183) micro l/min (10.4%, p = 0.014). POBF increased at 8 am (p = 0.004), 12 noon (p = 0.002), and 4 pm (p <0.001) with latanoprost, while it increased only at 8 am (p = 0.016) with brimonidine. After adjusting for the factor of IOP, neither latanoprost nor brimonidine increased POBF significantly. CONCLUSIONS: Latanoprost increases the mean POBF that is related to its IOP lowering effect. The increase in POBF noted after brimonidine is within the range of long term variation and may not be attributable to the drug effect.

Pulsatile ocular blood flow in asymmetric exudative age related macular degeneration.

BACKGROUND/AIMS: Decreased perfusion or increased vascular resistance of the choroidal vessels had been proposed as the vascular pathogenesis for age related macular degeneration (AMD). This study planned to answer the question whether pulsatile ocular blood flow (POBF) was different in patients with asymmetric exudative AMD between eyes with drusen, choroidal neovascularisation (CNV), or disciform scar. METHODS: 37 patients with asymmetric exudative AMD were enrolled in this observational case series study. POBF were measured in both eyes of each subject. Eyes with high myopia, anisometropia, recent laser treatment, and glaucoma were excluded. RESULTS: After adjusting for ocular perfusion pressure, intraocular pressure, and pulse rate, multivariate regression analysis with generalised estimating equation showed POBF was significantly higher in eyes with CNV (1217 (SD 476) microl/min) than the contralateral eyes with drusen (1028 (385) microl/min) (p = 0.024). Eyes with disciform scar had lower POBF than the contralateral eyes with drusen (999 (262) microl/min and 1278 (341) microl/min, respectively, p<0.001). There was no significant correlation between the POBF and the lesion size of the CNV. CONCLUSION: The POBF in eyes with drusen was lower than their fellow eyes with CNV, but higher than their fellow eyes with disciform scar. This finding suggests that haemodynamic differences between fellow eyes in individuals are relevant to the development of CNV and the formation of disciform scar. Further studies on the follow up patients might shed light on the pathogenesis of exudative AMD.

Visual acuity and contrast sensitivity in different types of posterior capsule opacification.

PURPOSE: To compare the visual acuity (VA) and contrast sensitivity in 2 types of posterior capsule opacification (PCO) in pseudophakic eyes before and after neodymium:YAG (Nd:YAG) capsulotomy and to evaluate vision test results after Nd:YAG capsulotomy. SETTING: Department of Ophthalmology, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan. METHODS: Fourteen eyes with fibrosis-type PCO and 15 eyes with Elschnig-pearl-type PCO were enrolled prospectively. Before and 1 week after Nd:YAG capsulotomy, VA and contrast sensitivity were assessed using the illiterate E version of the Bailey-Lovie chart and the Vistech VCTS 6000 chart, respectively. RESULTS: Before capsulotomy, the mean logMAR acuity in the group with Elschnig-pearl-type PCO was 0.47 +/- 0.32 (SD) and in the group with fibrosis-type PCO, 0.17 +/- 0.07. The difference between the 2 groups was significant (P =.002). After capsulotomy, there was no significant between-group difference (P >.05). Before capsulotomy, the contrast sensitivity was significantly worse (P <.01) at all spatial frequencies in the group with pearl-type PCO, especially at 6 cycles per degree. After capsulotomy, there was no significant between-group difference (P >.05) at any spatial frequency. CONCLUSIONS: After cataract surgery, patients with pearl-type PCO had lower VA and contrast sensitivity than those with fibrosis-type PCO. An Nd:YAG capsulotomy improved the VA and contrast sensitivity in patients with both types of PCO.

Ophthalmic findings in patients with acquired immunodeficiency syndrome.

Ocular manifestations have been reported in up to 60% of individuals infected with human immunodeficiency virus (HIV) in the United States, and it is becoming increasing apparent that these ocular manifestations almost invariably reflect extent of progression of the disease. The prevalence of ocular abnormalities among acquired immunodeficiency syndrome (AIDS) patients in Taiwan has not been reported. In the present study, we examined and followed up the ophthalmic conditions of a total of 274 HIV-infected patients during the period from March 1993 to May 1999. The results show that cotton-wool spots was the most common ocular finding in this series of patients with AIDS, occurring in 22 (32.8%) of 67 AIDS patients. Cytomegalovirus (CMV) retinitis was the most commonly seen opportunistic ocular infection, occurring in 14 (20.8%) of 67 AIDS patients. These findings suggest that AIDS patients should be closely followed for signs of opportunistic ocular disease which may initially be asymptomatic. Close co-operation between the ophthalmologist and the internist is essential to ensure timely therapeutic intervention, which can decrease the risk of further complications including visual impairment and blindness.

Detection of human cytomegalovirus retinitis and monitoring of ganciclovir treatment using conjunctival swab with polymerase chain reaction in AIDS patients.

This report studies the accuracy of conjunctival swab polymerase chain reaction (CS-PCR) for the diagnosis of human cytomegalovirus retinitis (HCMV) in AIDS patients. PCR and virus culture were used for the detection of HCMV in conjunctival swab, serum, and urine specimens from 38 AIDS patients between April 1996 and April 1998. The clinical utility of the identification of HCMV retinitis by these 6 different methods was demonstrated by their prediction power to estimate AIDS patients at risk of contracting HCMV retinitis. The sensitivity, specificity, positive predictive value, and negative predictive value of CS-PCR for the detection of HCMV retinitis were 91.5%, 80.9%, 60.8%, and 92.7%, respectively; for serum PCR were 74.3%, 81.7%, 57.2%, and 90.3%; for urine PCR were 100%, 17.3%, 20.4%, and 100%; for conjunctival swab culture were 22.7%, 100%, 100%, and 86%; for serum culture were 27.3%, 98.1%, 75%, and 86.4%; and for urine culture were 90.9%, 44.2%, 25.6%, and 95.8%.

Rearrangements of immunoglobulin gene and oncogenes in ocular adnexal pseudolymphoma.

The organization of immunoglobulin heavy chain (IgH), light chain (kappa and lambda) and T cell receptor (TCR) beta chain gene loci in 10 patients with ocular adnexal pseudolymphoma was investigated. Eight of them showed IgH gene rearrangement in at least one of the 3 restriction enzymes-digested DNAs extracted from ocular adnexal neoplasms. In contrast, none of them exhibited clonal TCR beta chain gene rearrangement. The configuration of bcl-1, bcl-2 and c-myc oncogenes was also studied by Southern blot technique. Two patients had a rearranged joining region, IgH-containing fragment that comigrated with the rearranged bcl-1 fragment. C-myc gene rearrangement was found in only one patient who also had bcl-1 gene rearrangement. In ocular adnexal pseudolymphoma, none demonstrated bcl-2 gene rearrangement; however, in bone marrow cells, one patient with systemic lymphadenopathy exhibited both IgH and bcl-2 gene rearrangements. Three genotypic subsets of these ocular adnexal pseudolymphoma can be identified by the configuration of IgH gene and related oncogenes: with germline configuration of IgH gene and bcl-1, bcl-2 and c-myc oncogenes; with rearrangement of IgH gene but germline configuration of these oncogenes; and with recombination between rearranged IgH and bcl-1 genes. These results suggest in ocular adnexal pseudolymphoma a spectrum of clonal change evolving from polyclonal to monoclonal B-population, and further to monoclonal B-population with rearranged bcl-1, c-myc and/or bcl-2 oncogenes.

Retrograde dissection of the vascular pedicle in toe harvest.

A retrograde approach to dissection of the vascular pedicle in toe-to-hand transfer is presented, along with a simplified view of the vascular anatomy of the first web space. This approach has several advantages. First, the dominant vascular supply to the toe is elucidated early in the procedure, allowing for less unnecessary dissection of an inadequate pedicle. This also eliminates the need for preoperative arteriography. Furthermore, in cases where a lengthy pedicle is not required, retrograde dissection dispenses with harvest of a proximal vessel, which will not be needed for the transfer, and destructive dissection of the foot can be minimized.

The salvage of a degloved hand skin flap by arteriovenous shunting.

Nine cases of hand degloving injuries were treated successfully with arteriovenous shunting technique. Of these nine cases, four were degloved from the wrist level and one from the forearm, three were degloved at the palm and one at the dorsum of the hand. All injuries resulted in distally based skin flaps, which were either superficial to the palmar fascia or within the subcutaneous layer. Lack of active bleeding from the periphery of the avulsed flaps substantiated circulatory compromise before revascularization. Survival of the avulsed flaps was achieved by directing the proximal arterial flow into the venous channel within the avulsed skin flaps. The post-operative care and rehabilitation were straightforward, and functional results were satisfactory.

Optic neuritis in herpes zoster ophthalmicus.

BACKGROUND: Optic neuritis in herpes zoster ophthalmicus (HZO) has been reported rarely. We report two cases of HZO optic neuritis with detailed magnetic resonance imaging study and treatment responses. CASES: One patient presented with anterior optic nerve involvement, and the second presented with retrobulbar optic neuritis. Contrast enhanced T(1)-weighted images were obtained in these 2 patients. Intravenous acyclovir and oral prednisolone were given simultaneously. OBSERVATIONS: Magnetic resonance imaging revealed peripheral enhancement of the optic nerve sheath complex on T(1)-weighted scan. Both patients recovered their vision within 3 months following the start of treatment. CONCLUSIONS: Magnetic resonance imaging is helpful for the diagnosis of HZO optic neuritis. Systemic acyclovir and steroid are effective in the treatment of HZO optic neuritis.

Clinical and manometric evaluation of postoperative fecal soiling in patients with Hirschsprung's disease.

We examined the usefulness of manometry as an indicator of fecal soiling after surgical correction of Hirschsprung's disease, and attempted to identify measures to alleviate this complication. Sequential clinical and manometric evaluations of postoperative fecal soiling were performed in 35 patients (30 males, 5 females) with Hirschsprung's disease. The resting anal pressure (RAP), resting rectal pressure, and anorectal pressure gradient (ARPG) all decreased significantly from the preoperative values after corrective pull-through surgery. This correlated well with the clinical change from preoperative obstipation to frequent stool passage or soiling postoperatively. A total of 80% of the patients had mild or severe fecal soiling within 4 years after surgery, but only 40% had persistent symptoms thereafter. The manometric profile showed significant elevations in RAP and ARPG 4 years after surgery. Only five patients had positive conversion of rectoanal sphincteric inhibitory reflex (RASIR) after surgery, and the presence of RASIR was not related to continence. Also, there was no difference in the manometric profile between patients with and without RASIR. However, patients without RASIR were prone to suffer from severe diarrhea or soiling on consuming specific foods or catching cold. In conclusion, anorectal manometry can be an objective tool for the evaluation of postoperative fecal soiling in patients with Hirschsprung's disease. The low conversion rate of RASIR combined with hypersensitivity of the bowel in patients with Hirschsprung's disease suggests that some kind of enteric nervous system disorder might exist other than aganglionosis.

Enteric mucocele formation after endorectal pull-through: report of a case.

We report a case of enteric mucocele formation in a 4-year-old boy after endorectal pull-through correction for Hirschsprung's disease with proximal intestinal neuronal dysplasia. On 17 April 1997, when the patient was 2 years old, a loop ileostomy was performed after an ineffective endorectal pull-through operation involving the right colon. Because of frequent prolapse of the stoma, when the child was two-and-a-half years old an end ileostomy was made by a resection of the distal ileotoma and redundant terminal ileum. When he was 4 years old, he was readmitted because of ileus, peritonitis, and a huge abdominal mass. Complete atresia of the colon at the level of pelvic reflection with proximal enteric mucocele formation was noted at laparotomy. He made an uneventful recovery after resection of the mucocele. This is the first reported case of such a complication after an endorectal pull-through operation. The possible causes and techniques for the prevention of this complication are discussed.

Perforated peptic ulcer in an infant.

We describe a case of perforated peptic ulcer (PPU) in a 9-month-old boy. Abdominal distension was the first clinical sign of PPU. Before he developed abdominal distension, the patient had suffered from an upper respiratory tract infection with fever for about 2 weeks, which was treated intermittently with ibuprofen. A plain abdominal radiograph revealed pneumoperitoneum with a football sign. At laparotomy, a 0.8-cm perforated hole was found over the prepyloric area. Simple closure with omental patching was performed after debridement of the perforation. Pathologic examination showed chronic peptic ulcer with Helicobacter pylori infection. The postoperative course and outcome were satisfactory. The stress of underlying disease, use of ibuprofen, blood type (A), and H. pylori infection might have contributed to the development of PPU in this patient. PPU in infancy is rare and has a high mortality rate; early recognition and prompt surgical intervention are key to successful management.

Renal oncocytoma in acquired renal cystic disease.

Renal oncocytoma is a rare benign tumor of the kidney that accounts for about 5% of renal tumors. Acquired renal cystic disease (ARCD) is commonly seen in dialyzed patients. However, the occurrence of renal oncocytoma in ARCD has rarely been reported. We report such a case in a 67-year-old man who had hypertension-associated end-stage renal disease and had received regular hemodialysis for 5 years. Radiologic diagnostic studies demonstrated a renal mass in the left atrophic cystic kidney that increased in size from 2 cm to 4 cm during 2 years of follow-up. Under the diagnosis of renal cell carcinoma, he received left radical nephrectomy. The pathologic examination revealed renal oncocytoma with a well-cirumscribed, homogenous, mahogany-brown tumor on a background of ARCD. Although patients with ARCD have a higher incidence of renal malignancies, renal oncocytoma may occur in these patients and may be managed conservatively.

Juvenile dermatomyositis complicated with vasculitis and duodenal perforation.

Duodenal perforation has been reported in patients taking steroids and non-steroidal anti-inflammatory drugs (NSAIDs). However, its association with juvenile dermatomyositis is extremely rare. A 4-year-old boy with dermatomyositis presented with intractable abdominal pain which was aggravated after steroid and NSAID therapies. A widespread retroperitoneal abscess was noted on abdominal computerized tomography. An emergency operation showed an ulcer and perforation at the junction of the third and fourth portions of the duodenum. Debridement of the necrotic tissue and repair of the perforation were performed. The postoperative course was complicated by an anastomotic leak, which was corrected by reanastomosis. In addition to intestinal vasculitis, duodenal vasculitis complicated with ulcers and perforation should be included in the differential diagnosis of a child with juvenile dermatomyositis presenting with abdominal complaints.