Gas tamponade and cyclocryotherapy of a chronic cyclodialysis cleft.

AIMS: To describe a minimally invasive technique to treat a chronic large cyclodialysis cleft that had failed to respond to medical therapy. METHODS: A 51-year-old man with a history of blunt trauma developed a unilateral chronic ocular hypotony. He was treated with topical atropine 1% for 3 months. 12 months later, the patient was referred to our glaucoma service for evaluation and treatment of persistent hypotony. Ultrasound biomicroscopy (UBM) displayed a cyclodialysis cleft extending from the 6 to 12 o'clock positions. B-scan echography revealed a peripheral choroidal effusion. A single bubble of 20% sulfur hexafluoride was injected into the vitreous cavity and transconjunctival cyclocryotherapy was performed. RESULTS: After gas absorption, intraocular pressure increased to 12 mm Hg and became steady during the follow-up. B-scan echography showed the disappearance of choroidal effusion, and UBM displayed a complete closure of the cyclodialysis cleft from the 6 to 8:30 o'clock positions and from the 9:30 to 12 o'clock positions. A small cleft extending from the 8:30 to the 9:30 positions remained after the treatment, but the distance between the scleral spur and the ciliary boby decreased, and the cleft was limited at the back due to the scar formation. CONCLUSION: Gas tamponade with cyclocryotherapy represents a minimally invasive technique that is worth considering for patients with cyclodialysis clefts associated with a shallow anterior chamber and that had failed to respond to medical therapy. This technique should be useful in cases of cyclodialysis clefts that are not amenable to treatment with more conservative efforts.

Simultaneous bilateral retinal detachment following coronary artery bypass graft: case report.

PURPOSE: To present an unusual case of simultaneous bilateral retinal detachment (RD) following a coronary artery bypass graft in a patient with acute myocardial infarction (AMI). METHODS: A 78-year-old man was first seen for bilateral sudden visual loss after surgical treatment of AMI. The patient underwent ultrasound biomicroscopy (UBM) and ocular B-scan echographic examination. RESULTS: The ocular assessment showed a bilateral seclusion of the pupil with bombe of the iris, an anterior chamber without cells or flare, and hypotonia. The evaluation of the visual acuity revealed no light perception in the right eye (RE) and uncertain light perception in the left eye (LE). The UBM analysis of the anterior segment confirmed the presence of bilateral pupillary block due to the seclusion of the pupil and a peripheral serous choroidal detachment involving the RE. The echographic B-scan analysis of the posterior segment showed a bilateral closed funnel-shaped RD and confirmed the presence of the peripheral flat serous choroidal detachment in RE. CONCLUSIONS: The cause for simultaneous bilateral RD remained unclear. It may have been a consequence of a persistent choroidal detachment with multiple swelling and 'kissing' of retinal surface. The increased venous pressure caused by congestive heart failure due to AMI could have caused a bilateral uveal effusion. Alternatively, the absence of retinal tears, the presence of a closed funnel-shaped morphology, and seclusion of the pupils allowed us to suspect an exudative pathogenetic mechanism due to a previous unrecognized ocular inflammatory state.

The first large population based twin study of coeliac disease.

BACKGROUND AND AIMS: The genetic load in coeliac disease has hitherto been inferred from case series or anecdotally referred twin pairs. We have evaluated the genetic component in coeliac disease by estimating the concordance rate for the disease among twin pairs in a large population based study. METHODS: The Italian Twin Registry was matched with the membership lists of a patient support group. Forty seven twin pairs were recruited and screened for antiendomysial (EMA) and antihuman-tissue transglutaminase (anti-tTG) antibodies; zygosity was verified by DNA fingerprinting and twins were typed for HLA class II DRB1 and DQB1 molecules. RESULTS: Concordance rates for coeliac disease differ significantly between monozygotic (MZ) (0.86 probandwise and 0.75 pairwise) and dizygotic (DZ) (0.20 probandwise and 0.11 pairwise) twins. This is the highest concordance so far reported for a multifactorial disease. A logistic regression model, adjusted for age, sex, number of shared HLA haplotypes, and zygosity, showed that genotypes DQA1*0501/DQB1*0201 and DQA1*0301/DQB1*0302 (encoding for heterodimers DQ2 and DQ8, respectively) conferred to the non-index twin a risk of contracting the disease of 3.3 and 1.4, respectively. The risk of being concordant for coeliac disease estimated for the non-index twin of MZ pairs was 17 (95% confidence interval 2.1-134), independent of the DQ at risk genotype. CONCLUSION: This study provides substantial evidence for a very strong genetic component in coeliac disease, which is only partially due to the HLA region.

Effects of 2% ibopamine on pupil, refraction, anterior segment anatomy and intraocular pressure.

The aim of the study was to determine the effects of a dopaminergic drug, 2% ibopamine, on the pupil, intraocular pressure and other ocular and ultrasound biometric variables. Thirty healthy subjects and 15 patients with primary open-angle glaucoma, aged from 40 to 78 years (mean age: 59.2 +/- 11), were included in two prospective open controlled trials. In the first, the mydriatic effect of 2% ibopamine and its inhibition and reversibility were evaluated in 15 healthy subjects using the alpha1-adrenergic drug, 0.5% dapiprazole. In the second, refraction, visual acuity, pupil diameter, intraocular pressure and 5 A-scan ultrasound biometric variables were evaluated in 15 healthy subjects and in 15 glaucoma patients. As early as forty min after administration of 2% ibopamine, a marked mydriatic effect (7.3 vs 3.9 mm; P < 0.0001), which was completely inhibited or reversed by 0.5% dapiprazole, was detected. The drug induced no changes in refraction, visual acuity or A-scan ultrasound biometric variables in any of the subjects examined. In healthy subjects, the intraocular pressure values were not changed to a statistically significant extent (13.8 vs 14.8 mm Hg; P = 0.668), whereas a slight, though significant, hypertensive effect (24 vs 22.2 mm Hg; P = 0.002) was observed in the glaucoma patients. The study confirms the intense mydriatic effect of 2% ibopamine with no changes in refraction, visual acuity or A-scan ultrasound biometric variables. The drug has no effect on intraocular pressure in healthy subjects, but induces a significant hypertensive effect in patients with initial glaucoma. This characteristic could be used for early diagnosis of primary open-angle glaucoma.

Existence of a genetic risk factor on chromosome 5q in Italian coeliac disease families.

Coeliac disease (CD) is a malabsorptive disorder of the small intestine resulting from ingestion of gluten. The HLA risk factors involved in CD are well known but do not explain the whole genetic susceptibility. Several regions of potential linkage on chromosomes 3q, 5q, 10q, 11q, 15q and 19q have already been reported in the literature. These six regions were analyzed with the Maximum Lod Score method on a dense set of markers. A new sample of 89 Italian sibpairs was available for study. There was no evidence for linkage for any of the regions tested, except for chromosome 5q. For this region, our data, as well as a sample of 93 sibpairs from our first genome screen (Greco et al. 1998), are compatible with the presence of a risk factor for CD with a moderate effect.

An attempt of identifying MS-associated loci as a follow-up of a genomic linkage study in the Italian population.

Subsequent to a genomic linkage study on Sardinian and Continental Italian families, we considered the possibility that some of the tested microsatellite markers showed association to MS. Markers selected on the basis of the data obtained in the original set of 70 multiplex families were tested for MS association in an additional set of 154 simplex families. A limited set of markers were further tested on an additional set of 100 simplex families. The results indicate the presence of a putative MS gene in 19q13.13.

High-performance liquid chromatographic analysis of physiological amino acids in human brain tumors by pre-column derivatization with phenylisothiocyanate.

A reversed-phase high-performance liquid chromatographic technique for the determination of free amino acids in five biopsies of human brain tumors (two meningiomas, one glioblastoma and two oligodendrogliomas) is described. The frozen tissues were homogenized, deproteinized with perchloric acid and neutralized with potassium hydroxide. Aliquots of the supernatant containing the physiological amino acids are used for pre-column derivatization with phenylisothiocyanate. The derivatized PTC-amino acids (phenylthiocarbamyl derivatives) are stable for a five day period if stored as a powder at -20 degrees C in an inert atmosphere and they can be analyzed on a reversed-phase column (PicoTag) using a gradient of two eluents with absorption detection at a wavelength of 254 nm. Good resolution of several amino acids (>30) is achieved within ca. 60 min. For most amino acids this method is suitable for an accurate measurement over a wide range of physiological concentrations (50-400 pmol) starting from a very small amount of sample.

Effects of 0.2% brimonidine on ocular anterior structures.

The aim of the study was to evaluate the effect of an alpha2-adrenergic agonist, 0.2% brimonidine, on a number of echobiometry and ultrasound biomicroscopy ocular parameters. Ten healthy subjects ranging in age from 20 to 40 years (mean age 29+/-3.39) were recruited into this prospective open-label trial. After instillation of 0.2% brimonidine eye drops, the following parameters were assessed: refraction, visual acuity, pupil diameter, intraocular pressure, five A-scan echobiometric parameters and 15 ultrasound biomicroscopy parameters. As early as the first hour after administration of the drug, a marked ocular hypotensive effect was detected associated with a miotic effect, without any refractive or visual acuity alterations. The A-scan echobiometry parameters were unchanged, while, as far as the ultrasound biomicroscopy variables were concerned, we observed an increase in iris-lens contact distance and a reduction in iris root thickness with a resulting increase in posterior chamber depth and in iris-ciliary process distances. No changes were observed in either the anterior chamber or the anterior iris profile. Brimonidine 0.2% proved to be an ocular hypotensive agent which is also endowed with a mild miotic effect, without giving rise to refractive or visual acuity alterations. The drug does not alter the thickness and position of the lens and does not facilitate pupil block; it reduces the iris thickness with an increase in posterior chamber depth and in iris-ciliary process distance but with no changes in anterior chamber depth or chamber angle width.

Linkage analysis of multiple sclerosis with candidate region markers in Sardinian and Continental Italian families.

Previous genome screens in multiple sclerosis have shown some evidence of linkage in scattered chromosomal regions. Although in no case the evidence of each single study was compelling and although in general the linkage 'peaks' of the different studies did not coincide, some regions can be considered likely candidates for the presence of MS risk genes because of the clustering of MLS scores and homology with eae loci. We performed a linkage analysis of markers in these regions and of intragenic markers of some individual candidate genes (HLA-DRB1, CTLA-4, IL9, APOE, BCL2, TNFR2). For the first time, Southern European populations were targeted, namely Continental Italians and Sardinians. A total of 69 multiplex families were typed for 67 markers by a semi-automatic fluorescence-based assay. Results were analysed for linkage by two non-parametric tests: GENEHUNTER and SimIBD. In general, the linkage scores obtained were low, confirming the conclusion that no gene is playing a major role in the disease. However, some markers, in 2p11, 3q21.1, 7p15.2 and 22q13.1 stood out as promising since they showed higher scores with one or the other test. This stimulates further association analysis of a large number of simplex families from the same populations.

Identification by denaturing high-performance liquid chromatography of numerous polymorphisms in a candidate region for multiple sclerosis susceptibility.

Genetic association analysis of candidate regions where evidence of linkage has accumulated is becoming a key issue in the study of complex diseases. A high density of markers, at least one per centimorgan, is required to improve the chances of observing linkage disequilibrium with disease alleles. A recently available single nucleotide polymorphism (SNP) map designed to cover the whole genome provides an average density of one marker per 2 cM. In the present study we show that the number of markers can be approximately doubled in a selected region, thus reaching a density suitable for association studies, by applying a completely automated technique for polymorphism detection, denaturing high-performance liquid chromatography (DHPLC). A systematic search for SNPs was performed in the region 5ptel-q13, where weak but convergent evidence for linkage with multiple sclerosis has accumulated. Screening for polymorphisms was performed on 124 sequence tagged sites (STSs) in the 3'UTR ends of expressed sequence tags totaling about 30,000 bp. Thirty SNPs in 28 STSs were found with less than 10% overlap with the markers already detected in the same region. The data confirm the validity of the approach using DHPLC on expressed gene sequences tagged by a set of standard commercially available primers.

Linkage disequilibrium between intra-locus variants in the aminopeptidase n gene and test of their association with coeliac disease.

Coeliac disease (CD) is a multigenic and multifactorial enteropathy triggered by gluten-composing proteins. A possible involvement of the intestinal Aminopeptidase N (APN) was investigated by an association analysis. SSCP analysis detected four variants at position 281, 378, 956 and 2957 (referred to no. g178535, GenBank) that were studied in 193 Italian CD families. The haplotypic combinations were determined from family segregation and pairwise linkage disequilibria (D' = D/Dmax) between the polymorphic sites were calculated. Significant D' values ranged between 0.78 and 0.31. Association with CD was tested by TDT (Transmission Disequilibrium Test) utilizing as markers the nucleotide substitutions and their haplotypic combinations. No statistically significant transmission distortion to the probands or to their clinically silent sibs was observed. Our data exclude an involvement in CD of the tested markers and of further undetected variation in strong linkage disequilibrium (D' approximately equal to 1) with them. The power of the test was not adequate to detect an association with an unknown polymorphism which is not in complete linkage disequilibrium with those analysed.

Choroidal calcification in Bartter syndrome.

PURPOSE: Bartter syndrome is characterized by hyperplasia of the renal juxtaglomerular apparatus, hyperaldosteronism, and hypokalemic alkalosis. We report a case of Bartter syndrome associated with normal serum calcium levels and posterior choroidal calcification. METHODS: Case report. A 59-year-old man with bilateral cataract and Bartter syndrome underwent a complete ophthalmic examination, including standardized echography before and after cataract surgery. RESULTS: Before cataract surgery, echography identified small, hyperreflective, multifocal, bilateral choroidal lesions with posterior shadowing. After surgery, these lesions appeared as yellow-white, barely elevated plaques with smooth edges and were diagnosed as choroidal calcification. CONCLUSIONS: Choroidal calcification may occur in patients with Bartter syndrome. This condition should be added to the differential diagnosis of posterior segment calcification.

Ultrasound biomicroscopic and conventional ultrasonographic study of ocular dimensions in primary angle-closure glaucoma.

OBJECTIVE: To determine the biometric findings of ocular structures in primary angle-closure glaucoma (PACG). DESIGN: An observational case series with comparisons among three groups (patients with acute/intermittent PACG [A/I-PACG], patients with chronic PACG [C-PACG], and normal subjects [N]). PARTICIPANTS: A total of 54 white patients with PACG (13 male, 41 female) were studied: 10 with acute, 22 with intermittent, and 22 with chronic types of PACG. Forty-two normal white subjects (11 male, 31 female) were studied as control subjects. Only one eye was considered in each patient or subject. TESTING: Ultrasound biomicroscopy (UBM) and standardized A-scan ultrasonography (immersion technique) were performed in each patient during the same session or within 1 to 3 days. MAIN OUTCOME MEASURES: The following A-scan parameters were measured: anterior chamber depth (ACD), lens thickness (LT), axial length (AL), lens/axial length factor (LAF), and relative lens position (RLP). Ten UBM parameters were measured, the most important of which were anterior chamber angle, trabecular-ciliary process distance (TCPD), angle opening distance at 500 microm from the scleral spur (AOD 500), and scleral-ciliary process angle (SCPA). RESULTS: Compared to normal subjects, the patients with PACG presented a shorter AL (A/I-PACG = 22.31 +/- 0.83 mm, C-PACG = 22.27 +/- 0.94 mm, N = 23.38 +/- 1.23 mm), a shallower ACD (A/I-PACG = 2.41 +/- 0.25 mm, C-PACG = 2.77 +/- 0.31 mm, N = 3.33 +/- 0.31 mm), a thicker lens (A/I-PACG = 5.10 +/- 0.33 mm, C-PACG = 4.92 +/- 0.27 mm, N = 4.60 +/- 0.53 mm), and a more anteriorly located lens (RLP values, A/I-PACG = 2.22 +/- 0.12, C-PACG = 2.34 +/- 0.16, N = 2.41 +/- 0.15). The LAF values in A/I-PACG, C-PACG, and N were 2.28 +/- 012, 2.20 +/- 0.11, and 1.97 +/- 0.12, respectively. Anterior chamber angle (A/I-PACG = 11.72 +/- 8.84, C-PACG = 19.87 +/- 9.83, N = 31.29 +/- 9.18 degrees) and SCPA (A/I-PACG = 28.71 +/- 4.02, C-PACG = 30.87 +/- 6.04, N = 53.13 +/- 9.58 degrees) were narrower, TCPD (A/I-PACG = 0.61 +/- 0.12 mm, C-PACG = 0.71 +/- 0.14 mm, N = 1.08 +/- 0.22 mm) and AOD 500 shorter (A/I-PACG = 0.13 +/- 0.09 mm, C-PACG = 0.21 +/- 0.10 mm, N = 0.36 +/- 0.11 mm) in patients with PACG. All the biometric differences proved statistically significant using the one-way analysis-of-variance test. CONCLUSIONS: In patients with PACG, the anterior segment is more crowded because of the presence of a thicker, more anteriorly located lens. The UBM confirms this crowding of the anterior segment, showing the forward rotation of the ciliary processes. A gradual progressive shift in anatomic characteristics is discernible on passing from normal to chronic PACG and then to acute/intermittent PACG eyes.

The natural history of an HLA haplotype and its recombinants.

The presence of haplotype-specific recombination sites can be determined by analyzing the conservation of extended haplotypes in the population. This approach considers all meioses in the history of the population and requires the presence of characteristic markers that easily allow the identification of the haplotype or of its recombined segments. The recombination breakpoint can then be mapped by looking for shared alleles between haplotypes selected through the specific marker/s. We identified a rare perfect tandem duplication of a 145 base pair segment in the LTA promoter, which tags a B60 (B60D) haplotype. The duplication was detected in 16/90 B60+ Europeans, while absent in 101 B60+ Orientals. The conservation of the class I end and the extreme variability of the class II end suggested that the present-day B60D haplotypes originated from an ancestral haplotype by recombination events centromeric to the duplicated sequence. Through a fine mapping using markers of the HLA central region a preferential recombination site was localized in the 60 kilobase interval between TNFd,e, and D6S273/K11 Amicrosatellite loci (i.e., between LST1 and BAT3 genes). This site behaves as a potent recombination enhancer leading to fragmentation in most of the extant B60D haplotypes and can be considered responsible for their "instability". In the relatively recently founded Finnish population, where the LST1/BAT3 interval recombination has probably not yet had the chance to occur, a founder effect can explain the presence of a rare DP (DPB1(*)1601) allele in most B60D haplotypes in this population.

Genome search in celiac disease.

Celiac disease (CD), a malabsorption disorder of the small intestine, results from ingestion of gluten. The HLA risk factors involved in CD are well known but do not explain the entire genetic susceptibility. To determine the localization of other genetic risk factors, a systematic screening of the genome has been undertaken. The typing information of 281 markers on 110 affected sib pairs and their parents was used to test linkage. Systematic linkage analysis was first performed on 39 pairs in which both sibs had a symptomatic form of CD. Replication of the regions of interest was then carried out on 71 pairs in which one sib had a symptomatic form and the other a silent form of CD. In addition to the HLA loci, our study suggests that a risk factor in 5qter is involved in both forms of CD (symptomatic and silent). Furthermore, a factor on 11qter possibly differentiates the two forms. In contrast, none of the regions recently published was confirmed by the present screening.