Novel mutations in the myocilin gene in Japanese glaucoma patients.

Myocilin is a gene responsible for juvenile onset primary open angle glaucoma (POAG) mapped as the GLC1A locus and, many mutations have been reported worldwide. Some mutations were found not only in patients with juvenile onset POAG, but also in patients with late onset POAG and in patients with normal tension glaucoma. To investigate the mutation prevalence in Japan, we performed a mutation analysis in 140 unrelated Japanese patients. We have identified the 10 sequence variants, of which four were highly probable for disease-causing mutations (Arg46ter, Arg158Gln, Ile360Asn, and Ala363Thr), and six polymorphisms (Gln19His, Arg76Lys, Asp208Glu, Val439Val, Arg470His, and Ala488Ala). Thus, myocilin mutations were found at the rate of 4/140 (2.9%) probands, similar to previous reports with other ethnic populations.

Identification of a nervous tissue-specific chondroitin sulfate proteoglycan, neurocan, in developing rat retina.

PURPOSE: To identify the expression of neurocan, a nervous tissue-specific chondroitin sulfate proteoglycan, in retina and to elucidate its changes during development. METHODS: Expressional changes of neurocan mRNAs in developing rat retinas were investigated by a semiquantitative reverse transcription-polymerase chain reaction (RT-PCR). The localization and characterization of neurocan core proteins were also investigated with the use of Western blot analysis and immunohistochemistry. RESULTS: Gene expression of neurocan was identified in retinas by RT-PCR. Semiquantitative analysis using Southern blot analysis revealed that mRNA expression for neurocan increased at increasing postnatal stages and that it reached its peak around postnatal day 7 (P7). Immunohistochemical studies demonstrated that in differentiating rat retinal (neuroblast) cells weak neurocan immunoreactivities were observed throughout the retina on embryonal days 14 (E14) and E16. During the early postnatal period, the immunoreactivities became most conspicuous in the inner and outer plexiform layers on P7 through P14. In adult retinas, only faint immunostaining was detected. Immunoblot analysis showed two positive bands of 220- and 150-kDa core glycoproteins after treatment with chondroitinase ABC. Further immunoblot analysis revealed that the expression of these two immunolabeled variants was regulated differently during retinal development. CONCLUSIONS: The temporal and spatial regulation of expression of neurocan and its proteolytic variant during retinal development suggest that it may play a role in differentiation and neural network formation.

Expression of ciliary neurotrophic factor activated by retinal Müller cells in eyes with NMDA- and kainic acid-induced neuronal death.

PURPOSE: To elucidate the role of retinal Muller cells in N-methyl-D-aspartate (NMDA)- or kainic acid (KA)induced retinal damage. METHODS: In experimental eyes, NMDA or KA was injected into the vitreous of rat eyes. Immunohistochemistry and western blot analysis were conducted to elucidate expression and localization of glial fibrillary acidic protein (GFAP) and ciliary neurotrophic factor (CNTF). In addition, the neuroprotective effects of CNTF were calculated by counting cells in the ganglion cell layer (GCL) and by measuring the thickness of the various retinal layers. RESULTS: Morphometric analysis of retinal damage in NMDA- and KA-injected eyes showed significant cell loss in the GCL and thinning of the inner plexiform layer (IPL) of the retina, but not of other retinal layers. Immunohistochemistry demonstrated disappearance and/or decrease in immunoreactivities of calbindin- and calretinin- positive cells and their neurites and upregulated expression of both GFAP and CNTF in experimental eyes. Western blot analysis showed an increase in protein expression for CNTF in retinas of experimental eyes. Confocal images and sequential localization demonstrated colocalization of CNTF and GFAP in the inner retinal layer and possibly in Muller cells. In addition, pretreatment with CNTF (1 microg) before the intravitreal injection of NMDA (or KA) demonstrated that CNTF has neuroprotective effects against NMDA- or KA-induced neuronal death in the retina. CONCLUSIONS: These studies revealed the upregulated expression of CNTF and GFAP in Muller cells in response to NMDA- and KA-induced neuronal death, suggesting that production of CNTF in Muller cells may be a part of the endogenous neuroprotective system in the retina.

Expression of proteoglycan decorin in neural retina.

PURPOSE: To identify the expression of chondroitin/dermatan sulfate proteoglycan decorin in retina and to elucidate its changes during development and ischemia-reperfusion. METHODS: Expression of decorin in rat retina was investigated by reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry. Distributional changes during development and transient ischemia in model eyes also were investigated by immunohistochemical experiments. RESULTS: Gene expression of decorin core protein was identified in rat retina by RT-PCR. Decorin immunoreactivities were shown throughout the retina, especially in the ganglion cell layer. In developing rat retinas, at embryonic stages (embryonic day 16), decorin was distributed uniformly throughout the retina. As retina matured, the intensity of decorin immunostaining in retinal inner layers and retinal pigment epithelium increased. Furthermore, in experimental transient retinal ischemia, after transient downregulation of the decorin core protein gene between 24 and 48 hours after the ischemia, recovered (or increased) expression was shown by semiquantitative RT-PCR experiments. Immunohistochemical studies revealed strong decorin immunoreactivities in the damaged inner layers 1 week later. CONCLUSIONS: The expression of decorin was identified in adult and developing rat retina. The distributional changes of decorin during the retinal development suggest that this proteoglycan may play a role in the differentiation of retinal ganglion cells. Moreover, in rat ischemia-reperfusion models, the alterations in gene expression and immunohistochemical localization showed the contribution of this proteoglycan to the damage and repair processes in diseased retina.

Neuroglycan C, a neural tissue-specific transmembrane chondroitin sulfate proteoglycan, in retinal neural network formation.

PURPOSE: Neuroglycan C (NGC) is a transmembrane chondroitin sulfate proteoglycan present exclusively in central nervous system tissues. In the current study the expression pattern and characterization of NGC during the development of the retina were investigated. METHODS: Expressional changes of NGC mRNAs during rat retinal development were examined by semiquantitative reverse transcription-polymerase chain reaction (RT-PCR). The localization and characterization of NGC core proteins were investigated by immunoblot analysis and immunohistochemistry using an anti-NGC antibody. RESULTS: Immunohistochemical analysis revealed that NGC was highly expressed in the nerve fiber layer (NFL) and inner plexiform layer (IPL) in rat postnatal developing retina. At embryonal stages, NGC immunoreactivities were faint. In contrast, at postnatal developmental stages (approximately postnatal day [P]7), intense immunoreactivity was observed in the NFL and IPL, where active dendrite branching was observed, and conventional synapses began to be formed. As retinal layer differentiation proceeded (from P14 to P42), immunoreactivities in the inner retinal layers gradually became fainter. Immunoblot and semiquantitative RT-PCR analyses showed that the peak level of NGC expression occurred on approximately P7 and P14. Glycosylation of the NGC core protein changed as the retinal layers matured. In immunoelectron microscopic analysis, NGC immunoreactivity was located on the axonal membranes of neuronal cells in the postnatal retina, whereas immunoreactivity was reduced on membranes at the adult stage. In retinal ganglion cells in vitro, NGC was highly localized in their spiny budding neurites. CONCLUSIONS: The results show spatiotemporal expression patterns of NGC, and suggest that it plays a role in the formation of neural networks in retinal development.

Spatiotemporal expression patterns of 6B4 proteoglycan/phosphacan in the developing rat retina.

PURPOSE: To investigate expression of 6B4 proteoglycan/phosphacan, the major constituent of chondroitin sulfate proteoglycan and a possible modulator of neural network formation in the developing central nervous system, in developing rat retina. METHODS: Changes in expression and localization of 6B4 proteoglycan in developing rat retina were investigated by reverse transcription-initiated polymerase chain reaction (RT-PCR), immunohistochemistry, and immunoblot analysis. RESULTS: Semiquantitative RT-PCR revealed that mRNA expression of 6B4 proteoglycan in retinas peaked at postnatal day 14 (P14) and then decreased at P42. Immunohistochemical analyses using MAb 6B4, a monoclonal antibody against 6B4 proteoglycan, revealed faint immunoreactivity in the inner aspects of the retina at embryonal day 16 (E16). At birth, weak immunoreactivity was present in the nerve fiber layer (NFL) and inner plexiform layer (IPL). At P7 and P14, the NFL, IPL, and outer plexiform layer (OPL) stained intensely, but the ganglion cell layer (GCL) remained unstained. Between P21 and P42, immunoreactivity in the NFL and IPL weakened slightly. Immunoblot analyses showed a MAb 6B4 immunopositive band in the retinal soluble fraction treated with chondroitinase ABC. The amount of the immunopositive band increased rapidly as retinal development proceeded. Surprisingly, a significant amount of the immunopositive band was present in the retina even before digestion with chondroitinase ABC, indicating that at least part of 6B4 proteoglycan in rat retina exists in a non-proteoglycan form. CONCLUSIONS: The existence of 6B4 proteoglycan/phosphacan was thus demonstrated in rat retina, although some biochemical parameters were different from those of the 6B4 proteoglycan seen in brain.

Inhibitory effects of neurocan and phosphacan on neurite outgrowth from retinal ganglion cells in culture.

PURPOSE: Neurocan and phosphacan are nervous tissue-specific chondroitin sulfate proteoglycans (CSPGs) that are highly expressed in postnatal rat retina. To elucidate potential roles of neurocan and phosphacan on neurite outgrowth from retinal ganglion cells (RGCs), in vitro experiments were conducted with purified RGCs. METHODS: Neurocan and phosphacan were purified from postnatal rat brain by DEAE-column chromatography and subsequent gel chromatography. RGCs were obtained from postnatal rat retinas by a two-step immunopanning procedure using an anti-Thy 1,1 antibody and an anti-macrophage antibody. Neurite outgrowth from RGCs was examined on poly-L-lysine (PLL)-conditioned plates, and PLL-conditioned plates treated with neurocan or phosphacan. RESULTS: Compared with PLL-conditioned plates, neurocan and phosphacan inhibited neurite outgrowth from RGCs at 48 and 72 hours after seeding. When chondroitin sulfate side chains linked to the core proteins were digested by chondroitinase ABC, the inhibitory effect remained, indicating that the core proteins are related to the effect. Furthermore, the digestion of chondroitin sulfate side chains linked to phosphacan core protein significantly promoted the inhibitory effect of phosphacan on neurite outgrowth from RGCs. CONCLUSIONS: Neurocan and phosphacan, which are highly expressed in postnatal rat retina, inhibit neurite outgrowth from postnatal rat RGCs, indicating that these proteoglycans may be inhibitory factors against neurite outgrowth from RGCs during retinal development.

Upregulated expression of neurocan, a nervous tissue specific proteoglycan, in transient retinal ischemia.

PURPOSE: Neurocan, a nervous tissue-specific chondroitin sulfate proteoglycan synthesized primarily by neurons, is expressed abundantly in developing rat retina, whereas it is rarely expressed in adult rat retinas. This study investigated the reexpression of neurocan in a pathologic condition of adult rat retina. METHODS: Transient retinal ischemia was produced by occlusion of the retinal artery for 60 minutes. After transient retinal ischemia, neurocan expression was investigated by reverse transcription-initiated polymerase chain reaction (RT-PCR), immunohistochemistry, and immunoblot analysis. RESULTS: Semiquantitative analysis using RT-PCR revealed that mRNA expression for neurocan increased at 24 hours after reperfusion. Furthermore, on immunoblot analysis using an anti-neurocan antibody, MAb 1G2, the intensity of the 220-kDa band as well as the 150-kDa band increased markedly at 24 and 72 hours after reperfusion. The 220-kDa band was predominant at 24 hours after reperfusion, whereas the intensity of the 150-kDa band became almost the same as that of the 220-kDa band at 72 hours after reperfusion. Immunohistochemical analysis revealed that upregulated neurocan immunoreactivity was associated with glial Müller cells. CONCLUSIONS: Thus, upregulated expression of neurocan in transient retinal ischemia was demonstrated. Furthermore, the immunohistochemical analysis revealed that the upregulated expression of neurocan is derived from Müller cells, although it has been thought that neurocan is synthesized by neurons so far. The neurocan expression by Müller cells suggests that this proteoglycan plays a role in the damage and repair processes in diseased retina.

Effects of rho-associated protein kinase inhibitor Y-27632 on intraocular pressure and outflow facility.

PURPOSE: To elucidate the roles of Rho-associated protein kinase (ROCK) in regulating intraocular pressure (IOP) and outflow facility in the rabbit eye. METHODS: A specific ROCK inhibitor Y-27632 was used. The IOP, the outflow facility, and the pupil diameter were determined before and after the topical, intracameral, or intravitreal administration of Y-27632 in rabbits. Western blot analysis was used to identify specific ROCK isoform in human trabecular meshwork (TM) cells and bovine ciliary muscle (CM) tissues. The cell morphology and distribution of actin filaments and vinculin in TM cells were studied by cell biology techniques. Carbachol (Cch)-induced contraction of isolated bovine CM strips after administration of Y-27632 was measured in a perfusion chamber. RESULTS: In rabbit eyes, administration of Y-27632 resulted in a significant decrease in IOP in a dose-dependent manner. An increase of the outflow facility and pupil size dilation was also observed in Y-27632-treated eyes. Western blot analysis revealed the presence of p160ROCK in human TM cells and bovine CM tissues. In cultured human TM cells, exposure to Y-27632 caused retraction and rounding of cell bodies as well as disruption of actin bundles and impairment of focal adhesion formation. Y-27632 in addition inhibited Cch-induced contraction of isolated bovine CM strips. CONCLUSIONS: Administration of Y-27632 caused a reduction in IOP and an increase in the outflow facility. The in vitro experiments suggest that the IOP-lowering effects of Y-27632 may be related to the altered cellular behavior of TM cells and relaxation of CM contraction. These studies suggest that ROCK inhibitors may have great potential to be developed for treatment of glaucoma and other ocular diseases.

Novel cytochrome P4501B1 (CYP1B1) gene mutations in Japanese patients with primary congenital glaucoma.

PURPOSE: To investigate CYP1B1 gene mutations in Japanese patients with primary congenital glaucoma (PCG). METHODS: Sixty-five unrelated Japanese patients with PCG were screened by PCR-single-strand conformational polymorphism (SSCP) analysis followed by direct sequencing. No patients were offspring of consanguineous marriages, a common occurrence among patients in previous reports. PCG haplotypes were constructed with intragenic polymorphisms in affected individuals. Three-dimensional atomic structures of human CYP1B1 and four mutant CYP1B1 sequences representing missense mutations were assembled using homology modeling and were regularized by an energy-minimization procedure. RESULTS: Eleven novel mutations, including seven definite and four probable mutations, were detected in 13 (20%) of the 65 unrelated patients. Of the seven definite mutations, three were predicted to truncate the CYP1B1 open reading frame. The other four were missense mutations (Asp192Val, Ala330Phe, Val364Met, and Arg444Gln), all located in conserved core structures determining proper folding and heme-binding ability of cytochrome P450 molecules. Molecular modeling demonstrated that two of four mutations in positions 330 and 364 were structurally neutral, but Arg444Gln caused significant structural change. Of the four probable mutations, three were missense (Val198Ile, Val320Leu, and Glu499Gly); the other was a base substitution in the noncoding region of exon 1. CONCLUSIONS: The 11 varied CYP1B1 mutations found in 13 unrelated Japanese patients with sporadic occurrence of PCG represent an allelic heterogeneity and may be unique to a specific population.

Effects of protein kinase inhibitor, HA1077, on intraocular pressure and outflow facility in rabbit eyes.

OBJECTIVE: To elucidate the roles of protein kinase in regulating the intraocular pressure (IOP) and outflow facility in rabbit eyes. MATERIALS AND METHODS: A protein kinase inhibitor, 1-(5-isoquinolinesulfonyl)-homopiperazine (HA1077), was used. The IOP and the outflow facility were measured before and after topical, intracameral, or intravitreal administration of HA1077 in rabbits. Western blot analysis was performed to detect the 20-kd light chain of myosin in human trabecular meshwork (TM) cells and bovine ciliary muscle (CM) tissues. The cell morphologic condition and distribution of actin filaments and vinculin in TM cells were studied using cell biology techniques. Carbachol-induced contraction of isolated bovine CM strips following administration of HA1077 was examined in a perfusion chamber. RESULTS: In rabbit eyes, the administration of HA1077 resulted in a significant decrease in IOP in a dose-dependent manner. An increased outflow facility was also observed. Western blot analysis revealed the presence of 20-kd light chain of myosin in human TM cells and bovine CM tissues. In cultured human TM cells, exposure to HA1077 disrupted actin bundles and impaired focal adhesion formation. In addition HA1077 showed relaxation of bovine CM strips. CONCLUSIONS: Use of HA1077 caused a reduction in IOP and an increase in the outflow facility. The results of in vitro experiments suggest that the IOP-lowering effects of HA1077 may be related to the altered cellular behavior of TM cells and relaxation of CM contraction. The results of these studies suggested that protein kinase inhibitors have the potential to be developed into a treatment modality for glaucoma.

Neuroprotective effects of brain-derived neurotrophic factor in eyes with NMDA-induced neuronal death.

PURPOSE: To determine if brain-derived neurotrophic factor (BDNF) has a neuroprotective effect against N-methyl-D-aspartate (NMDA)-induced cell death in retina. METHODS: NMDA was injected into the vitreous of rat eyes. NMDA-induced neuronal death was measured by morphometric analyses on cell counts of ganglion cell layer cells and thickness of retinal layers. Also, we conducted additional experiment using retrograde labeling with a fluorescent tracer (Fluoro-Gold) for exact counting of retinal ganglion cells (RGCs). In addition, intravitreal glutamate levels were measured with the use of a high-performance liquid chromatography (HPLC) system. RESULTS: Morphometric analysis of retinal damage in NMDA-injected eyes showed that BDNF could protect inner retinal cells from glutamate receptor-mediated neuronal death. Also, counts of RGCs labeled with a fluorescent tracer showed that BDNF could protect RGCs from glutamate receptor-mediated neuronal death. Furthermore, measurements of intravitreal glutamate levels indicated an increase in this excitatory amino acid in the vitreous after NMDA injection. CONCLUSIONS: Exogenous BDNF can protect inner retinal cells (possible RGCs and amacrine cells) from NMDA-induced neuronal death. However, increased intravitreal glutamate levels in response to NMDA-mediated neurotoxicity may augment retinal degeneration.

Dual effects of interleukin-1beta on N-methyl-D-aspartate-induced retinal neuronal death in rat eyes.

In this study we determine if interleukin-1beta (IL-1beta) modulates N-methyl-D-aspartate (NMDA)-induced retinal damage. Sprague-Dawley rats were anesthetized with inhalation of halothane, after which a single injection of 5 microl of IL-1beta (0.1 to 10 ng/eye) (and/or IL-1 receptor antagonist (IL-1ra)) for experimental eyes was administered. Two days later (or simultaneously), NMDA (20 nmol) was injected into the vitreous space. One week later, each eye was enucleated and transverse sections were subjected to morphometric analysis. Enzyme-linked immunosorbent assay (ELISA) was conducted for the determination of IL-1beta levels in retina. Immunohistochemical and immunoblot studies were also performed. In eyes that received an intravitreal injection of IL-1beta (0.1 to 10 ng/eye), significant thinning of the inner plexiform layer (IPL) was observed (P<0.05). Immunohistochemical and ELISA studies demonstrated upregulated expression of IL-1beta in retinas that had undergone NMDA injection. Treatment with 10 ng of IL-1ra induced a protective effect against NMDA-induced retinal damage. Pretreatment with IL-1beta induced a significant protective effect on NMDA-induced retinal damage. Our studies suggest that IL-1beta induces neuronal cell death directly, as shown by the protective effects of IL-1ra, but has a protective effect on NMDA-induced retinal damage indirectly after an incubation time of at least 2 days.

Upregulated expression of N-syndecan, a transmembrane heparan sulfate proteoglycan, in differentiated neural stem cells.

Adult rat hippocampus-derived neural stem cells are incorporated into neural tissues, and differentiate to neuronal and glial cells. However, the cell surface protein molecules are, to date, undefined. RT-PCR, immunoblotting and immunocytochemistry showed the increased expression of N-syndecan, a transmembrane heparan sulfate proteoglycan, in the neural stem cells after the differentiation induced by retinoic acid. Our data indicate that N-syndecan may be involved in the differentiation of neural stem cells.

Mitomycin C trabeculectomy in eyes with cicatricial conjunctiva.

PURPOSE: To demonstrate favorable outcome of mitomycin C-augmented trabeculectomy in eyes with broad cicatricial conjunctiva created by previous surgeries. METHODS: Forty-six eyes (40 patients) with extensive conjunctival scarring that had undergone mitomycin C trabeculectomy were reviewed retrospectively. RESULTS: After a mean follow-up +/- SD of 13.7 +/- 7.8 months (range, 6 to 36 months), intraocular pressure was well controlled, below or equal to 16 mm Hg and 21 mm Hg, respectively, in 33 (72%) and 44 (96%) of the 46 eyes. In all eyes, a functional filtering bleb was present during the follow-up periods. CONCLUSION: Mitomycin C trabeculectomy after dissection of conjunctival scar tissue may be useful for treating refractory glaucoma.

Secondary glaucoma associated with crystalline lens subluxation.

PURPOSE: To elucidate the clinical characteristics of secondary glaucoma associated with subluxation of the crystalline lens. SETTING: Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, and Department of Ophthalmology, Tenri Hospital, Nara, Japan. METHODS: This retrospective study comprised 14 eyes of 13 patients with uncontrolled intraocular pressure (IOP) and lens subluxation. The subluxated lens was extracted through surgery. RESULTS: Angle closure caused by the subluxated lens was complicated in 3 eyes. In the remaining 11 eyes, uncontrolled IOP elevation was found despite the presence of deep anterior chambers and wide open angles. A mean of 14.1 months +/- 13.7 (SD) after cataract surgery, IOP was well controlled (lower than 21 mm Hg) in all 14 eyes. Mean IOP was 15.4 +/- 2.2 mm Hg at the final examination. Complications included transient vitreous hemorrhage in 5 eyes, choroidal detachment in 2 eyes, and retinal tears in 1 eye. CONCLUSION: Lens extraction surgery was effective in controlling IOP in eyes with secondary glaucoma associated with lens subluxation.

Phacoemulsification, intraocular lens implantation, and trabeculotomy to treat pseudoexfoliation syndrome.

PURPOSES: To determine the long-term risk/benefit ratio of phacoemulsification and intraocular lens (IOL) implantation combined with trabeculotomy to manage eyes with pseudoexfoliation syndrome and co-existing cataract. SETTING: Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine; Kurihara Eye Clinic; Departments of Ophthalmology, Tenri Hospital, Kumamoto University, and Matsue Red Hospital; Nagata Eye Clinic, Japan. METHODS: This multicenter retrospective study comprised 49 eyes of 36 patients with pseudoexfoliation syndrome and co-existing cataract who had the combined procedure for uncontrolled intraocular pressure (IOP) (> 21 mm Hg) even on antiglaucoma medication. RESULTS: After a mean follow-up of 20.0 months +/- 13.2 (SD), IOP in all 49 eyes was well controlled (< or = 21 mm Hg). Mean IOP at the final examination was 14.6 +/- 2.6 mm Hg on a mean of 0.9 +/- 0.8 glaucoma medications. Complications included an IOP spike in 11 eyes and fibrin exudation in 1 eye. CONCLUSION: Phacoemulsification and IOL implantation combined with trabeculotomy was an effective treatment for patients with pseudoexfoliation syndrome and cataract.

External trabeculotomy for the treatment of steroid-induced glaucoma.

PURPOSE: To investigate the effect of external trabeculotomy on eyes with steroid-induced glaucoma. METHODS: We retrospectively analyzed the surgical results of 14 eyes of seven patients that underwent trabeculotomy for the first surgical procedure. All patients had the history of receiving topical or systemic corticosteroids before the rise of intraocular pressure had been noted. RESULTS: After an average follow-up of 60.6 +/- 33.5 months, in all of the 14 eyes, intraocular pressure was well controlled below or equal to 21 mm Hg at the final examinations. CONCLUSIONS: Surgical results of external trabeculotomy remain effective for a long time. It has been shown that the trabeculotomy can be a useful and effective surgical treatment of patients with steroid-induced glaucoma.

Relationship between acetazolamide blood concentration and its side effects in glaucomatous patients.

Although acetazolamide, a carbonic anhydrase inhibitor, has an effect of lowering intraocular pressure, a number of side effects have been reported. Therefore, we investigated the relationship between the concentration of acetazolamide and its side effects, including plasma electrolyte imbalance. This study was conducted on 23 glaucomatous patients who received repeated doses of oral acetazolamide for one week or more. The concentrations of total and unbound plasma acetazolamide, as well as in the whole blood from the patients, were measured by high-performance liquid chromatography. The serum creatinine concentration, electrolyte concentrations, and adverse reactions were monitored. We found that plasma concentrations of chloride ion after repeated doses became higher than the normal range. This chloride ion concentration significantly correlated with the acetazolamide concentration in the erythrocytes, but not with the plasma concentration. The patients with erythrocyte acetazolamide concentration more than 20 microg/ml had higher incidences of the side effects. Periodical monitoring of erythrocyte acetazolamide concentration and plasma chloride ion can be easily and safely applied to elderly glaucomatous patients treated with acetazolamide for long periods to prevent overdosage and side effects.

Transient intraocular pressure elevation after trabeculotomy and its occurrence with phacoemulsification and intraocular lens implantation.

PURPOSE: To elucidate the characterization of intraocular pressure (IOP) spike after trabeculotomy, and after the combined procedure of phacoemulsification and aspiration (PEA) and intraocular lens (IOL) implantation. METHODS: Included in this study were 39 patients (53 eyes) with primary open-angle glaucoma with IOPs uncontrolled even with anti-glaucoma medication. We conducted a retrospective study for the following two groups: Patients who underwent trabeculotomy alone (25 eyes) and patients undergoing trabeculotomy combined with PEA and implantation of an IOL (28 eyes). RESULTS: In 7 (28%) of the 25 eyes after trabeculotomy alone and 7 (25%) of the 28 eyes after the combined procedure, transient IOP elevation was found postoperatively. The incidence of hyphema-related IOP spike was significantly higher in eyes after trabeculotomy alone (16%) than after the combined procedure (0%). After removal of the blood present in the anterior chamber in eyes with hyphema-related IOP spikes, the IOP levels were well controlled. CONCLUSIONS: Hyphema-related IOP spike is one of the common complications in eyes after trabeculotomy alone, and the combined procedure decreases the incidence of this complication. It is thought that removal of prolonged massive hyphema is effective as treatment for hyphema-related IOP spike.