Retrobulbar blood flow in idiopathic dilated episcleral veins and glaucoma.

BACKGROUND: Dilated episcleral veins may occur in the presence of orbital tumors, carotid cavernous sinus fistula and other orbital obstructive lesions. HISTORY AND SIGNS: A 39-year-old man had a history of a red left eye for two years. The visual acuity was 20/20, episcleral and conjunctival veins were dilated, and both the intraocular (24 mmHg) and episcleral venous (18 mmHg) pressures were increased. The canal of Schlemm was filled with blood, and glaucomatous damage was pronounced in the optic nerve head and the visual field of the left eye. The retrobulbar blood flow in the left eye was normal in the ophthalmic and central retinal arteries, but markedly decreased in the central retinal vein. There were no signs of fistula or shunts. The right eye was without any pathology. MR and catheter angiography of the head and orbit were both normal. THERAPY AND OUTCOME: Following trabeculectomy, the intraocular and episcleral venous pressures dropped to 9 mmHg and 8 mmHg, respectively, at 6 months follow-up. The episcleral and conjunctival venous congestion regressed, and the blood flow in the central retinal vein increased. CONCLUSION: The reason for the observed clinical picture (Radius-Maumenee syndrome) and haemodynamic improvement after reduction of the intraocular pressure is not clear. We outline a hypothesis involving an increase of the vascular resistance in the vortex veins and the superior ophthalmic vein with a shift in local blood volume and vascular pressure due to high intraocular pressure.

Retrobulbar blood flow in patients with cataract.

OBJECTIVE: To investigate retrobulbar haemodynamics in patients with cataract. SUBJECTS AND METHODS: Colour Doppler imaging of the ophthalmic artery was carried out on the eye scheduled for surgery in 30 patients with cataract and in one randomly selected eye of 100 healthy controls. The peak systolic velocity, mean velocity, end diastolic velocity and resistivity index in the ophthalmic artery were computed and adjusted for the influence of age and mean arterial pressure. Cataract type was recorded and lens opacity was measured with an opacity lensmeter. Odds ratio (OR) for cataract was analysed in a logistic regression model, depending on the adjusted blood-flow parameters, age and smoking status. RESULTS: The mean (SD) age was 45.5 (17.7) and 67.6 (5.8) years in controls and patients with cataract, respectively (p<0.001). The female to male ratio was 54:46 and 13:17, respectively (p = 0.41). Significant predictors of cataract in a forward stepwise logistic regression analysis were age (OR = 1.194; 95% confidence interval (CI) = 1.103 to 1.292; p<0.001), smoking status (OR = 14.119; 95% CI = 2.753 to 72.398; p = 0.002) and mean blood-flow velocity in the ophthalmic artery (OR = 0.731; 95% CI = 0.607 to 0.881; p = 0.001). Adjusted mean velocity was significantly lower in patients with cataract, even when only age-matched (age >55 years) non-smokers (31 controls, 19 patients with cataract) were considered (p = 0.003). Lens opacity and the type of cataract had no influence on the present findings. CONCLUSION: High mean velocity in the ophthalmic artery may be associated with a reduced risk of cataract.

Peripheral vasospasm and nocturnal blood pressure dipping--two distinct risk factors for glaucomatous damage?

PURPOSE: To evaluate the relationship between peripheral vasospasm and circadian blood pressure rhythm in patients with primary open angle glaucoma (POAG). METHODS: Nail-fold capillaroscopy, combined with a cold provocation test, and 24-hour blood pressure monitoring was carried out in 130 patients with POAG (M:F 58:72; mean age 60 +/- 14 years), 99 with high-tension glaucoma (HTG) and 31 with normal-tension glaucoma (NTG). Peripheral blood flow parameters were compared for patients with a nocturnal fall in mean systemic blood pressure (MBP) of less than 10% (non-dippers), patients with a nighttime MBP fall of 10-20% (dippers), and patients with a nighttime MBP fall of more than 20% (over-dippers). RESULTS: Patients with POAG showed a significantly lower blood flow velocity both at baseline (p < 0.01) and after cold provocation (p < 0.02) and a significantly higher percentage of cold-induced blood-flow standstill (p < 0.0001) in the nail-fold capillaroscopy than normal controls. The numbers of non-dippers (50), dippers (66) and over-dippers (14) did not differ between the HTG and NTG group. There were no significant differences between non-dippers, dippers, and over-dippers in peripheral blood flow parameters. CONCLUSIONS: Our findings indicate that vasospasm and low blood pressure may be distinct risk factors for glaucomatous damage. It also appears that screening for vascular dysregulation and systemic hypotension should not be restricted to NTG patients alone.

Cold feet and prolonged sleep-onset latency in vasospastic syndrome.

People with vasospastic syndrome have cold hands and feet and abnormal vasoconstriction after local cold exposure. Normally there is a circadian rhythm of distal vasodilation, with onset in the early evening, which directly influences ability to fall asleep. We gave a sleep questionnaire to 32 patients with primary vasospastic syndrome and 31 healthy controls. People with vasospasticity had significantly prolonged sleep-onset latency both at onset of night-time sleep and after nocturnal disturbance. This prolonged latency could be associated with impaired capacity for distal vasodilation.

Interocular difference in progression of glaucoma correlates with interocular differences in retrobulbar circulation.

PURPOSE: To evaluate the correlation between interocular difference in progression of glaucomatous damage and interocular differences in retrobulbar blood flow. METHODS: On the basis of a retrospective analysis of visual fields, progressive damage was identified in 20 patients with primary open-angle glaucoma. As a parameter of interocular difference in progression of visual field damage, the angle (gamma) between the regression lines of the visual field index mean defect over time per eye was calculated for each subject. The relationship between the angle gamma and interocular differences in intraocular pressure and retrobulbar color Doppler imaging parameters was analyzed by a multiple linear regression analysis in a stepwise forward approach. RESULTS: With larger interocular differences in progression of glaucomatous damage, lower mean blood flow velocities in the ophthalmic artery (partial r = -.69; P <. 0016), higher resistivity indices in the central retinal artery (partial r =.48; P <.0456), and higher peak systolic velocities in the ophthalmic artery (partial r =.52; P <.0285) were noted in the eyes with more marked progression of damage (multiple r =.71; P <. 0099). Interocular differences in progression of visual field damage were not related to intraocular pressure or extent of visual field damage. CONCLUSION: Independent of the extent of the interocular difference in glaucomatous damage and intraocular pressure, interocular difference in progression of glaucomatous visual field damage correlates with interocular difference in retrobulbar hemodynamic parameters.

Retrobulbar and peripheral capillary blood flow in hypercholesterolemic subjects.

PURPOSE: To assess retrobulbar blood flow velocities and finger nailfold capillary blood flow velocities (two readily accessible vascular beds) in subjects with primary hypercholesterolemia before and during lipid-lowering therapy. METHODS: Retrobulbar blood flow velocities and finger nailfold capillary blood flow velocities were assessed in 15 hypercholesterolemic subjects and in 15 age-matched and sex-matched healthy control subjects. In addition, the change in blood flow velocities after a 3-month period of lipid-lowering therapy was evaluated. RESULTS: No alterations in retrobulbar blood flow velocities after lipid-lowering therapy could be observed in hypercholesterolemic patients. Nailfold capillary blood flow velocity was slower in hypercholesterolemic subjects than control subjects immediately after local cooling (P = .0052), but this vascular dysregulation did not improve after lipid-lowering therapy (P = .58). CONCLUSIONS: Blood flow alterations, potentially caused by perturbed vascular endothelial function, may occur in nailfold capillaries of hypercholesterolemic subjects. Such alterations were not seen in retrobulbar vessels, and blood flow measures did not change during lipid-lowering therapy.

Is vascular regulation in the central retinal artery altered in persons with vasospasm?

OBJECTIVE: To assess the relation between ocular perfusion pressure and blood flow velocity in the central retinal artery in patients with acral vasospasm. SUBJECTS AND METHODS: Eighteen otherwise healthy subjects with acral vascular dysregulation, as demonstrated by nail-fold capillaroscopy, and 18 age- and sex-matched healthy volunteers without vasospasm were recruited. After subjects had rested for 20 minutes in a supine position, intraocular pressure and blood flow velocity in the central retinal artery were determined by applanation tonometry and color Doppler imaging, respectively. The peak systolic velocity, end-diastolic velocity, and resistivity index were assessed. Correlations between the mean ocular perfusion pressure (2/3 x [2/3 x diastolic blood pressure + 1/3 x systolic blood pressure] - intraocular pressure) and blood flow velocities in the central retinal artery were determined by the Pearson linear correlation factor. The Student t test was used to evaluate differences between controls and subjects with vasospasm. RESULTS: The mean +/- SD ocular perfusion pressure was 42.0 +/- 7.4 mm Hg in the group with vasospasm and 47.1 +/- 6.5 mm Hg in the control group (P= .04). In the subjects with vasospasm, the peak systolic and end-diastolic velocities and the resistivity index of the central retinal artery correlated significantly with the mean ocular perfusion pressure (R = 0.49, P = .04 P = .01; and R = -0.67, P = .002, respectively). Such correlations were not found in the control group. CONCLUSIONS: An altered blood flow regulation is suggested in the ocular circulation of patients with acral vasospasm.

Fludrocortisone in the treatment of systemic hypotension in primary open-angle glaucoma patients.

BACKGROUND: Fludrocortisone is a potent mineralocorticoid, which has no known direct vasoactive properties, and is the first-line drug for treatment of orthostatic hypotension. The present study evaluated the systemic hemodynamic effects of fludrocortisone treatment in glaucoma patients. PATIENTS AND METHODS: A retrospective analysis of the charts of glaucoma patients of the University Eye-Clinic Basel was performed. Twenty-two patients with open-angle glaucoma under treatment with fludrocortisone were selected. The selected patients had one 24-h blood pressure recording immediately prior to treatment with fludrocortisone and one recording at least 2 months after starting the treatment. Parallel to blood pressure recordings, diurnal intraocular tension curve recordings and visual field testings were carried out. In addition, twelve patients also had nail-fold video-capillaroscopy. RESULTS: IOP and visual fields remained stable. The average values for all systemic blood-pressure readings showed an improvement in the follow-up compared to primary examination. Mean (+/- SD) night-to-day ratio ('nocturnal dips') of systolic, diastolic and mean arterial blood pressure decreased from 13.6 +/- 4.3%, 16.9 +/- 5.2% and 15.9 +/- 3.5%, respectively, to 9.9 +/- 5.9% (p = 0.01), 13.2 +/- 4.3% (p = 0.044) and 11.7 +/- 3.9% (p = 0.0004). Baseline capillary blood-flow velocity increased and capillary blood-flow standstill time after cold provocation decreased significantly under fludrocortisone therapy. CONCLUSION: Hemodynamic parameters show a tendency towards improvement in a magnitude which might be of clinical relevance.

Cold-induced acral vasospasm in migraine as assessed by nailfold video-microscopy: prevalence and response to migraine prophylaxis.

In order to learn the prevalence of cold-induced vasospasm in migraine patients, blood cell velocity measurements of finger nailfold capillaries were performed in 58 consecutive patients suffering from migraine with and without aura. In 5 (8.6%) patients capillaroscopy could not be performed because of reduced nailfold transparency; 21 of the remaining 53 patients (39.6%) showed blood flow stop due to vasospasm under cold provocation. There was no significant difference (P = 0.69) in the occurrence of vasospastic reaction between migraine with (12 of 32 patients = 37.5%) and without (9 of 21 patients = 42.9%) aura. The clinical and capillaroscopic course under migraine prophylaxis was observed in 18 vasospastic patients. After sixteen weeks 14 patients showed good clinical improvement of their migraine. The vasospastic reaction persisted in only 1 patient. This patient and 3 others with abolished vasospasm were still suffering from migraine. These findings suggest that observing blood cell velocity noninvasively in nailfold capillaries under cold provocation could be useful for objectively monitoring the response to prophylactic treatment in migraine patients or for testing new potentially antimigraine drugs.

Reaction of capillary blood cell velocity in nailfold capillaries to L-carnitine in patients with vasospastic disease.

By using nailfold videomicroscopy in conjunction with local cold exposure, the haemodynamic responses in capillary blood cell velocity were evaluated in 12 patients with vasospastic disease after receiving L-carnitine 3 g per day orally for 20 days. The results obtained showed that the cold-induced blood flow stop duration was significantly (P < 0.05) decreased and capillary blood cell velocity significantly (P < 0.05) increased after local cooling. Systolic blood pressure was significantly (P < 0.05) decreased after treatment with L-carnitine. Diastolic blood pressure, heart rate and skin temperature did not differ significantly before and after treatment. There were no significant differences in the meteorologic data such as atmospheric temperature, atmospheric pressure or atmospheric hygrometry between the two investigations. It is concluded that L-carnitine might be a useful agent in the treatment of digital vasospastic disease. In addition, in vivo videomicroscopy is one of the few non-invasive and clinically useful direct methods for evaluating the effect of a drug on the microcirculation.

Silent myocardial ischemia in glaucoma and cataract patients.

BACKGROUND: Glaucoma and cataract are multifactorial diseases. They have been described to be associated with cardiovascular risk factors. METHODS: Twenty-four-hour ECG monitoring was done in 22 normal-tension glaucoma patients, 27 open-angle glaucoma patients, 25 cataract patients, and 20 normal controls. The frequency of silent myocardial ischemia (SMI) as well as that of ventricular extrasystoles (VES) was evaluated. RESULTS: At least one episode of significant asymptomatic ST-T segment depression occurred in 45% of the normal-tension glaucomas, in 25.9% of open-angle glaucomas, in 12% of cataract patients, and in 5% of normal controls. The frequency of VES was not significantly different among the groups. CONCLUSIONS: Glaucoma, especially normal-tension glaucoma, is significantly associated with the occurrence of episodic asymptomatic myocardial ischemias. Cataract patients, however, had only a slightly, statistically not significantly increased frequency of both SMI and VES compared with normals.

[Development of instrumental and technical measurement aspects for clinical capillary microscopy]. / Die Entwicklung der apparativen und messtechnischen Aspekte für die klinische Kapillarmikroskopie.

Clinically oriented investigation in microcirculation was stimulated by the internist O. Müller. After the second World War new electronic methods were established and later converted into clinical techniques. Therefore it became possible to measure capillary blood cell velocity, dynamic capillary blood pressure and transcapillary diffusion of fluorescent tracers in human skin. For many years vital capillaroscopy has been successfully used to study the microcirculation of human skin capillaries. Capillary video-microscopy at the finger nailfold in connection with local cold exposure test are presented as a method with clinical applicability in vasopastic disease.

Tympanic versus rectal thermometry in pregnant women.

OBJECTIVE: To assess the accuracy of the tympanic membrane thermometer for use with pregnant women. DESIGN: Cross-sectional descriptive study. SETTING: A major medical center in the midwestern United States. PARTICIPANTS: Thirty-three hospitalized, afebrile pregnant women. MAIN OUTCOME MEASURES: Tympanic membrane thermometers and glass mercury thermometers were used to measure body temperature at the ear and rectum, respectively. The results were compared using two statistical methods: the Pearson correlation coefficient and a new technique suggested by Bland and Altman (1986). RESULTS: Auditory canal temperature measured by a tympanic membrane thermometer correlated with rectal temperature as measured by a glass mercury thermometer (r = 0.38, p = 0.01). Thus, the tympanic membrane thermometer is acceptable for monitoring the body temperature of pregnant women. However, the device's estimation of rectal temperature is not clinically reliable. CONCLUSIONS: Tympanic membrane thermometers, when applied with direct measures, are acceptable for use with pregnant women. It is not recommended that the rectal estimate mode be used with pregnant women.

Cold-induced vasospasm in patients with fibromyalgia and chronic low back pain in comparison to healthy subjects.

Using capillary videomicroscopy of the nail fold, the frequency of cold-induced vasospasm and capillary hemodynamic parameters were studied after application of cold in 50 patients with primary fibromyalgia, 50 patients with chronic low back pain, and 50 healthy controls. Cold-induced vasospasm was detected in 38% of the patients with fibromyalgia. In this group it was significantly more frequent than in the patients with chronic low back pain (20%, p < 0.05) and healthy subjects (8%, p < 0.001). In the fibromyalgia group, the magnitude of vasospasm as measured by the capillary blood flow deceleration after cold application correlated negatively with the pain intensity as measured by pain score (r = -0.3839, p < 0.01). No differences in clinical appearance were found between patients with and without cold-induced vasospasm in both the fibromyalgia and low back pain group.

[Pupil perimetry with the Octopus 1-2-3. Initial experiences]. / Pupillenperimetrie mit dem OCTOPUS 1-2-3. Erste Erfahrungen.

PURPOSE: Development of a clinically useful pupil perimetry on an OCTOPUS 1-2-3. MATERIALS AND METHODS: Various test parameters were investigated on a moderately modified OCTOPUS 1-2-3. We evaluated the pupillary responses of 122 eyes of 122 healthy volunteers qualitatively. RESULTS: Pleasing pupillary responses were obtained with the following parameters: 200 ms stimuli, Goldmann size 5 (1.5 degrees), background illumination 3 apostilb. Acoustic signals 0.5 seconds before stimulus presentation were helpful to minimize blinking artifacts. The pupillary reactions were fare stronger in central areas of the visual field than in mid-peripheral areas (i.e. 26 degrees). CONCLUSIONS: Pupil perimetry can be preformed on a moderately modified OCTOPUS 1-2-3. The results reveal considerable inter- and intra-individual variability. Equal pupillary responses at all eccentricities would improve subsequent mathematical evaluation.