[Our two-year experience with the bevacizumab (Avastin) treatment of the age related macular degeneration wet form]. / Nase dvouleté zkusenosti s lécbou vlhké formy vekem podmínené makulární degenerace bevacizumabem (Avastin).

AIM: To evaluate the results of the intravitreal Avastin injection treatment in patients with the wet form of the age related macular degeneration and to point out some problems of this treatment. MATERIAL AND METHODS: The study group consisted of 71 eyes of 71 patients; the follow up period was 6-24 months, on average, 18.5 months. The first subgroup consisted of 31 eyes treated in the first year, the second subgroup 40 eyes treated in the second year of the study. At the beginning of the treatment, the visual acuity in the first subgroup was 0.05-0.8, on average 0.26, in the second subgroup 0.1-0.6, on average 0.3. Most frequently, the occult form of the subretinal neovascular membrane was diagnosed (60.6%). RESULTS: There were applied 1-6 injections, on average, 3.52 injections. The frequency of applications was set according to the PRONTO study schedule for Lucentis application. The neuroepithelium thickness decreased by more than 100 microm in 35.2% of eyes, was stabilized in 46.5% of eyes, and increased by more than 100 microm in 11.3% of eyes. In the first subgroup, the visual acuity stabilized in 90.3% of eyes, in the second one in 95%, and in the whole group in 93% of eyes. Improvement by more than 15 letters of the ETDRS chart was recorded in the whole group in 8 eyes (11.3%) and, on the other hand, the worsening by more than 15 letters in 5 eyes (7%). We recorded no systemic complications; in no eye we had to treat the endophthalmitis, nor the retinal detachment. CONCLUSIONS: Several times lower price, safety, and positive results of intravitreal Avastin injection treatment support its use in the competition with other anti-VEGF substances.

[Cardiovascular rehabilitation today]. / Kardiovaskulární rehabilitace v soucasnosti.

The authors submit a clearly-arranged article summarizing the contemporary situation in cardiorehabilitation. They explain the term "cardiorehabilitation" as well as to whom it is assigned and who should put it in practise. It contains facts gathered from analysis of numerous randomized studies executed worldwide on thousands of patients. Benefits for various groups of patients are emphasized. The positive effect of cardiorehabilitation is proved by decrease of both morbidity and mortality, total as well as cardiovascular. The physical condition of patients, their weight, blood pressure, lipid profile, glycaemia and sensitivity to insuline, fibrinolytical activity are favourably influenced by cardiorehabilitation. It was observed that the ectopic activity of myocardium decreases, anginose attacks are reduced and that the consumption of oxygen after excercise rises. Among the other benefits may be counted lower occurrence of tumorous diseases, improved quality of life and minimalisation of depressions. There is given evidence that the risks of cardiorehabilitation are often overvalued. Positive effect of this treatment is proven, as well as the effect of the pharmacological or cathetrisation and surgical treatments.

[The treatment of the exsudative age-related macular degeneration with choroidal neovascular membrane, its possibilities and economical indexes]. / Moznosti a ekonomické ukazatele lécby exsudativní vekem podmínené makulární degenerace s choroidální neovaskulární membránou.

AIM: To establish the probable prevalence and incidence of the exsudative (wet) age-related macular degeneration (AMD) in the Czech Republic and to compare possibilities and the expensiveness of the photodynamic therapy (PDT) and the treatment with substances blocking the vascular endothelial growth factor (anti-VEGF). METHODS: The calculation of the probable prevalence and incidence of the exsudative AMD in the Czech Republic (CR) was based on the world epidemiological studies. The expenses of the PDT and the anti-VEGF treatment for the patient and for the health insurances were based on the calculation of the Visudyne and anti-VEGF substances' prices in CR and worldwide. RESULTS: If the European prevalence of the exsudative AMD in patients over 65 years of age is 2.3% and the prevalence of the risk soft drusen is 15 %, so in the CR out of 1.44 millions of inhabitants older than 65 years have approximately 33 000 the AMD, and the drusen at risk 216.000 inhabitants. If the 5-years incidence of the exsudative AMD in patients with drusen at risk is 3.4%, it may be expected the turn of the soft drusen into the exsudative AMD during the 5-years period in 7340 patients, or 1460 patients a year. The PDT is indicated in approx. 20% of exsudative AMD with the classical or predominantly classical choroid neovascularization (CNV), i.e. approx. 300 patients a year. If, at the average, 5.6 PDT sessions during 2 years are needed and the price is 42.500 CZK (Czech Crowns; 1 USD = approx. 20-22 CZK; 1 Euro = approx. 27-29 CZK) for one injection of Visudyne, so the average cost per patient is 238,000 CZK and the costs for all of them 71.4 millions of CZK. If the patient's participation is 7395 CZK per one dose of Visudyne, then the average patient's expense for the PDT during the 2 years period is 41 412 CZK. Anti-VEFG drugs as intravitreal injections are effective in all forms of exsudative AMD. Macugen (pegaptanib), already registered in the CR, should be applied in six-weeks intervals, during the two-years treatment period altogether up to 17 injections. At the price of 1000 USD for one application, the average treatment cost is 17,000 USD (= approx. 350, 000 CZK). If the one-year incidence of exsudative AMD is 1460 patients,their treatment with Macugen would cost 511 mil. CZK, and the treatment of 1140 patients with occult CNV not suitable for PDT would cost 410 mil. CZK. Lucentis (ranibizumab), which is about to be registered in the CR, is applied in one-months intervals, during two years altogether up to 20 injections. At the price 1200 USD a dose, the treatment costs for one patient would be 24,000 USD (approx. 500 000 CZK), treatment of all patients with exsudative AMD 730 mil. CZK, and costs for patients not suitable-for PDT treatment would be 585 mil. CZK. The intravitreal application of Avastin (bevacizumab) is "off label"; in the first three months is applied monthly, and later on, in 1-3 months interval, until the disappearance of exsudative changes. The maximum of applications is 10 injections during 2 years. At the price 3000 CZK for 1 injection, the treatment costs for one patient would be 30,000 CZK; treatment costs for all patients would be 43.8 mil. CZK, and for patients not suitable for PDT would be 34.8 mil. CZK. CONCLUSION: Nowadays, the PDT and anti-VEFG substances are the optimal treatment methods in exsudative AMD with CNV. PDT i s indicated in theclassical or predominantly classical choroid neovascularization (CNV), anti-VEFG drugs are effective in all forms of exsudative AMD. The high prices of Visudyne, Macugen, and Lucentis create barriers to their general use in all patients with exsudative AMD. Ten times lower price of "off label" applied Avastin supports its use in the competition with other anti-VEGF drugs. The combination of PDT with anti-VEGF drugs suggests the possible way, how to, not only, improve the effectiveness, but also to lower the number of applications, and by this means, also to reduce the economical expenses of the treatment dramatically.

[Possibilities and limitations of the surgery of the eye's posterior segment under the outpatient conditions]. / Moznosti a meze chirurgie zadního segmentu oka v ambulantních podmínkách.

The goal of this article was to analyze possibilities of the vitreoretinal surgery under the outpatient conditions and to set its limitations. During the period January 1st-September 30th, 2004, there were performed 95 operations of 78 eyes in 77 patients. Number of men and women was practically equal; the age ranged 17-86 years (average 62.6 years). We operated on mostly the retinal detachment. These as well as other procedures, including also the extreme surgery with relaxing retinectomy, extraction of the subretinal tractions and membranes, silicone oil implantation or extraction, or operations combined with the cataract surgery and intraocular lens implantation. Surgeries were performed under local anesthesia combined with analgesia and sedation introduced by anesthesiologist, who was always present and monitored the patient. Surgeries were performed by means of A.V.I. lens and Biom as well, with the assistance of a doctor, and later on, solely of a theatre nurse. The surgeon performed the operations by herself and long-term followed up the patients. The variety of vitreoretinal procedures did not differ from those performed at the departments of ophthalmology at university hospitals. The retinal detachment surgery was more often performed by means of cryosurgical procedure than pars plana vitrectomy undoubtedly because of early recognition of the beginning detachment. All vitreoretinal procedures may be performed on the outpatient basis. The only limiting factors are the physical condition of the patient and an acute ocular disease demanding urgent surgery in a facility with permanent service. Vitreoretinal surgery in outpatient facility performed under local anesthesia is well tolerated by the patients and the postoperative care under outpatient conditions is of equal quality as in inpatient facilities.

[Transpupillary thermotherapy in exsudative age-related macular degeneration. Two-years results and findings on the other eye]. / Transpupilární termoterapie u exsudativní vekem podmínené makulární degenerace. Výsledky po 2 letech a nálezy na druhém oku.

UNLABELLED: The purpose of the prospective randomized study was to analyze long-term results of transpupillary thermotherapy (TTT) in exsudative age-related macular degeneration (ARMD) after 24 months of follow-up and to compare them with findings on the other, not treated eye. MATERIAL AND METHODS: Seventy-two patients aged 50-93 years (average age 70.6 years) with one eye treated by means of TTT and the other considered as control were in the study. Occult choroidal neovascularization (CNV) was treated in 33 eyes (45.8%), serous ablation of the pigment epithelium (SAPE) in 21 eyes (29.2%), and classical CNV in 18 eyes (25.0%). In all patients, the central visual acuity (VA) on EDTRS chart was specified, the macular findings were observed by means of indirect binocular ophthalmoscope and bio-microscopically with the contact lens on the slit lamp, and fluorescence angiography and optical coherence tomography (OCT) examinations were performed before and 3, 6, 12, 18, and 24 months after the TTT treatment. RESULTS: The final VA improved or remained unchanged in 27 eyes (37.5%), and worsened in 45 eyes (62.5%), by 5 or more lines the VA worsened in 19 eyes (26.4%). The average VA decreased from initial 0.24 to final 0.13, but the decrease in different forms of ARMD varied. In SAPE the highest initial as well as final average VA was found, in occult and classical CNV the initial and final average VA was almost identical. Exsudative changes observed by means of biomicroscopical, fluoroangiographical, and OCT examinations totally disappeared in 59.7%, 63.9%, and 59.7% respectively. At the end of the follow-up period we observed chorioretinal atrophy of different stage in the macula in all eyes (100%) and subretinal fibrosis in 44 eyes (61.7%). Both these findings represented final stages of natural course of exsudative ARMD. On the contrary, differently pronounced areas of chorioretinal atrophy corresponding with applied laser burns represented scars after the coagulation. It developed in 31 eyes (43.0 %) and pointed to the possible destructive consequence of the TTT. In 33 patients (45.8%), late stages of exsudative ARMD, mostly disciform scars with chorioretinal atrophy were found on the other not treated eye. In these eyes the final average VA was 0.05, e.g. more than one half worse than final average VA in treated eyes. CONCLUSIONS: Results of TTT treatment after 24 month of follow-up demonstrated full regression of exsudative changes in the macula in 60% of eyes and improved or stable VA in 37.5 % of eyes. Results in SAPE and classical CNV confirmed the efficacy of TTT treatment in those forms of ARMD. The TTT did not prevent the appearance and progress of the chorioretinal atrophy and subretinal fibrosis, causing the main obstacle of better functional results. Extremely unfavorable course of exsudative ARMD in the other (not treated) eye could indirectly confirm the positive influence of the TTT in theARMD treatment. Despite all positives are the possibilities of the TTT limited and determined by the basis and natural course of exsudative ARMD.

[Transpupillary thermotherapy in age-related serous detachment of retinal pigmented epithelium]. / Transpupilární termoterapie u vekem podmínené serózní ablace pigmentového epitelu sítnice.

UNLABELLED: The goal of this prospective study was to evaluate results of the transpupillary thermotherapy (TTT) in the age related macular degeneration (ARMD) where the serous detachment of the pigment epithelium (SDPE) was the dominant sign. MATERIAL AND METHODS: Thirty eyes of 29 patients were treated by TTT. All patients were examined before and 3, 6, 9, 12, 18, and 24 months after TTT in terms of visual acuity (VA), indirect binocular ophthalmoscopy, and indirect slitlamp biomicroscopy, fluorescein angiography, and optic coherent tomography (OCT) of the macular region. In 25 eyes (83,3%) signs of choroidal neovascularization (CNV) were present (vascular SDPE). TTT was performed with a standard technique by diode laser (wavelength 810 nm). In 14 eyes (46.7%) the TTT procedure was repeated after 3 to 38 weeks. The follow-up period was 7 to 28 month (mean 15.2 months). RESULTS: After TTT, VA improved in 6 eyes (20.0%), remained stable in 8 eyes (26.7%), and deteriorated in 16 eyes (53.3%). Indirect slitlamp biomicroscopy revealed, that the SDPE re-attached in 13 eyes (43.3%), decreased in size in 12 eyes (40.0%); fluorescein leakage disappeared in 16 eyes (53.3%) and was reduced in 10 eyes (33.3%). By OCT, the re-attachment of SDPE was confirmed in 14 eyes (46.7%) and it's reduction in 13 eyes (43.3%). The leading cause of the same or worse VA after diminishing of SDPE was chorioretinal atrophy, with or without subretinal fibrosis. CONCLUSION: In the long term, the TTT led to the decline of SDPE in the majority of eyes and improved or stabilized VA in nearly on half of eyes. In most cases, signs of neovascularization were present. After the SDPE regression, the chorioretinal atrophy prevented the better functional results. TTT is not economically expensive and widens treatment possibilities in exsudative form of ARMD including SDPE.

[Is it possible to sucessfully treat severe penetrating injuries?]. / Lze úspesne lécit tezké perforující poranení?

The number of serious devastating eye injuries caused by violent crimes or transport accidents is growing. The patients are mostly young men and the preserving of the eye, especially its function is often difficult. From June 2000 to March 2003, 4 eyes of 3 men (aged 16-23 years) with extraordinary serious devastating penetrating injuries were treated in the Department of Ophthalmology in Pilsen. One eye was enucleated because of serious laceration of the whole globe and eyelids at the initial treatment. In three eyes, a pars plana vitrectomy (PPV) with inner silicone tamponade was performed after the initial treatment of the penetrating and eventually exiting site. In all vitrectomized eyes a pars plana lensectomy (PPL) was performed, at the time of PPV in one eye, and in two eyes subsequently. When the eyes were stabilized, and the retina was attached, the silicone oil was removed in two eyes. The visual acuity before the surgery decreased to uncertain light projection, and in two eyes of one patient, we were not able to detect the visual acuity because of the unconsciousness of the patient. The follow-up period was 3 months to 2 years; all three eyes are aphakic, and the central visual acuity improved in two eyes to 6/6-9 (20/20-30 or 1.0-0.66) with the aphakic correction or with the contact lens, in one eye with the silicone eye remained the visual acuity is 6/60 (20/200 or 0.1). Even as the prognosis in such patients is unfavorable, in some cases good functional results may be obtained. The basic precondition for successful reconstruction of the seriously injured eye is meticulous primary treatment. For salvage of visual functions, there are often necessary repeated surgeries on the anterior as well as posterior segment of the eye. Their good timing and adequate technique may rapidly decrease the risk of complications after the injury and/or after the surgery respectively.

[Surgical treatment of retinal detachment with bilateral idiopathic retinal dialysis]. / Chirurgická lécba odchlípení sítnice s bilaterální idiopatickou retinální dialýzou.

The retrospective study was aimed at demonstrating anatomical and functional results of surgical treatment in patients with bilateral idiopathic retinal dialysis (BIRD). In the period of 1985-2001 the authors operated on BIRD in 10 eyes of five patients (three men and two women). No eye injury or inflammation was present in the case history of the patients. The age of the patients was between 11 and 30 years, the mean age was 19.2 years. The symptoms typical for retinal detachment were present in four eyes only and absent in the other six eyes. Hyperopia of both eyes in analogy with myopia of both eyes was observed in two patients, respectively, whereas emmetropia was present in one patient. The retinal dialysis (RD) occurred in lower temporal quadrant in all eyes (100%), in one eye (10%) it also occurred together with an discontinuous RD in upper temporal quadrant and in another eye it was extended into lower nasal quadrant. Demarcation lines were present in 5 eyes (50%), subretinal solid strands in 1 eye (10%). Scleral buckling procedures were performed as the primary surgical procedure in all 10 eyes of 5 patients. Eight eyes was operated on with the use of segmental circumferential sponge buckles of silicone and two eyes with the use of encircling elements of solid silicone. Retina was successfully reattached postoperatively in 9 eyes (90%) and remained detached in one eye (10%). The visual acuity preoperatively 6/12 or better remained unchanged postoperatively in 8 eyes (80%). The visual acuity postoperatively improved in 1 eye (10%) and in 1 eye (10%) visual acuity was decreased. The mean period of observation of the patients was 86 months. The necessity of a routine examination of the extreme retinal periphery of the fellow asymptomatic eye of the young adult with no history of trauma and with the retinal detachment associated with retinal dialysis in one eye is also discussed.

[Relation between levels of acute phase proteins and copper and the parameters of systolic and diastolic left ventricular function in patients with chronic heart failure]. / Vztah koncentrací proteinu akutní fáze a koncentrací medi k parametrum systolické a diastolické funkce levé komory u pacientu s chronickým srdecním selháním.

BACKGROUND: Acute phase protein concentrations and serum copper levels in patients in acute phase of myocardial infarction were significantly higher in subjects with heart failure compared to patients with non-complicated course of myocardial infarction. Acute phase protein concentrations correlated with the parameters of the left ventricular systolic function in patients in acute phase of myocardial infarction. The aim of the study was to evaluate the relation of acute phase protein concentrations and serum copper levels with the parameters of left ventricular systolic and diastolic function in patients with chronic heart failure out of the acute phase post myocardial infarction. METHODS AND RESULTS: Authors analysed relation between the acute phase proteins, C-reactive protein, fibrinogen, and copper concentrations and the left ventricular systolic and diastolic function assessed by echocardiography in 38 patients (26 men and 12 women, average age 68 years) with chronic heart failure and advanced left ventricular systolic dysfunction post myocardial infarction with ejection fraction lower or equal to 35%. Serum C-reactive protein concentrations correlated significantly with the left ventricular ejection fraction (r = -0.38, p < 0.05) and with isovolumic relaxation time IRVT (r = -0.51, p < 0.001)--inverse correlation. C-reactive protein concentration correlated with the ratio of the maximal flow velocity of the early transmitral diastolic filling (E vave) and with the maximal transmitral flow velocity during atrial contraction (A wave)--E/A ration (r = 0.43, p < 0.01). C-reactive protein concentration also correlated with the ration of the time velocity integrals of the E wave and the A wave--TVIE/TVIA (r = 0.45, p < 0.01)--positive correlation. Correlation between the fibrinogen and copper concentrations and the left ventricular ejection, or that with parameters of the diastolic left ventricular function were not statistically significant. CONCLUSIONS: Study revealed significant correlation between C-reactive protein concentration and parameters of the left ventricular systolic and diastolic function in patients with chronic heart failure post myocardial infarction. Correlation between copper and fibrinogen levels and parameters of the left ventricular function was not significant.

[Transpupillary thermotherapy in age-related macular degeneration. Preliminary results]. / Transpupilární termoterapie u vekem podmínené makulární degenerace. Predbezné výsledky.

OBJECTIVE: To evaluate anatomical and functional results of transpupillary thermotherapy (TTT) in age-related macular degeneration (ARMD) with a chorioid neovascular membrane (CNVM). MATERIAL AND METHODS: TTT was performed by means of a diode laser (Iris Medical Oculight Six) in 38 eyes of 35 patients aged 46-93 years, mean 70.6 years. Ocult CNVM was treated in 34 eyes, classical CNVM in 4 eyes. In TTT we applied 1 to 5 points (on average 1.9 spot) and used a laser beam with a diameter of 0.5-3 mm (mean width 1.61 mm). In 10 eyes with occult CNVM (29%) TTT was repeated after 1-6 months. The patients were followed up after TTT for 6-18 months on average for 9.5 months. RESULTS: The final visual acuity (VA) improved after TTT in two eyes (5.3%), remained unchanged in 22 eyes (57.9%) and deteriorated in 14 eyes (36.8%). The mean VA after TTT declined from 0.23 to 0.17. Biomicroscopic manifestations of exudation disappeared or receded in 29 eyes with occult CNVM (85.3%) and in 3 eyes with classical CNVM (75%). Fluoroangiographic examination revealed a reduced or absent extravasation of the dye in 24 eyes with occult CNVM (70.5%) and in 3 eyes with classical CNVM (75%). Optic coherent tomography confirmed regression of exudative changes and the development of a chorioretinal scar in 23 eyes with occult CNVM (67.6%) and 3 eyes with classical CNVM (75%). CONCLUSION: TTT is a new potential therapy of ACMD with CNVM. It is indicated in particular in occult CNVM. It can be however used also in classical CNVM. TTT is not economically pretentious and can be used also in other than large clinical departments. It is important to test the possibilities and limitations of TTT on a large number of patients and assess its position among other therapeutic procedures.

[Best's vitelliform dystrophy with complications of a neovascular membrane and hemorrhage]. / Bestova viteliformní dystrofie komplikovaná neovaskulární membránou a krvácením.

UNLABELLED: The objective of the paper is to draw attention to an uncommon picture of Best s vitelliform dystrophy of the macula (BVD) complicated by a choroidal neovascular membrane (CNVM) and haemorrhage. In an 8-year-old boy where incidentally at the age of 5 years cystic changes in both maculars were found and a reduced central visual acuity (CVA) of the left eye, the CVA of the so far asymptomatic right eye suddenly deteriorated. In the right macula a vitelliform focus was present the lower half of which was formed by a vascularized scar with subretinal haemorrhage on the margin. In the left macula was a round chorioretinal scar with hyperplasia of the pigmented epithelium (RPE) and remnants of macular yellow. Fluoroangiographic examination (FAG) visualized classical CNVM, optical coherence tomography (OCT) ablation of the RPE. The electrooculogram (EOG) was bilaterally reduced, CVA of the right eye was 6/60, of the left eye 6/36. Examination of the mother revealed though the ophthalmological finding was normal, a significantly reduced EOG and in an older brother there was a small vitelliform focus in both maculae and reduced EOG with CVA of 6/6. CONCLUSION: CNVM with haemorrhage is a rare complication of BVD. This complication markedly extends the polymorphism of findings, is a risk of the CVA and makes the diagnosis more difficult. EOG examination is decisive for the diagnosis of less common forms of BVD.

[Eye injury from a paintball projectile]. / Poranení oka paintballovým projektilem.

A fourteen-year-old adolescent suffered after a direct hit with a plastic projective (paintball) a severe injury of the anterior and posterior segment of the eye manifested by intraocular haemorrhage, cyclodialysis, detachment of the retina with two giant tears and oedema and haemorrhages of the retina. After cerclage, pars plana vitrectomy and transient four-month tamponade with silicone oil the retina reattached. Late complications, cataract, broad anterior adherence with scars of the chamber angle and ciliary body, a lamellar defect of the macula and partial atrophy of the optic disc determined the subsequent development and were an indication for cataract surgery, implantation of an artificial lens into the lenticular capsule and reconstruction of the pupil. The final result was from the cosmetic and functional aspect (visual acuity 0.3) very satisfactory. Plastic projectiles (paintballs) are a new cause of severe eye injuries. At risk are in particular participants of games who do not protect their eyes with spectacles or masks. To save the function of the eye in unnecessary injuries frequently several operations are needed and close collaboration of surgeons for the anterior and posterior segment.

[Optical coherence tomography in age-related macular degeneration]. / Optická koherentní tomografie u vekem podmínené makulární degenerace.

INTRODUCTION: Optic coherent tomography (OCT) is a new non-contact and non-invasive diagnostic method which visualizes biological tissues in their transverse section, similarly as ultrasound examination. It uses however infrared radiation and during examination of the posterior pole of the eye it has a greater differentiating capacity. THE OBJECTIVE: Of the paper is to compare biomicroscopic OCT and angiographic findings in different forms and developmental stages of age-related macular degeneration (ARMD), to evaluate the asset of OCT for classification and therapy of ARMD. PATIENTS AND METHODS: The authors examined 183 patients (266 eyes) with ARMD in different developmental stages. The clinical diagnosis of ARMD was established by biomicroscopic and/or angiographic examination with fluorescein. RESULTS: In the majority of patients the different manifestations of ARMD were associated, and the OCT findings were polymorphous. OCT defined more accurately the site and character of changes in the retina and adjacent structures, made it possible to assess objectively the thickness of the retina and surrounding structures and to detect the presence of fluid and/or newly formed intra- and subretinal tissue and tissue benewath the RPE. The CNVM classification, introduced by fluorescent angiography differentiating classical and occult forms did not have an accurate correlate in the OCT image in our group of patients. CONCLUSION: OCT is in the diagnosis and follow up of the development of ARMD a suitable supplement of commonly used methods. It provides information on spatial relations of pathologically altered tissues. Visualization of the retina on the section is particularly valuable when evaluating the results of laser or surgical treatment.

Value of first day angiography/angioplasty in evolving Non-ST segment elevation myocardial infarction: an open multicenter randomized trial. The VINO Study.

AIMS: Direct angioplasty is an effective treatment for ST-elevation myocardial infarction. The role of very early angioplasty in non-ST-elevation infarction is not known. Thus, a randomized study of first day angiography/angioplasty vs early conservative therapy of evolving myocardial infarction without persistent ST-elevation was conducted. METHODS: One hundred and thirty-one patients with confirmed acute myocardial infarction without ST-segment elevations were randomized within 24 h of last rest chest pain: 64 in the first day angiography/angioplasty group and 67 in the early conservative group (coronary angiography only after recurrent or stress induced myocardial ischaemia). RESULTS: All patients in the invasive group underwent coronary angiography on the day of admission (mean randomization-angiography time 6.2 h). First day angioplasty of the infarct related artery was performed in 47% of the patients and bypass surgery in 35%. In the conservative group, 55% underwent coronary angiography, 10% angioplasty and 30% bypass surgery within 6 months. The primary end-point (death/reinfarction) at 6 months occurred in 6.2% vs 22.3% (P<0.001). Six month mortality in the first day angiography/angioplasty group was 3.1% vs 13.4% in the conservative group (P<0.03). Non-fatal reinfarction occurred in 3.1% vs. 14.9% (P<0.02). CONCLUSIONS: First day coronary angiography followed by angioplasty whenever possible reduces mortality and reinfarction in evolving myocardial infarction without persistent ST-elevation, in comparison with an early conservative treatment strategy.

[In Time? Time interval between first symptoms to hospital admission of patients with acute coronary syndromes]. / VCAS? Casový interval od prvních symptomu do prijetí do nemocnice u nemocných s akutními koronárními syndromy.

OBJECTIVE: To assess the pre-hospital delay, i.e. the period which elapses between the onset of pain on the chest and admission to hospital in patients hospitalized on account of acute coronary syndrome. To analyze factors which influence this time interval and obtain thus data for a strategy leading to reduction of the pre-hospital delay. METHOD: Collection of data by means of a questionnaire focused on the time of onset of pain on the chest, time of contact with the health service, time of admission to hospital, type of transport of the patient to hospital, socioeconomic data, manifestations of ischaemic heart disease during the premorbid period and health care provided. Statistical evaluation by the non-paired Mann-Whitney test. RESULTS: Data were assembled from 126 patients admitted to hospital on account of acute coronary syndrome. The median of pre-hospital delay was 5 hours 40 mins., the median of the patient's hesitation 3 hours 44 mins., the median of the transport period was 59 mins. The pre-hospital delay is significantly reduced by transport by the rapid emergency service (p < 0.0001), dispensary care of a cardiologist (p < 0.02) and a previous hospitalization on account of acute myocardial infarction or unstable angina pectoris (p < 0.04). Pre-hospital delay is significantly prolonged in old age pensioners (p < 0.05). On the borderline of signficance is the reduction of pre-hospital delay in patients younger than 80 years (p < 0.06) and patients with higher than elementary education (p = 0.102). CONCLUSION: Prehospital delay in the investigated group is almost three times longer as compared with data from abroad. A most significant part in this delay is played by the long hesitation of patients and transport of the patient to the health institution by other means than the rapid emergency service. In order to provide effective treatment to a larger number of patients with acute coronary syndrome within the shortest time interval it is necessary to inform the population at large on the importance of sudden pain on the chest and the necessity of the quickest possible contact with the rapid emergency service on phone 155. Only then can we expect further improvements of the prognosis of these patients.

[Stickler's syndrome (dystrophia vitreoretinalis hereditaria). Results of surgery for retinal detachment]. / Stickleruv syndrom (dystrophia vitreoretinalis hereditaria). Výsledky operace odchlípení sítnice.

OBJECTIVE: Stickler's syndrome (SS) is an autosomal dominant hereditary disease of the collagenous connective tissue where impaired development of the vitreous body gel and peripheral retina and detachment of the retina are associated with general manifestations. The objective of the retrospective study was to evaluate the long-term results of surgery of retinal detachment in SS. PATIENTS: The group of patients comprised 7 patients, 6 men and 1 woman aged 4 to 45 years, average age 16.8 years. Autosomal dominant heredity was obvious in 6 members (85.7%) of two families. General manifestations of SS included abnormalities of the facial skeleton (6 patients), cleft palate (4 patients), impaired hearing (2 patients), marfanoid habitus (2 patients) and hyperextensibility of the joints (4 patients). In the eyes with SS was manifested by myopia from -1 to -9 D and a liquid vitreous body. Multiple foci of lattice degeneration supplemented the finding in 6 patients (85.7%). Detachment of the retina was a manifestation of SS in 12 of 14 eyes (85.7%). It was manifested in 5 of 7 patients concurrently or within 12 years in both eyes. The causes of retinal detachment were multiple equatorial and postequatorial tears due to lattice degeneration in 8 eyes (66.7%) or a giant tear in 4 eyes (33.3%). Advanced proliferative vitreoretinopathy (PVR) was associated with retinal detachment in 8 eyes (66.7%) and in 6 eyes (50%) it was not possible to assess the beginning of retinal detachment. RESULTS: In 3 of 5 patients with bilateral retinal detachment the adverse course of retinal detachment on the first eye was followed 8 to 12 years previously in another department: two retinal detachments with giant tears were evaluated as inoperable and one inveterated detachment with advanced PVR was operated unsuccessfully. Retinal detachment was operated in 9 eyes of 7 patients, in two patients both eyes were operated simultaneously. The patients were followed up after surgery for 11 months to 15 years, on average for 65 months. A cryosurgical approach was used in 6 retinal detachments (66.7%), accentuated cerclage with drainage of subretinal fluid in 5 and radial plombage in one eye. The retina attached in 5 of 6 eyes (83.3%) and the final visual acuity was 0.25-0.1, mean 0.66. Pars plana vitrectomy (PPV) and implantation of silicone oil (ISO) were the final surgical solution in 3 eyes of 3 patients (33.3%). In one eye with retinal detachment with a circumferential width of 320 degrees and advanced PVR PPV and ISO were the primary operation, in two eyes re-operation on account of a relapse of retinal detachment with advanced PVR after an unsuccessful cryosurgical operation. Anatomical and functional success was achieved in 2 of 3 eyes (66.7%), in one eye after removal of silicone oil from the eye. The final visual acuity of successfully operated eyes was 0.2 and 0.16. CONCLUSIONS: Retinal detachment in SS usually affects both eyes, the second eye may be affected after many years. The cause of retinal detachment are multiple tears or a giant tear. Early surgery of retinal detachment has as a rule a favourable effect, while late diagnosis of retinal detachment in children leads frequently to blindness. Dispensarization and regular ophthalmological check-ups of patients with SS are an essential prerequisite of successful prevention and treatment of retinal detachment.

[Cataract surgery in eyes treated with vitrectomy for idiopathic macular holes]. / Operace katarakty u vitrektomovaných ocí pro idiopatickou makulární díru.

The authors evaluated the final functional results in 30 eyes where on account of nuclear and cortical cataract an intraocular lens was implanted. The operation was preceded by pars plana vitrectomy (PPV) with internal gas tamponade on account of an idiopathic macular hole (IMD). The cataract the development of which was recorded in 57 eyes was the manifestation of a late postoperative complication from a total number of 84 phakic eyes (67.9%) which were operated on account of IMD between April 1996 and June 1999. After cataract surgery the corrected visual acuity improved in 23.3% eyes. The investigation confirmed improvement and stabilization of the final corrected visual acuity in 24 eyes (80%) and confirmed the importance of these surgical procedures.

[Removal of the juxtafoveal neovascular membrane in age-related macular degeneration]. / Odstranení juxtafoveální neovaskulární membrány u vekem podmínené makulární degenerace.

Surgical extraction of the submascular neovascular membrane (SNM) is one of the new indications for surgery of the macula. The functional results after surgical extraction of the SNM depend on the state of the submascular pigmented epithelium and neuroepithelium which is, last not least, conditioned by the etiology of SNM. The majority of SNM in age-related macular degenerations has a poor prognosis, These SNM are as a rule nourished from several vascular sources and markedly destroy the pigmented epithelium because they penetrate beneath and above it. The authors evaluate in the submitted paper the results of surgical removal of the SNM in two eyes of two patients with age-related macular degeneration. Despite the relatively favourable juxtafoveal localization of the membrane, a non-complicated course of the operation and postoperative course the functional result of the operation in the two eyes was not very satisfactory. Chorioretinal scars with extensive defects of the pigmented epithelium in the region of the macula were the cause of a decline of visual acuity to a level which however could be hardly preserved by a conservative procedure.

[Ultrastructural analysis of tissue removed during surgery of idiopathic macular holes]. / Ultrastrukturální analýza tkáne odstranené pri operacích idiopatických makulárních der.

AIM: To analyze the ultrastructural features of epimacular tissue removed during idiopathic macular hole (IMH) surgery and to compare them with those of idiopathic epimacular membranes. METHODS: Three consecutive patients with unilateral stage 3 IMH underwent pars plana vitrectomy with surgical removal of delicate gelatinous membranous epimacular tissue. One patient was previously treated with laser photocoagulation. The excised material was investigated by means of light and transmission electron microscopy. Results were compared with the findings of the excised material in two idiopathic epimacular membranes. RESULTS: The excised material included variable proportions of cellular and membranous material. Glial cells (Müller cells, fibrous astrocytes) and fibroblast-like cells dominated in the cellular component both in the specimens from IHM eyes and in the comparative material. Neural elements were revealed in two of three specimens from IMH eyes. Membraneous material was formed by fragments of internal limiting membrane. CONCLUSIONS: Dominance of the glial cells in the cellular component of epimacular formations may reflect the important role of these cells both in formation and in healing process of IMH. The presence of neural elements in the removed epimacular tissue suggests that, at least in some cases, IMH surgery with peeling of an epimacular membrane can be associated with some injury of the macula.