Early deep anterior lamellar keratoplasty for fungal keratitis poorly responsive to medical treatment.

PurposeTo investigate the efficacy of early therapeutic deep anterior lamellar keratoplasty (DALK) in eradicating fungal keratitis that is poorly responsive to medical treatment.Patients and methodsTwenty-three eyes (23 patients) underwent early therapeutic DALK within 15 to 50 days from the onset of symptoms. The adopted eligibility criteria for early DALK included the following: active fungal keratitis affecting the optical zone with ulcer confined in the 6.00 mm central cornea; deeper than 150 µm but not exceeding 300 µm; and poorly responsive to medical treatment.ResultsThe big bubble technique was accomplished in 74% (17) of eyes, whereas manual dissection was performed in the remaining 26% (6) of eyes. Histopathological examination did not show any sign of fungal colonization in the peripheral and deep stromal lamellae in any case. All grafts were transparent postoperatively, and no recurrence of infection occurred. Median best spectacle corrected visual acuity significantly improved from 2.0 (1.0 interquartile range) logMAR to 0.1 (0.1 interquartile range) logMAR (P<0.01). The mean follow-up was 32±10 months. Neither episode of rejection nor graft failure was noted during the follow-up period.ConclusionEarly DALK could represent a safe therapeutic approach to eradicate fungal keratitis that affects the optical zone and is poorly responsive to medical treatment.

Mini-incision cataract surgery and toric lens implantation for the reduction of high myopic astigmatism in patients with pellucid marginal degeneration.

PURPOSE: To evaluate the clinical outcomes, safety, and efficacy of cataract surgery with the implantation of a toric intraocular lens (IOL) in eyes with stable pellucid marginal degeneration (PMD). METHODS: Eleven eyes (eight patients) diagnosed as stable PMD and cataract underwent mini-incision 2.2 mm cataract surgery followed by the implantation of hydrophobic toric aspheric IOL (AcrySof IQ Toric IOL, Alcon, Fort Worth, TX, USA). Perioperative variables of interest included uncorrected (UDVA) and corrected (CDVA) distance visual acuities, manifest refraction, and corneal topography. Paired samples t-tests were used to analyze preoperative and postoperative visual acuity, astigmatism, and spherical equivalent (SE) parameters. Follow-up was 6 months. RESULTS: The mean CDVA was 0.62±0.26 logMAR preoperatively and 0.07±0.07 logMAR postoperatively. The mean preoperative sphere and cylinder was -3.14±3.58D and -4.84±2.02D, respectively. The mean postoperative manifest refractive sphere and cylinder was -0.30±0.51D and -0.81±1.51D, respectively. There was a significant reduction in refractive astigmatism after toric IOL implantation (P<0.002). The toric IOL axis rotation was <5° in all cases at the final follow-up. CONCLUSIONS: Implantation of hydrophobic toric IOL was a safe and effective surgical procedure to correct mild to moderate stable PMD.

Spontaneous in-the-bag intraocular lens luxation into the vitreous cavity: last-stage complication of pseudoexfoliative syndrome after phacoemulsification.

PURPOSE: We describe 8 cases of late spontaneous in-the-bag intraocular lens (IOL) luxation into the vitreous cavity, which occurred at the Department of Ophthalmology and Neurosurgery of the University of Siena between January and December 2006. METHODS: In this interventional case series, the medical records of all patients with posterior luxation of in-the-bag IOLs - who had undergone a pars plana vitrectomy with IOL removal and scleral fixation IOL implantation between January and December 2007 at the Department of Ophthalmology and Neurosurgery of Siena, Italy - were retrospectively reviewed. RESULTS: The final post- operative visual acuity was 20/30 or better in 6 patients, while myopic macular degeneration and total retinal detachment limited visual acuity in the remaining 2 patients. CONCLUSION: The high prevalence of pseudoexfoliation (PEX) in the patients who had been operated for cataract phacoemulsification in our department could explain the occurrence of 8 posterior luxations of in-the-bag IOLs in only 1 year. Our study suggests that for the next years we will expect an increase in occurrence of spontaneous in-the- bag IOL luxations in the vitreous cavity. This condition could represent the last stage of PEX syndrome.

A randomized prospective study comparing trabeculectomy with and without the use of a new removable suture.

INTRODUCTION: The aim of this prospective study is to verify, in terms of both early postoperative complications and intraocular pressure (IOP) outcomes, the performance of a scleral flap removable suture. MATERIALS AND METHODS: Sixty-six patients that underwent trabeculectomy were randomly divided into two groups: in the first group (group A, 33 eyes) a standard fornix-based trabeculectomy was performed by using a conjunctival chain suture. In the second group (group B, 33 eyes) the same technique was performed with the additional employment of a new removable suture to the scleral flap. The patients were followed-up for 12 months. RESULTS: After 1 year the mean IOP was 16.58 mmHg (+/-3.73 mmHg) in group A, and 16.12 mmHg (+/-4.21 mmHg) in group B; statistical analysis did not show significant differences between the two groups (P = 0.19). Early postoperative hypotony and shallowing of the anterior chamber were significantly more frequent after standard trabeculectomy than after trabeculectomy using the removable suture (P < 0.02). CONCLUSIONS: The employment of a fornix-based conjunctival chain suture for the flap allows the use of the removable scleral flap suture, which has proved very effective in preventing insufficient flap resistance with aqueous overdrainage and hypotony, and which is also easy to apply and to remove. Compared with standard trabeculectomy, this device has proved to have similar IOP-lowering efficacy, together with a lower rate of early postoperative complications.

In vivo confocal microscopy in bilateral herpetic keratitis: a case report.

PURPOSE: Bilateral herpetic keratitis is a rare infection of the cornea. Ocular herpes in atopic patients is more often bilateral, with more frequent recurrences. The authors report a case of bilateral herpes simplex virus (HSV) keratitis during the active phase studied by in vivo confocal microscopy. METHODS: A 28-year-old man with 5 years history of unilateral HSV keratitis and atopic dermatitis was referred to the authors for a clinical and diagnostic evaluation.RESULTS. The corneas showed the typical features of dendritic HSV keratitis in both eyes. Examination by in vivo confocal microscopy demonstrated similar lesions in both eyes: a distortion of the superficial and basal epithelium and the presence of irregular hyperreflective structures and dendritic particles near the epithelial cells. The subbasal nerve plexus presented a tortuous appearance with hyperreflective areas and beadlike formations along the fibers. After a week of antiviral treatment, in vivo confocal microscopy examination demonstrated an irregular epithelium with highly reflective deposits and reflective areas. A reduction of nerve fiber bundles with a large number of beadlike formations and abnormal tortuosity was also noted. CONCLUSIONS: In vivo confocal microscopy enables a noninvasive evaluation of the ocular surface at a high magnification level. It could be useful for the early and differential diagnosis of corneal infections and when HSV keratitis recurrence is suspected.

Unilateral corneal endothelial dystrophy and anterior keratoconus.

PURPOSE: To describe a case of keratoconus and Fuchs' corneal endothelial dystrophy in the left eye with no corneal disease in the right eye. METHODS: A 64-year-old woman presented with visual impairment in her left eye; computer-assisted topographic analysis and specular microscopy were performed in both eyes and left cornea was histopathologically examined. RESULTS: Keratoconus was diagnosed by slit-lamp examination, keratometry, and computer-assisted topographic analysis. Corneal endothelial dystrophy was diagnosed on the basis of clinical examination and specular microscopy. Histopathologic examination revealed a stromal degeneration typical of keratoconus and a non-guttae form of endothelial dystrophy. CONCLUSIONS: This is a rare case of unilateral corneal endothelial dystrophy and keratoconus.

Human herpesvirus-6B active infection associated with relapsing bilateral anterior optic neuritis.

BACKGROUND AND OBJECTIVES: Human herpesvirus-6 (HHV-6) is the causative agent of exanthem subitum. Both HHV-6 variants, A and B, have been associated with central nervous system (CNS) diseases, suggesting a wide neuropathogenic potential. We describe a case of recurrent bilateral anterior optic neuritis with HHV-6 active infection associated with clinical relapses. CASE REPORT: A 23-year old woman presented with progressive visual impairment, bilateral papillitis and painful ocular movements. Nested polymerase chain reaction (PCR) for DNA viruses, HHV-6 variant specific real time quantitative PCR, serological analysis and retrotranscription PCR (RT-PCR) for HHV-6 mRNA transcripts were performed. Nested PCR in PBMC and CSF samples was negative for all viruses but positive for HHV-6 DNA, subtyped as HHV-6B. The disease had a relapsing/remitting course. During relapses PBMC samples remained positive for HHV-6 DNA, and HHV-6 active infection was confirmed by the presence of anti-HHV-6 IgM and of HHV-6 U27 mRNA transcript. High viremia levels and relapses were overlapping. After the last relapse, the patient was successfully treated with gancyclovir. CONCLUSIONS: The case reported here suggests a possible association of HHV-6 in bilateral optic neuritis. HHV-6 could be monitored when bilateral optic neuritis is identified, in order to establish an appropriate antiviral therapy.

Cytoplasmic and nuclear interaction between Rb family proteins and PAI-2: a physiological crosstalk in human corneal and conjunctival epithelial cells.

Extracellular plasminogen activator inhibitor type-2 (PAI-2) is a potent inhibitor of urokinase-type plasminogen activator (u-PA) and also acts as a multifunctional protein. However, the biological activity of intracellular PAI-2, as well as its intracellular targets, until now remain an enigma. Here, we show that pRb2/p130 and Rb1/p105, but not p107, interact with PAI-2 in both the cytoplasm and nucleus of normal primary human corneal and conjunctival epithelial cells. We provided the first in vivo evidence that a specific fragment of the PAI-2 promoter is bound simultaneously by pRb2/ p130, PAI-2, E2F5, histone deacetylase 1 (HDAC1), DNA methyltransferase 1 (DNMT1), and histone methyltransferase (SUV39H1), in normal primary human corneal epithelial cells, and by pRb2/p130, PAI-2, E2F5, HDAC1, and DNMT1, in normal primary human conjunctiva epithelial cells. Our results strongly indicate a physiological interaction between pRb family members and PAI-2, suggesting the hypothesis that pRb2/p130 and PAI-2 may cooperate in modulating PAI-2 gene expression by chromatin remodeling, in normal corneal and conjunctival cells.

Closed-system and open-sky capsulorhexis for combined cataract extraction and corneal transplantation.

We describe a triple procedure combining corneal transplantation, cataract extraction, and intraocular lens implantation in which the continuous curvilinear capsulorhexis (CCC) is performed in a closed system when corneal transparency is sufficient or using an open-sky method when corneal transparency is poor. With the closed system, the CCC is performed first followed by trephination and hydroexpulsion of the nucleus. A Caporossi coaxial forceps is used to reduce the corneal incision to 1.2 mm, preventing the need for sutures. Tunnel formation, which could limit the size of trephination, is avoided. In addition, endothelial cell loss at the periphery of the recipient cornea is reduced. This technique was performed in 10 eyes without intraoperative complications. With the open-sky method, the CCC is created while counterpressure is applied to the center of the lens with a large spatula, reducing posterior pressure and thus the risk of capsule tear. This technique was performed in 9 eyes without intraoperative complications.

RB2/p130 gene-enhanced expression down-regulates vascular endothelial growth factor expression and inhibits angiogenesis in vivo.

Angiogenesis is an essential step in the progression of tumor formation and development. The switch to an angiogenetic phenotype can occur as a distinct step before progression to a neoplastic phenotype and is linked to genetic changes such as mutations in key cell cycle regulatory genes. The pathogenesis of the angiogenetic phenotype may involve the inactivation of tumor suppressor genes such as the "guardian of the genome," p53, and the cyclin-dependent kinase inhibitor p16. Retinoblastoma family member RB2/p130 encodes a cell cycle regulatory protein and has been found mutated in different tumor types. Overexpression of RB2/p130 not only suppresses tumor formation in nude mice but also causes regression of established tumor grafts, suggesting that RB2/p130 may modulate the angiogenetic balance. We found that induction of RB2/p130 expression using a tetracycline-regulated gene expression system as well as retroviral and adenoviral-mediated gene delivery inhibited angiogenesis in vivo. This correlated with pRb2/p130-mediated down-regulation of vascular endothelial growth factor protein expression both in vitro and in vivo.

Genetic alterations of the retinoblastoma-related gene RB2/p130 identify different pathogenetic mechanisms in and among Burkitt's lymphoma subtypes.

Alterations of cell cycle-associated genes probably contribute to the pathogenesis of Burkitt's Lymphoma (BL), in addition to c-myc translocation. Mutations disrupting the nuclear localization signal of the retinoblastoma-related gene RB2/p130 have been documented recently in BL cell lines and primary tumors. Given the importance of the RB2/p130 gene in controlling cell growth, mutations of this gene may result in uncontrolled cell proliferation. We tested the expression and genomic organization of the RB2/p130 gene in relation to the proliferative features of a series of BL samples collected from the endemic and sporadic regions, regardless of whether the samples were acquired immune deficiency syndrome (AIDS)-related. The expression of the Rb2/p130, p107, and cell proliferation-related proteins (cyclin A and B) was determined by immunohistochemistry. The structures of exons 19 through 22 of the RB2/p130 gene, encoding for the B domain and C terminus, were analyzed by polymerase chain reaction (PCR) analysis and single-strand conformation polymorphism (SSCP) technique. The direct PCR products were sequenced to identify the actual mutations. Our results suggest that BL is composed of a mixture of molecular types with distinct genetic and phenotypic patterns, probably resulting from different pathogenetic mechanisms. In endemic BL, the RB2/p130 gene is mutated in most of the cases, and the protein is restricted to the cytoplasm. In AIDS-related BL, high levels of nuclear expression of the wild-type pRb2/p130, p107, and cell proliferation-related proteins were detected. This finding is in line with the molecular mechanisms observed in virus-linked oncogenesis. Sporadic BLs were mainly characterized by the low nuclear values of the wild-type pRb2/p130 and, conversely, the high values of p107. The increased cell proliferation due to different alterations of cell growth control by Rb-related proteins may be the first step in lymphomagenesis, during which additional genetic changes, including missense mutations of c-myc, may subsequently occur.

Mutations in the retinoblastoma-related gene RB2/p130 in lung tumors and suppression of tumor growth in vivo by retrovirus-mediated gene transfer.

The retinoblastoma (Rb) family consists of the tumor suppressor pRb/p105 and related proteins p107 and pRb2/p130. Recent immunohistochemical studies of the retinoblastoma family of proteins in 235 specimens of lung cancer show the tightest inverse association between the histological grading in the most aggressive tumor types and pRb2/p130. This led us to study a panel of human lung cancers for mutations in the RB2/p130 gene. Mutations in the Rb-related gene RB2/p130 were detected in 11 of 14 (78.5%) primary lung tumors by single-strand conformation polymorphism and sequence analysis. A Moloney leukemia virus-based retroviral system was set up, and a comparable viral concentration of 1 x 10(7) infectious units/ml was obtained. Retrovirus-mediated delivery of wild-type RB2/p130 to the lung tumor cell line H23 potently inhibited tumorigenesis in vitro and in vivo, as shown by the dramatic growth arrest observed in a colony assay and the suppression of anchorage-independent growth potential and tumor formation in nude mice. The tumors transduced with the RB2/p130 retrovirus diminished in size after a single injection, and a 12-fold reduction in tumor growth after RB2/p130 transduction compared with the Pac-transduced tumors (92% reduction, P = 0.003) and lacZ-transduced tumors (93% reduction, P < 0.001) was found to be statistically significant. These findings provide the missing confirmation that RB2/p130 is a "bona fide" tumor suppressor gene and strengthen the hypothesis that it may be a candidate for cancer gene therapy for lung cancer.

Genetic alterations disrupting the nuclear localization of the retinoblastoma-related gene RB2/p130 in human tumor cell lines and primary tumors.

The prototypic tumor suppressor gene, the retinoblastoma gene (RB/ p105), is mutated in a variety of human tumors. However, to date, mutational data on retinoblastoma family members p107 and RB2/p130 in tumors is lacking. We studied the expression of pRb2/p130 by immunocytochemistry and Western blot analysis in a panel of human osteosarcoma and lymphoid cell lines. Only the lymphoid cell lines showed an abnormal cytoplasmic localization of pRb2/p130, suggesting possible alterations within the region of nuclear localization signaling. We screened these cell lines for genetic alterations of the RB2/p130 gene in the region of the putative bipartite nuclear localization signal (NLS). This region is highly homologous with that of the RB/p105 gene. In addition, we screened four primary Burkitt's lymphomas for genetic alterations in the RB2/p130 gene. Naturally occurring mutations, which disrupt the putative bipartite NLS, were found in lymphoma cell lines and primary tumors, but not in the osteosarcoma cell lines, where normal nuclear localization of the protein was detectable. Site-directed mutagenesis and transfection assay using NLS mutants displayed markedly reduced biological activity as measured by flow cytometric analysis. This study clearly describes RB2/ p130 as an important target for mutations and subsequent inactivation in lymphoma pathogenesis, thus validating that RB2/p130 is a classical tumor suppressor gene.

Conjunctival edema and alopecia of the external third of the eyebrows in a patient with Meige syndrome.

PURPOSE: To describe a patient with Meige syndrome in whom we observed the coexistence of hereditary lymphedema of the lower legs, conjunctival edema and alopecia of the lateral third of the eyebrows. METHODS: Case report. RESULTS: Histological examination of the conjunctival and skin specimens showed dermal edema and a slight reduction in the number of severely ectatic lymphatics in the reticular dermis. The vessel were identified as lymphatics on the basis of immunohistochemical evidence of discontinuity and/or absence of basement membrane. CONCLUSIONS: Clinical and histological findings suggest that the etiopathogenesis of the edema in Meige syndrome is related to a structural ectatic defect of lymphatics. This anomaly seems to involve both skin and other sites, such as conjunctival mucosa.

Long-term results of combined 1-way phacoemulsification, intraocular lens implantation, and trabeculectomy.

PURPOSE: To analyze the results of 1-way phacoemulsification and posterior chamber intraocular lens (IOL) implantation combined with trabeculectomy. SETTING: Department of Ophthalmology and Neurosurgery, University of Siena, Siena, Italy. METHODS: This retrospective study comprised 42 eyes of 36 patients with glaucoma and cataract who had phacoemulsification with posterior chamber IOL implantation combined with trabeculectomy. The mean follow-up of 28.24 months +/- 10.99 (SD) (range 11 to 52 months) included measurement of intraocular pressure (IOP), visual acuity, visual field, endothelial cell loss, and notation of complications. RESULTS: There was a statistically significant postoperative improvement in visual acuity (P < .001). Mean preoperative best corrected visual acuity (BCVA) was 20/200 (range 20/30 to hand movements). Mean 1 year postoperative BCVA was 20/30 (range 20/20 to 20/60). The preoperative mean IOP of 24.06 mm Hg decreased to 15.36 mm Hg at 1 year (P < .001). All 42 eyes had a postoperative IOP of less than 21.00 mm Hg. Mean central cornea endothelial cell density preoperatively was 2238 +/- 396 cells/mm2 (range 1697 to 2906 cells/mm2) and postoperatively, 2005 +/- 397 cells/mm2 (range 1302 to 2801 cells/mm2). Early postoperative complications consisted of a choroidal detachment in 2 patients (4.76%). Three and 4 days after surgery, respectively, 2 patients (4.76%) had surgery to remove viscoelastic substance under the IOL. Late complications included posterior synechias in 3 eyes (7.14%). One year after surgery, because of a significant decrease in vision, a neodymium:YAG laser posterior capsulotomy was necessary in 2 eyes, 1 with an acrylic IOL (3.70%) and 1 with a silicone lens (9.09%). CONCLUSION: Combined phacoemulsification, posterior chamber IOL implantation, and trabeculectomy was safe and effective in patients with coexisting glaucoma and cataract.

Cell composition and immunohistochemical detection of VEGF, TGF-beta, and TNF-alpha in proliferative vitreoretinopathy.

Formation of vascularized membranes inside the vitreous leads to retinal detachment and blindness. In this paper it is shown that vitreal membranes are composed of newly formed vessels and myofibroblasts, immersed in a loose stroma with sparse histocytes. Vascular endothelial growth factor (VEGF) is clearly present in cellular constituents of the membranes and, therefore, represents a fundamental cytokine in their formation, while transforming growth factor-beta (TGF-beta) and tumor necrosis factor-alpha (TNF-alpha) are not. Considering that the composition of vitreal membranes clearly resembles scar tissue, the absence of TGF-beta in the membranes could explain their peculiar histological appearance.

Histology of anterior capsule fibrosis following phacoemulsification.

PURPOSE: To determine the histology and immunohistochemistry of anterior capsule fibrosis. SETTING: Department of Ophthalmology and Neurosurgery and Institute of Pathology, University of Siena, Siena, Italy. METHODS: Tissue sections from 3 patients with anterior capsule fibrosis after phacoemulsification and intraocular lens implantation were examined histologically. RESULTS: The proliferating tissue was devoid of vessels and composed of dense fibrous tissue and numerous activated fibroblasts with contractile capacity (myofibroblasts). No TGF-beta, which is the most important cytokine in modulating myofibroblasts, was present in the fibrotic tissue. CONCLUSION: The absence of the cytokine TGF-beta and inflammatory cells in the proliferating tissue confirms the unique character of the reparative activity within the eye.