Comparisons of intraocular pressure measurements: Goldmann applanation tonometry, noncontact tonometry, Tono-Pen tonometry, and dynamic contour tonometry.

AIMS: To compare intraocular pressure (IOP) readings between Tono-Pen tonometry and GAT, between noncontact tonometry (NCT) and GAT, and between dynamic contour tonometry (DCT) and Goldmann applanation tonometry (GAT). The correlation between IOP reading and possible confounder was identified. METHODS: This observational cross-sectional study enrolled sixty-two healthy subjects. All IOP and ocular pulse amplitude (OPA) measurements were taken by a single ophthalmologist; mean keratometric power (MK), central corneal thickness (CCT), and lens thickness (LT) were measured by a single experienced technician. RESULTS: Stepwise multiple regression analysis indicated that GAT (P=0.017) and DCT (P=0.002) readings correlated positively with MK; GAT, NCT, and Tono-Pen readings correlated positively with CCT (P<0.05); NCT (P=0.035), and DCT (P=0.016) readings correlated negatively with LT; GAT (P=0.006) and Tono-Pen (P=0.009) readings correlated positively with OPA. CONCLUSIONS: The K, CCT, LT, and OPA are confounders in tonometry readings.

Screening amblyopia of preschool children with uncorrected vision and stereopsis tests in Eastern Taiwan.

UNLABELLED: AIMS OR PURPOSE: Screening for amblyopia at earliest age is important for early treatment and better prognosis. This study aimed at evaluating the validity of uncorrected distant and near visual acuity and random dot stereopsis for screening amblyopia. METHODS; In Eastern Taiwan, population-based screen tests were performed for children at age from 3 to 6 years. The tests included uncorrected distant and near visions and random dot stereopsis (300 s) test. The screen performers were registered nurses of local public health service posts. The golden standards of the tests were the results of examination by the ophthalmologists. RESULTS: Including Hans and aboriginal Taiwanese, 5232 children were included. Screened by distance visual acuity with different cutoffs and near visual acuity, 10.3, 30.3 and 8.2% children were abnormal. Screened by random dot, only 2% children were abnormal. By a senior ophthalmologist, 115 amblyopic children were diagnosed amblyopic. The sensitivities of distance visual acuity with low/high cutoff and near visual acuity were 74.7/84.8 and 49.4%, whereas that of the NTU random dot stereogram was 20.5%. Simultaneous testing of either two of the three tests improved the sensitivity. CONCLUSION: Screening for amblyopia by the local nurses using the visual acuity tests or random dot stereopsis test alone does not display a high sensitivity. Simultaneous testing of distant visual acuity and stereopsis test elevate the sensitivity and preserve the specificity.

Relation between the axial length and lenticular progressive myopia.

PURPOSE: To investigate the possible risk factors associated with lenticular progressive myopia and to compare the differences between patients with lenticular progressive myopias and senile cataracts. METHODS: We retrospectively reviewed cases that had been diagnosed as lenticular progressive myopia with a discrete nuclear sclerotic cataract and progressive myopic changes in one hospital from January 1998 to February 2003. A total of 47 eyes of 35 patients were enrolled in this study. In all, 32 eyes of 29 cases of common senile cataract receiving cataract extraction surgery during the study period were randomly chosen (every four cases in time sequence within a 2-month period by two ophthalmologists' clinic in 2002) as the control group. We compared the preoperative refraction status, keratometry (K-values) and axial lengths between these two groups. The possible ocular or systemic associating diseases were also investigated in the study group. RESULTS: In the lenticular progressive myopia group, the mean age at surgery (52.9+/-9.2 years) is younger than that in the senile cataract group (68.1+/-7.3 years). The mean axial length in the study group (25.68+/-1.93 mm) is statistically significant longer than that in the control group (22.97+/-0.83 mm) (P<0.0001). Besides, patients with lenticular progressive myopia had significantly lower mean K-values (43.25+/-1.42 diopters) than patients with senile cataracts (44.25+/-1.28 diopters) (P<0.01). There were no other ocular or systemic diseases closely associated with lenticular progressive myopia. CONCLUSIONS: Patients with nuclear cataract combined with lenticular progressive myopia have longer axial length than patients with senile cataract. The longer axial length may be one of the important risk factors predisposing to lenticular progressive myopia.

Bilateral orbital pseudotumor with suprasellar and pulmonary involvement: report of a case.

A 39-year-old man had bilateral proptosis and blurred vision for I week. Computed tomography and magnetic resonance imaging showed signs of bilateral orbital pseudotumor, a suprasellar mass, and pulmonary infiltration. Biopsies from retrobulbar and bronchial sites showed similar inflammatory tissue. His disease resolved with pulsed corticosteroid therapy.

Acute lymphoblastic leukemia in one of two siblings with Alstrom syndrome.

Alstrom syndrome is a rare autosomal recessive disease; less than 60 cases have been reported. No Chinese patient with this disease has been reported previously in the literature. Here, we describe an 11-year-old Chinese boy with this condition. His elder sister also had Alstrom syndrome, and his father had non-insulin-dependent diabetes mellitus. Both siblings had degenerative retinopathy, obesity, mental retardation, perceptive hearing loss, short stature, non-insulin-dependent diabetes mellitus, nephropathy, hyperlipidemia, acanthosis nigricans, and hepatic dysfunction. The boy also developed acute lymphoblastic leukemia, which was confirmed by cytochemistry and immunophenotyping findings. He received chemotherapy and radiotherapy for the malignancy. The present case suggests that acute lymphoblastic leukemia may be coincident with or may be a previously undescribed systemic manifestation of Alstrom syndrome.

Painful fourth cranial nerve palsy caused by posteriorly-draining dural carotid-cavernous sinus fistula.

A 65-year-old man with a dural carotid-cavernous fistula (DCCF) presented with sudden onset of painful trochlear nerve paresis. Typical signs of DCCF including conjunctival arterialization, chemosis, and proptosis did not become manifest until 4 months later. This unusual presentation of DCCF was caused by drainage of the fistula posteriorly into the inferior petrosal sinus with low flow. With this condition, patients may present with trochlear nerve palsy without a red eye. Although rare, DCCF must be considered in patients presenting with isolated painful trochlear palsy.

Ocular manifestations in children with developmental delay preliminary report.

To investigate systemic diseases and ocular problems among children with developmental delay, forty-one children (28 boys and 13 girls with a mean age of 3.53 +/- 2.25 y/o) were enrolled in this study. In addition to ocular examinations, we used centrality, steadiness, fixation and flash visual evoked potentials (VEPs) tests on all of the children. We found that 23 children (56.10%) had ocular problems with optic atrophy and strabismus being the two most common ocular abnormalities. The two major clinical manifestations of developmentally delayed children were mental and motor retardation. The primary test of centrality, steadiness and fixation and visual evoked potentials could be useful tools in evaluating the visual pathway and ocular motility. Preliminary results showed that more than half of the children with developmental delay had certain ocular abnormalities. The high incidence of ocular abnormalities deserves careful attention when these children are brought to seek medical help. Further study of ocular problems among developmentally delayed children and a search for more reliable examination method should be encouraged.

Correlation between clinical activity score and thyroid autoantibodies in patients with thyroid ophthalmopathy.

To investigate the relation between clinical activity score (CAS) and thyroid autoantibodies of thyroid ophthalmopathy, we measured the level of TSH receptor antibody (TRAb), antithyroglobulin antibody (ATA), and antimicrosomal antibody (AMA) in 41 patients with thyroid ophthalmopathy. The results of thyroid autoantibodies level were compared with CAS. Under the multiple regression and correlation analysis among CAS and the levels of TRAb, ATA, and AMA, no correlation was shown in this study. In conclusion, there is no correlation of thyroid ophthalmopathy among CAS and the levels of TRAb, ATA, and AMA in our study. If we use these three kinds of thyroid autoantibodies to match the activity of thyroid ophthalmopathy, it seems to be inappropriate. Further search of other simplified index to reflect the activity of ophthalmopathy should be encouraged.

Fungal corneal ulcers of onion harvesters in southern Taiwan.

Fungal corneal ulcers related to agriculture has been reported throughout the world, especially in tropical areas. Most of them were sporadic and had histories of ocular trauma or use of topical corticosteroids and topical antibiotics. Five onion harvesters had fungal corneal ulcers during the same harvest period in Southern Taiwan. The authors think that this is the first report of a group occurrence relating to agricultural workers. Although all of the patients improved after medical and surgical management, their vision was greatly decreased. It is suggested that the tropical climate, the harvest procedure, the characteristic monsoon, and lack of eye protection were involved. Therefore, the importance of the eye protection, hygiene education, and improving medical care to reduce the occurrence of fungal corneal ulcer in agriculture workers must be emphasised.

Acute painful oculomotor nerve paresis caused by pituitary apoplexy--a case report.

In a typical case of pituitary apoplexy, a patient, who may or may not be known to harbor a pituitary adenoma, suddenly develops a severe headache. The headache may be retro-orbital, frontal, frontotemporal, or diffuse and may be associated with neck stiffness, neck pain, or both. Ophthalmoplegia may develop within a few hours after the onset of headache. Here we report a rare case of one middle-aged female with pituitary apoplexy initially presenting with acute onset of pupil-involved third cranial nerve palsy, headache and peri-ocular pain. Emergent neuroimaging revealed pituitary apoplexy and immediate intravenous corticosteroid was given and third nerve paresis was improved thereafter. Definite tumor removal was done smoothly after steroid treatment and complete recovery of ophthalmoplegia was noted 2 weeks after operation.

Intraocular use of fluconazole in the management of ocular fungal infection.

In this study, we investigate the efficacy and safety of intraocular use of fluconazole in the treatment of ocular fungal infection. Ten patients with intraocular fungal infections were examined. Among these patients, eight were infected with keratomycosis with intraocular spreading, one had postoperative fungal endophthalmitis after cataract operation with an intraocular lens implant, and another suffered from endogenous fungal endophthalmitis. In addition to the conventional local application with or without systemic administration of antifungal drugs, all ten patients were treated with intraocular administration of 5-10 micrograms/ml of fluconazole. The ocular fungal infections resolved in nine patients without obvious side effect. One failed in the antifungal treatment with loss of vision. In our experience, the results revealed that fluconazole is a safe and effective antifungal agent that can be administered intraocularly. We suggest that intraocular administration of this drug could be considered as an alternative or additional choice for the treatment of severe ocular fungal infections.

Acute esotropia may be a presenting sign of intracranial neoplasm.

Here we report eight consecutive patients with intracranial neoplasm at different ages clinically presenting with acute esotropia. Among these patients, two had divergent paresis, four had bilateral abducens paresis and the other two had unilateral abducens nerve paresis. All of these patients have intracranial neoplasm demonstrated by neuroimaging studies. Besides of acute esotropia, four had papilledema, one had optic atrophy, and three had associated other neurological signs. Of the eight patients, three patients are children, and the other five are adults. In the adult group, four patients are less than 45 years old. In conclusion, acute esotropia may be an early presenting sign of brain tumor and careful evaluation of associated clinical symptoms/signs is mandatory, especially in the young age group.

Expression of bcl-2, p53 and Ki-67 in arsenical skin cancers.

To investigate the regulation of apoptosis and proliferation in arsenic-induced skin cancers, we examined the expression of bcl-2, p53, and Ki-67 using immunohistochemical staining. Thirty patients with Bowen's disease (BD), ten with basal cell carcinoma (BCC), eight with squamous cell carcinoma (SCC) and eleven of perilesional normal skin (PLN) of the non-sun exposure sites from endemic area were examined. The results showed that: 1) bcl-2 was expressed in all of the BCC homogeneously, in none of the SCC, and in 12/30 of the BD focally or homogeneously; 2) p53 was expressed in all of the arsenical skin cancers with a labelling index of 75 +/- 14% of BD, 50 +/- 17% of BCC, 61 +/- 15% of SCC, and also in all of the perilesional normal skin with a labelling index of 55 +/- 24%; 3) Ki-67 was expressed in all of the skin cancers with labelling index of 58 +/- 17% of BD, 12 +/- 7% of BCC, 47 +/- 21% of SCC, and in 9/11 of PLN with a labelling index of 41 +/- 24%. Expression of bcl-2 in BCC or BD is related to the phenotype of germinative basal cell. The constant expression of bcl-2 i early dysplastic cells of BD and the earliest expression of P53 in the basal cells of perilesional normal skin indicate that the initial step of arsenic-induced carcinogenesis is from the basal germinative cells. There is no mutual relationship between bcl-2, p53 or Ki-67 expression in any type of the arsenical skin cancers, but there is a positive correlation between p53 and Ki-67 expression identified in perilesional normal skin. BD had the highest labelling index of p53 and Ki-67.

Intravenous methylprednisolone in treatment of traumatic optic neuropathy.

Traumatic optic neuropathy is one of true ophthalmic emergencies and there is no proven form of treatment for traumatic optic neuropathy. Here we were presented with 30 cases of sudden visual loss following blunt eye trauma seen in Kaohsiung Medical College Hospital, Taiwan from April 1994 to March 1997. We analyze the treatment style, visual acuity, elapsed time since injury and orbit computed tomography retrospectively. Among them, 21 cases received intravenous methylprednisolone treatment, 2 cases received oral prednisolone, 2 cases underwent optic canal decompression in addition to intravenous methylprednisolone and 5 cases were carefully monitored without any kind of treatment. Thirteen of the 21 cases (62%) in intravenous methylprednisolone group got visual improvement. Patients with initial vision better than light perception benefitted more from treatment than did the patients who with no light perception in medical treatment group (85% VS 20%) (p < 0.05). Thirteen of the 30 cases (53.3%) had orbit fracture and 2 of the 30 cases (6.7%) had a fracture of the optic canal. These two cases also received optic canal decompression surgery in addition to intravenous steroid treatment but the prognosis was poor. In conclusion, intravenous methylprednisolone does offer help in traumatic optic neuropathy. Whether or not initial visual acuity was better than light perception was a key risk factor in the outcome. In this article, we also compare our results with other series in the literature and found that the value of different treatment in traumatic optic neuropathy still needs to be prospectively judged in the future.

Capability of neurite regeneration of retinal explant from adult rat after optic nerve injury.

Axons of the central nervous system in adult mammals do not regenerate spontaneously after axotomy. To understand whether the optic nerve of adult mammals loses the intrinsic capability to regenerate after injury, we have studied the capability of neurite regeneration of retinal explant from adult rat after optic nerve axotomy in vitro. After experimental blunt damage to the optic nerve of adult Wistar rat, the retinal explants from three days, one week, two weeks and three weeks after axotomy were put in tissue culture to observe the neurite growth after four days' incubation. The neurites were identified as retinal neuron origin by immunocytochemical staining using monoclonal antibody to neurofilament. The results demonstrate that retinal explants from adult rat after optic nerve damage have the capability of neurite regeneration; the capability is strongest in the group of one week after axotomy of optic nerve, but it decreases with passage of the time. On the other hand, the retinal explant from the control group of uninjured eye does not regenerate neurite in tissue culture. These results indicate that the retinal explant of adult rat has intrinsic capability to regenerate after optic nerve injury in vitro, and the capability of neurite regeneration decreases after one week post-trauma.

Capability of neurite regeneration of rat retinal explant at different ages.

Neurite regeneration from central nervous tissue of mammalian has been demonstrated to occur in early postnatal stage but not in adult stage. To answer when the retinal explant of rat loses the neurite regeneration in vitro after birth, we have used tissue culture to study the neurite regeneration of retinal explant of Wistar rat at different ages. The retinal explants from rat at first postnatal day, 3rd postnatal day, one week, two weeks, three weeks, four weeks old and of the adult were put in tissue culture to observe the neurite growth after four-day incubation. The neurites were also identified by immunochemical staining using monoclonal antibody to neurofilament. The capability of neurite regeneration of retinal explant was decreased with the passage of time after birth, and it was lost after two weeks old. The age of losing retinal regenerative capability coincides with that of eye opening and retinal maturation of Wistar rat (15th-18th postnatal day, mean 16.2 +/- 1.3 days). These results indicate that when the development of retina has been completed, it will lose the capability of regeneration in vitro.

Risk factors of non-arteritic anterior ischemic optic neuropathy (NAION): ocular or systemic.

We retrospectively analyzed 22 patients with non-arteritic anterior ischemic optic neuropathy (NAION) seen at Chung-Ho memorial hospital between 1994 and 1996 to investigate the risk factors of NAION. The risk factors were divided into two groups: ocular and systemic. The ocular factors include refractive state, intraocular pressure, and cup-disk ratio of fellow eye. The systemic factors include diabetes, hypertension and cardiovascular diseases. The analysis revealed: (1) only 22.6% of patients with NAION have systemic risk factors; (2) intraocular pressure is not specific to NAION; (3) most of fellow eyes (72.6%) have cup-disk ratio not more than 0.1; and (4) most patients (90.9%) are hyperopic or emmetropic, only 9% of patients are myopic in either affected or fellow eyes. The statistical comparison between ocular (including cup-disk ratio and refractive state) and systemic factors is significant. The correlation with systemic factors in our study was not so high as previous study had reported. On the contrary, crowding effect of small cup-disk ratio, which induces a vicious circle of generally circulatory compromised disk, may play an important role in NAION. Besides, hyperopic or at least emmetropic eyes are more prone to NAION than myopic eyes. This may be due to lack of flattening of the temporal excavation, therefore adding a predisposing factor to a generally circulatory compromised disk. The risk factors associated with NAION seem more strongly correlated with ocular factors than with systemic factors.

ATRA-induced pseudotumour cerebri--one case report.

A 17-year-old girl with acute pomyelocytic leukemia (APL) went into complete remission following Daunorubicin, Ara-C and ATRA chemotherapy for 1 month. Unfortunately, prolonged administration of ATRA 6 weeks later caused binocular diplopia with left abducent nerve paresis, which gradually disappeared upon withdrawal of ATRA. We propose that it is ATRA induced pseudotumour cerebri and present this case to discuss the relationship between the ATRA and pseudotumour cerebri.

Central retinal vein occlusion associated with cryofibrinogenemia in a young adult--study of skin dynamic capillaroscopy.

A 26-year-old woman presented with a 2-month history of intermittent dim vision in her right eye and a diagnosis of central retinal vein occlusion (CRVO) was made. Investigations revealed Raynaud's phenomenon and cryofibrinogenemia. Skin capillaroscopy revealed tortuous vessels and decreased capillary blood-cell velocity in the capillaries of her finger nail fold which coincided with the CRVO attack. After treatment with oral aspirin for 3 months, the CRVO subsided, the capillary blood-cell velocity in the nail fold improved, and serum cryofibrinogen was undetectable. The time course of the cryofibrinogenemia and skin capillaroscopic findings correlated well with her ocular presentations. Study of cryofibrinogen should be included in the evaluation of young adults with CRVO.

Reversibility of ethambutol optic neuropathy.

Ethambutol hydrochloride is one of the routinely used drugs as the first line of antitubercular agents. The delayed onset of ocular toxicity is usually thought to be reversible following rapid withdrawal of the drug. We collected ten consecutive patients with severe visual defects due to ethambutol toxicity, and these patients had received presumably safe ethambutol dosages. Although ethambutol was stopped immediately in all cases, only five patients (50%) experienced visual improvement after a period of 12 months to 3 years follow-up. The other five patients (50%) had permanent visual impairment without recovery. There were no predisposing or risk factors to contribute to poor visual outcome. In the group over 60 years old, only 20% (1/5) experienced visual improvement; in the group less than 60 years old, 80% (4/5) had some visual recovery, the difference between these two age groups being statistically significant. We need more patient collections to answer whether the older patients with ethambutol optic neuropathy have poor prognoses. Ethambutol optic neuropathy, in our follow-up study, is not always reversible, especially in the older population. It may cause permanent visual disability. There is no so-called "safe-dosage". We suggest reconsideration regarding the use of ethambutol as one of the first-line antitubercular drugs, especially in older patients.