Early Clinical Experience with Double Ring Implantation for Aortic and Mitral Valve Repair.

Reconstruction of cardiac valves is associated with reduced mortality, including in multiple valve surgery. However, multiple valve repair is still considered a challenge, even with established techniques. Recently, internal aortic ring annuloplasty has been introduced and could simplify multiple valve reconstruction. This study reports early results with double ring aortic and mitral valve repair. Three patients with bivalvular degenerative regurgitation were managed with combined aortic and mitral valve repair using double rings. Mean (±SD) age was 41 ± 21 years, preoperative left ventricular end-diastolic volume was 119 ± 53 mL/m2, and ejection fraction was 0.50 ± 0.07. Mean aortic ring diameter was 21 mm, and mitral rings averaged 32 mm. No operative mortalities or major complications were observed. No valve-related events occurred. Postoperative echo showed complete resolution of mitral and aortic regurgitation. Postoperative left ventricular end-diastolic volume decreased to 98 ± 10 mL/m2; no left ventricular outflow tract obstruction or significant transvalvular gradients were observed. Postoperative cardiac CTs showed an optimal three-dimensional configuration of aortic and mitral annuloplasty devices. This initial series demonstrated the feasibility and safety of combined aortic and mitral repair with double rings. Clinical and hemodynamic results were promising. Increasing application and more clinical experience with combined aortic and mitral double ring repair seems indicated.

Color Doppler imaging of the retrobulbar circulation in glaucoma.

Color Doppler imaging is a noninvasive technique for investigating the retrobulbar circulation, showing specific retrobulbar vessels Ophthalmology Department, The Royal Victoria Hospital, Belfast, Northern Ireland and measuring blood velocity characteristics within these vessels. Color Doppler imaging is reproducible and has been used by many investigators to study blood velocity in the ophthalmic artery, the central retinal artery, and the short posterior ciliary arteries. The technique has shown statistically significant reductions in the flow velocities and increases in the resistance indices of these vessels in both primary open-angle glaucoma and normal tension glaucoma in comparison with normal control subjects. These changes correlate with disease severity and asymmetry and illustrate a compromised circulation in this region. Intraocular pressure and vasospasm have been shown to affect blood flow velocities in the same circulation. This article discusses studies that have elucidated these changes in various subpopulations of glaucoma subjects in an attempt to determine hemodynamic alterations between these disease types.

Color Doppler imaging and spectral analysis of the optic nerve vasculature in glaucoma.

PURPOSE: We used color Doppler imaging to study blood flow velocity in the central retinal artery and the short posterior ciliary arteries in patients with glaucoma. METHOD: Fifty-two patients with chronic open-angle glaucoma, 24 patients with normal-tension glaucoma, and 28 normal subjects were studied. The mean of the peak systolic velocity, the end diastolic velocity, and the resistive index were compared in the three groups. RESULTS: Compared with the normal subjects, the patients with chronic open-angle glaucoma showed a statistically significant (P < .05) decrease in the mean end diastolic velocity and an increase in the mean resistive index in all vessels studied. The patients with normal-tension glaucoma showed similar changes, achieving significance most prominently in the central retinal arteries, compared with normal subjects (P < .05). There were no statistically significant differences between the patients with chronic open-angle glaucoma and those with normal-tension glaucoma. CONCLUSIONS: Open-angle glaucoma appears to be associated with a decreased mean flow velocity and an increased mean resistive index in the ocular vasculature. These changes are in keeping with possibly compromised circulation in this region.

Color Doppler imaging in patients with asymmetric glaucoma and unilateral visual field loss.

PURPOSE: To determine whether lower blood velocities and high resistive index in the retrobulbar arteries are primary or secondary to glaucomatous damage in patients with open-angle glaucoma. METHODS: Color Doppler imaging was performed in 32 glaucomatous patients with unilateral visual field loss and in 31 control subjects. Peak systolic velocity and end diastolic velocity were measured, and resistive index was calculated in the central retinal artery and short posterior ciliary arteries. RESULTS: In patients with glaucoma, both the more affected and the contralateral eyes with normal visual fields had significantly lower peak systolic velocity and end diastolic velocity in their central retinal artery and short posterior ciliary arteries than did the control subjects of similar age (P < or = .03). The resistive index of the central retinal artery of both eyes of patients with glaucoma was also significantly higher than in the control subjects (P = .001). When considering the 16 patients who had the greatest visual field asymmetry, the more affected eyes had lower peak systolic velocity and end diastolic velocity in the central retinal artery than the contralateral eyes did (P = .02). CONCLUSIONS: Even eyes with normal visual fields in patients with asymmetric disease had decreased blood velocities in their retrobulbar vessels, suggesting that these circulatory changes probably precede detectable damage. Furthermore, the finding of lower central retinal artery blood velocities in the more affected eye of asymmetric patients suggests that low blood velocities may be one of the lateralizing factors in those patients and that they have a possible role in the pathogenesis of the disease.

Retinal blood flow measurements and neuroretinal rim damage in glaucoma.

AIM: To assess retinal blood flow characteristics in subjects with normal tension glaucoma (NTG), primary open angle glaucoma (POAG), and a group of controls using the Heidelberg retina flowmeter (HRF). The vascular parameters were correlated against structural damage of the optic nerve head, assessed using the Heidelberg retina tomograph (HRT). METHODS: HRF images were obtained in 76 subjects with NTG, 58 with POAG, and 38 controls. Optic nerve head images, acquired using the HRT, were analysed with Moorfields Regression Analysis software. The HRF variables, measured adjacent to a rim segment identified as "abnormal," were compared with the vascular parameters of the "normal" rim segments. The HRF parameters of the segments identified as normal in glaucoma subjects were compared with matched control segments. RESULTS: The glaucoma subjects had significantly lower retinal haemodynamics than the control subjects. There were no significant differences in the HRF parameters between the NTG and POAG subjects. The discs that had been identified as having abnormal segments had lower HRF values than those with a corresponding normal segment. The glaucoma subjects with normal rim segments had statistically significant lower velocity, flow, and volume measurements than the controls for each location sampled. CONCLUSION: This study shows a relation between structural damage of the optic nerve head and the level of retinal blood flow. The changes in the circulation could indicate that it may be an early marker of the pathological process.

Use of scanning laser ophthalmoscopy to monitor papilloedema in idiopathic intracranial hypertension.

AIMS: To determine the sensitivity of confocal scanning laser ophthalmoscopy (SLO) in detecting clinically significant changes in papilloedema secondary to idiopathic intracranial hypertension (IIH) and the correlation with visual field loss. METHODS: Eight patients--three new, two recurrent, and three chronic cases of IIH--were examined over a 9 month period with SLO (Heidelberg retina tomograph) of optic nerve head and 30-2 Humphrey visual fields (six cases). Optic disc swelling (volume) was assessed in each eye using a circular contour line placed around the swollen optic nerve head on the mean image of three topographic images. Nine volume measurements from single images in each eye of every patient were performed on one occasion to assess repeatability. RESULTS: In the five acute cases optic disc volumes (range 1-16 mm3) decreased with treatment to stable, normal levels. Three of these had mild, reproducible, field defects which resolved. Two chronic cases had stable or fluctuating disc volume with no detectable change in grade of papilloedema and mild field loss. In one case which underwent theco-peritoneal shunting both disc volume and field worsened, indicating therapeutic failure. Both improved postoperatively. CONCLUSIONS: SLO has a high sensitivity for detecting small changes in disc volumes and correlates closely with visual field change in the short term. It can confirm therapeutic failure by detecting stable or increasing disc volume. Decreasing volume may indicate resolution of papilloedema or secondary optic atrophy, so accompanying funduscopy and visual fields remain essential.

Retinopathy of prematurity in surfactant treated infants.

Seventy six babies of less than 1500 g birth weight who had surfactant replacement therapy for severe respiratory distress syndrome were studied to assess the presence and stage of subsequent retinopathy of prematurity (ROP). A control group of 90 babies, matched for birth weight and gestational age, who did not have surfactant therapy were also studied. Threshold ROP or greater was found in 1.7% of the surfactant group and 7.8% of the controls. For the babies of less than 1000 g birth weight 4.0% of the surfactant babies and 16.3% of the controls reached threshold disease or greater. It is concluded that surfactant therapy is not associated with an increased incidence or severity of severe ROP in this preterm population.

Peripapillary focal retinal arteriolar narrowing in open angle glaucoma.

PURPOSE: Optic disc photographs of 750 patients attending a glaucoma practice were examined to identify focal peripapillary arteriolar narrowing. METHODS: A subgroup of 110 of these patients' photographs, who had also had finger circulation tested for vasospasm to cold, were divided into patients with peripapillary focal narrowing and a control group without such a narrowing. These groups were compared with regard to their clinical status, optic disc morphology, and visual field characteristics. RESULTS: Patients with focal arteriolar narrowing were statistically significantly older (p < 0.0001) and had greater cup/disc ratio (p < 0.0001), suggesting more glaucomatous damage than those without focal narrowing. Focal narrowing was statistically significantly more common in patients with glaucoma than in patients with ocular hypertension (p < 0.0001) and were significantly more common when peripapillary atrophy was present (p < 0.0012). The location of the focal narrowing correlated with the presence of a visual field defect in the corresponding hemifield (p < 0.0001 for both upper and lower hemifields). There was no association between focal arteriolar narrowing and digital vasospasm to cold in our study. Peripapillary focal arteriolar narrowings appear to be related to the severity of glaucoma, although the effects of age were not excluded. A patient is presented in whom the narrowing disappeared within a few months suggesting focal vasoconstriction in her. CONCLUSION: Focal narrowing may be indicative of more widespread vascular pathology in the same region; however, we do not know whether these changes precede glaucomatous damage or occur secondarily to glaucomatous damage.

Visual field correlations with color Doppler studies in open angle glaucoma.

PURPOSE: This study was designed to assess the correlation between flow velocity, the resistive index and visual field defects in patients with chronic open angle glaucoma in comparison with a nonglaucomatous control population. METHODS: Color Doppler imaging was used to study flow velocity in the central retinal artery and short posterior ciliary arteries of 76 patients with chronic open angle glaucoma and 28 normal subjects. Velocity and resistive index were correlated with visual field abnormalities. RESULTS: The chronic open angle glaucoma patients showed a statistically significant lowering of the end diastolic velocity and a raised resistive index in all vessels studied. The end diastolic velocity of the central retinal arteries of glaucoma patients were significantly correlated with the Mean Deviation of the visual field (right eye, p = 0.0041; left eye, p = 0.0167). The glaucoma patients showed a statistically significant lowering of the end diastolic velocity and a raised resistive index in all vessels supplying those parts of the optic disc that corresponded to visual hemifield defects. CONCLUSION: Open angle glaucoma is associated with changes in central retinal and ciliary artery flow velocity and resistive index which suggest a compromised circulation in this region.

Severe hypercalcaemia four months after acute oliguric renal failure--successful treatment with intravenous clodronate.

A 33 year old man developed acute oliguric failure lasting 66 days, eight days after admission with multiple gun shot wounds. On day 99 after admission, serum calcium was elevated mildly at 2.54 mmol/l (normal range 2.1-2.5 mmol/l). Serum parathormone was undetectable. He was discharged soon afterwards. He presented again on day 164 with nausea, vomiting and blurred vision. Fundoscopy revealed an ischaemic retinopathy and extensive keratopathy. Serum calcium was 3.48 mmol/l and serum creatinine 262 umol/l (normal range 40-110 umol/l). Repeat parathormone was undetectable and there was no evidence of myeloma, sarcoidosis or malignancy. Following treatment with intravenous saline and frusemide, serum calcium fell to a nadir of 3.05 mmol/l. On day 168 an infusion of sodium clodronate 300 mg was given. Twenty-four hours later serum calcium was 2.65 mmol/l and 48 hours later calcium was 2.26 mmol/l. Normocalcaemia was maintained for 17 days and severe hypercalcaemia never recurred. This is the first report in which biphosphonates have been successfully used to treat hypercalcaemia following acute renal failure thus obviating the need for further dialysis.

Metastatic disease from untreated choroidal and ciliary body melanomas.

We report the case histories of three patients with untreated malignant melanoma of the choroid or ciliary body. Metastatic disease which resulted in death was diagnosed four years in two patients and 13 years in one patient after the diagnosis of choroidal melanoma was suspected. The diagnosis of malignant melanoma was confirmed by histopathology in two of these patients.

Glaucoma in optometric practice: a survey of optometrists.

AIMS/BACKGROUND: With the ageing population, numbers of glaucoma patients are an increasing problem in ophthalmic outpatient clinics. A postal questionnaire survey was carried out in Northern Ireland with the aim of finding out how well placed optometrists are to become involved in the monitoring of glaucoma. RESULTS: Of the 171 practices surveyed, 68% of the senior practitioners responded. One practice was without a tonometer and one practice was without visual field instrumentation. Age criteria were used by 95% of practitioners for measuring intraocular pressure (IOP) and 82% used appropriate selection criteria for visual field testing. An IOP of 25 or 26 mmHg was used by 45% of practitioners as the level for referral if there are no risk factors; 89% would refer at any level if a visual field defect and disc cupping were present. CONCLUSION: The results confirm that the majority of optometrists are well equipped for the screening of glaucoma. However a significant investment in training and equipment would be required if any sort of shared care scheme were to be introduced.

Surfactant replacement therapy and the prevalence of acute retinopathy of prematurity.

To determine if surfactant replacement treatment is associated with an increase in the prevalence of retinopathy of prematurity (ROP) we studied 76 preterm babies who were treated with porcine surfactant (Curosurf) for severe respiratory distress syndrome from 1985 to 1990. Babies were first examined by indirect ophthalmoscopy at the equivalent of 32 weeks post-menstrual age and subsequently at 2-week intervals until discharge from hospital. Findings were documented according to the International Classification of ROP. Sixty-two (82%) babies survived to discharge, 7 survivors were not examined due to transfer elsewhere. Acute ROP developed in 14 (29%) of the 49 babies examined (7 stage I, 4 stage II, 2 stage III, and 1 stage IV); one baby required cryotherapy. No baby of birthweight greater than 1,500 g developed ROP. The prevalence of ROP was similar to that reported for non-surfactant-treated very-low-birthweight babies. We conclude that Curosurf treatment does not increase the risk of acute ROP in surviving very-low-birthweight babies.