Lens-specific gene recruitment of zeta-crystallin through Pax6, Nrl-Maf, and brain suppressor sites.

Zeta-Crystallin is a taxon-specific crystallin, an enzyme which has undergone direct gene recruitment as a structural component of the guinea pig lens through a Pax6-dependent mechanism. Tissue specificity arises through a combination of effects involving three sites in the lens promoter. The Pax6 site (ZPE) itself shows specificity for an isoform of Pax6 preferentially expressed in lens cells. High-level expression of the promoter requires a second site, identical to an alphaCE2 site or half Maf response element (MARE), adjacent to the Pax6 site. A promoter fragment containing Pax6 and MARE sites gives lens-preferred induction of a heterologous promoter. Complexes binding the MARE in lens nuclear extracts are antigenically related to Nrl, and cotransfection with Nrl elevates zeta-crystallin promoter activity in lens cells. A truncated zeta promoter containing Nrl-MARE and Pax6 sites has a high level of expression in lens cells in transgenic mice but is also active in the brain. Suppression of the promoter in the brain requires sequences between -498 and -385, and a site in this region forms specific complexes in brain extract. A three-level model for lens-specific Pax6-dependent expression and gene recruitment is suggested: (i) binding of a specific isoform of Pax6; (ii) augmentation of expression through binding of Nrl or a related factor; and (iii) suppression of promoter activity in the central nervous system by an upstream negative element in the brain but not in the lens.

Augmented trabeculectomy in paediatric glaucoma.

AIMS: To report the experience with trabeculectomy augmented with mitomycin C and 5-fluorouracil for the treatment of paediatric glaucoma. METHODS: Retrospective, interventional case series design was used. The sample included 17 children (29 eyes) with primary (19 eyes) or secondary (10 eyes) glaucoma who were treated with augmented trabeculectomy as the primary procedure between 1990 and 2002. Data were collected on age and family history, preoperative and end of follow up intraocular pressure, cup/disc ratio (evaluated by drawing), visual acuity, complications, and post-surgery treatment. RESULTS: Patient age at surgery ranged from 1 month to 8 years; most patients (n = 14, 82.3%) were aged less than 1 year (range 1 month-8 months, mean 3.95 (SD 2.56) months); three patients (17.7%) were aged 3, 5, and 8 years. The duration of follow up was 3-120 months (mean 46 months). Intraocular pressure significantly improved from 21 mm Hg to 60 mm Hg (mean 33.1 (10) mm Hg) before surgery to 6-26 mm Hg (mean 17.1 (6) mm Hg) after, (p <0.0001). There was no significant change in cup/disc ratio: 0.1-0.8 (mean 0.42 (0.26)) before and 0.1-1.0 (mean 0.511 (0.27)) after (p = 0.45). In 22 eyes (75.8%), intraocular pressure was controlled at less than 20 mm Hg and the cup/disc ratio remained stable or improved. The life table success rate for intraocular pressure control remained stable at 86% at the 12, 24, and 36 months and after 48 months decreased to 53%. There was no significant difference in the life table results between primary and secondary glaucoma. 14 eyes (48.2%) had a visual acuity better than 20/120 by the end of follow up. Repeated surgery was necessary in eight eyes (27.5%), and additional antiglaucoma treatment in 13 (44.8%). Complications included retinal detachment 1 year after surgery, choroidal detachment, and blebitis (one eye each). CONCLUSIONS: Augmented trabeculectomy with mitomycin C and 5-fluorouracil may serve as the primary procedure in a selected group of paediatric patients with glaucoma.

A complex chromosome translocation resulting in deletion 11p and associated with uveal colobomata.

A boy with a complex chromosome rearrangement of chromosomes 3, 10, and 11 resulting in a deletion of the short arm of chromosome II is presented. The occurrence of uveal coloboma as an isolated congenital malformation might suggest a chromosomal site for this ocular anomaly in proximity to the aniridia locus.

Refraction and keratometry in 40 week old premature (corrected age) and term infants.

AIM: To compare refraction and keratometry readings between premature and term babies at 40 weeks' postconceptional age (PCA), and the possible effect of birth weight (BW) and gestational age (GA) on ocular parameters. METHODS: 33 preterm babies hospitalised in the neonatal unit between January and March 2002 were matched with 33 term babies born within the same period and hospitalised in the same unit. The preterm group underwent funduscopy at 4-5 weeks after delivery. Ophthalmic examination at 40 weeks' PCA included cycloplegic retinoscopy, funduscopy, and keratometric measurements. Mean and standard deviation of refraction, astigmatic power (plus cylinder), axis of astigmatism, and keratometric reading were calculated and compared between groups and correlated with BW and GA in the premature babies. RESULTS: Retinopathy of prematurity (ROP) stage 1 or 2 was noted in 88% of the premature babies on the first funduscopy examination, but only in 36% by the corrected age of 40 weeks. Statistically significant between groups differences were found for cycloplegic refraction (p = 0.02 for both eyes) and keratometry (p = 0.001 for both eyes). GA and BW had no impact on the refractive and keratometric findings in the preterm babies. CONCLUSIONS: Babies with mild ROP at the corrected age of 40 weeks have mild hypermetropia compared to the moderate hypermetropia found in term babies (a difference of 50%), and they have higher and steeper keratometric values. The greater corneal curvature may contribute to the development of myopia. Ophthalmologists and parents need to be aware of the possibility of visual dysfunction already very early in life even in relatively older premature infants.

Keratometry measurements in preterm and full term newborn infants.

AIM: To evaluate the relation between postconceptional age and birth weight with keratometric values in preterm and full term infants. METHODS: A prospective cross sectional study was performed. The cohort included 99 infants (198 eyes) admitted to the Neonatal and Neonatal Intensive Care Units at Schneider Children's Medical Center of Israel from February to September 2002. Keratometry in the horizontal and vertical meridians was performed in both eyes of each infant by two ophthalmologists using an autokeratometer. The results were evaluated according to: postconceptual age (<32 weeks, 32-36 weeks, >36 weeks) and birth weight (<1500 g, 1501-2500 g, >2501 g). RESULTS: Corneal curvature measurements decreased progressively with both postconceptual age and birth weight. At <32 weeks, mean (standard deviation) readings were 63.3 (3.2) diopters (D) for the horizontal meridian and 57.3 (2.6) D for the vertical meridian; corresponding values at >36 weeks were 54.0 (3.0) D and 50.7 (2.4) D. In the <1500 g group, mean (SD) readings were 61.3 (3.9) D for the horizontal meridian and 56.0 (2.9) D for the vertical meridian; corresponding values in the >2501 g group were 51.3 (2.1) D and 48.6 (1.8) D. CONCLUSIONS: There is an inverse relation of horizontal and vertical keratometric values with both postconceptional age and birth weight. Highest readings were noted in the babies with the lowest birth weight and youngest postconceptional age. The decrease in corneal dioptric power to normal values is linear and is apparently part of the normal ocular maturation.

A role of transforming growth factor-beta 1 in the control of corneal neovascularization.

Transforming growth factor beta 1 (TGF-beta 1) has been implicated in both the stimulation of angiogenesis in vivo and in the inhibition of endothelial cell proliferation in vitro systems. In this study we present evidence showing that under certain experimental conditions TGF-beta 1 may inhibit neovascularization in vivo. TGF-beta 1 was incorporated into ethylene vinyl acetate copolymer (Elvax 40) matrixes which provide a valuable vehicle for the controlled and sustained delivery of bioactive peptides. The biological effectiveness of TGF-beta 1 sequestered in polymer matrices was assessed by measuring the inhibition of [3H]-thymidine incorporation into the DNA of cultured mink lung epithelial cells. Neovascularization was induced in both corneas of albino rabbits by one deep-seated limbal silk suture. Elvax 40 matrixes loaded with TGF-beta 1 (release rate, 1.66 ng/24 h) were implanted in rabbit corneal stroma. "Empty" polymers in the contralateral eye served as controls. Aliquots of aqueous fluid were withdrawn, and the presence activity of phagocytic cells was assessed by the production of superoxide anion (O2) which was measured by the superoxide dismutase-inhibitable reduction of ferricytochrome C. Polymer-enclosed TGF-beta 1 implanted in rabbit corneas significantly suppressed angiogenesis (2.65 +/- 0.4 mm compared to 3.05 +/- 0.3 mm in contralateral controls p < 0.05). Superoxide production in 100 microliters aliquots of aqueous fluid was 0.95 +/- 0.18 and 0.6 +/- 0.18 nmol O2/10 min in control eyes and in the eyes bearing sequestered TGF-beta 1, respectively (p < 0.02). These results indicate that under the experimental conditions selected in this study, TGF-beta 1 significantly suppressed in vivo angiogenesis.

Retinopathy of prematurity in multiple-gestation, very low birth weight infants.

Ninety-nine infants from multiple gestation births and weighing < or = 1500 g at birth were matched with infants from single births to clarify the relationship of multiple gestation to retinopathy of prematurity (ROP). There was no significant difference in the incidence of ROP between the twins and the singletons (relative risk [RR] = 0.84, 95% confidence intervals [CI] = 0.61, 1.16). Logistic regression analysis confirmed that very low birth weight (VLBW), not single or multiple gestation, was the most significant predictor of ROP occurrence in either group. In 27 pairs of twin siblings from the original twin group, where both weighed < or = 1500 g at birth, we found that the second-born twin seemed at higher risk for developing ROP, but logistic regression showed that the lower birth weight of the second twin, not birth order, was the more significant predictor of ROP. These results indicate that ROP screening in VLBW twins may be conducted according to the same standard protocols as for singletons.

[Unilateral proptosis due to cholesterol granuloma].

Cholesterol granuloma is a rare cause of unilateral proptosis. We describe a 42-year-old man who presented with painless swelling of the left upper brow of a few months duration. Biopsy showed crystals of cholesterol surrounded by giant cells.

[Recurrent episodes of central retinal artery occlusion].

A 70-year-old man with arteriosclerosis of the carotid arteries developed acute occlusion of the central retinal artery and blindness during intravenous pyelography. 40 minutes after the occlusive episode he underwent paracentesis of the anterior chamber and vision returned (6/18). During the next 2 weeks, while receiving aspirin and then intravenous heparin, there were recurrent episodes of arterial occlusion and blindness that were immediately treated by repeated paracenteses of the anterior chamber. Visual activity again returned to 6/18 and his condition has remained stable as of his last clinic visit, 3 months after the first episode.

Contralateral lateral rectus muscle recession in patients with Duane retraction syndrome type 3.

AIMS: The aim of this study was to evaluate the motor, sensory, functional, and head posture results of recession of the lateral rectus muscle contralateral to the involved eye in patients with exotropic Duane retraction syndrome (DRS) type 3. METHODS: This was a retrospective, longitudinal, observational study of a consecutive clinical case series. Of the 11 patients with DRS type 3 operated on at a tertiary medical center from 1977 to 2012, 8 underwent recession of the lateral rectus muscle contralateral to the involved eye (with combined Y-splitting of ipsilateral lateral rectus muscle in 3 of them). Full ophthalmic, orthoptic, and neurological examination was performed before and after surgery. Main outcome measures included intragroup changes in motor misalignment, abnormal head turn, ocular upshoot, and stereopsis. RESULTS: Mean patient age was 8.75±3.1 years at surgery. Mean exodeviation for distance was -17.3±3.5 prism diopters (PD) preoperatively and -4.0±6.1 PD postoperatively; corresponding values for near were -23.1±7.2 PD and -5.9±8.7 PD. Motor deviation improved by 77% for distance (P=0.017) and 74.5% for near (P=0.01). In 7/8 patients, the postoperative residual exodeviation (distance and near) was <8.0 PD. There was an 80% improvement in head turn, from 15.3±4° before surgery to 3.1±5.0° after (P=0.01). Stereopsis improved significantly in 6/8 patients. Findings remained stable during follow-up (mean duration 35.9±50.8 months, range 5-132 months). CONCLUSIONS: Contralateral lateral rectus muscle recession appears to be a promising technique for the treatment of moderate unilateral DRS type 3, with patients showing significant motor and functional improvement and a decrease in head turn.

Refractive and structural changes in infantile periocular capillary haemangioma treated with propranolol.

PURPOSE: To evaluate the optical and anatomical effects of oral propranolol treatment for infantile periocular capillary haemangioma. METHODS: All children diagnosed with infantile capillary haemangioma in 2008-2010 at a tertiary paediatric medical centre underwent comprehensive evaluation, including imaging, by a multidisciplinary team followed by oral propranolol treatment. Clinical follow-up was performed regularly until the lesions disappeared. Main outcome measures included changes in anatomical extraocular extension, refractive sphere and cylindrical power, and spherical equivalent in the involved eye before and after treatment and between the two eyes. RESULTS: A total of 30 patients (8 male; mean age at diagnosis, 1.6±2.8 months) participated. The lesions affected the left eye in 53.3% and were located preseptally in 83.3%. Four patients (13.3%) received steroids before propranolol. A treatment dosage of 2 mg/kg per day was started at mean age 5.0±4.5 months, 3.3±4.3 months from disease onset. Side effects occurred in 11 patients and warranted a dose reduction (to 1 mg/kg per day) in 3 and treatment termination in 1. Findings were significant for mean reduction in involved extraocular area (P<0.0001), post-treatment reduction in mean cylindrical power in involved eyes (P=0.02), pre- and post-treatment differences in mean cylindrical power between involved and uninvolved eyes (P=0.02 and P=0.01, respectively), and post-treatment change in absolute values of mean spherical power between involved and uninvolved eyes (P=0.025). CONCLUSIONS: Early diagnosis of infantile periocular capillary haemangioma and prompt treatment with propranolol lead to a significant reduction in the involved ocular area, in astigmatism, and prevent ocular/facial disfiguration/deformation, without rebound. Propranolol is recommended as the preferred treatment compared with other accepted therapies.

Uveitis in juvenile Behçet's disease: clinical course and visual outcome compared with adult patients.

PURPOSE: To characterize the disease course and visual outcome of uveitis in juvenile Behçet's disease (BD) compared with adults. METHODS: The study population included 13 children (mean age 14+/-2.4 years; 22 eyes) and 16 adults (mean age 30+/-8.8 years; 27 eyes) with uveitis in BD diagnosed between 1997 and 2007. RESULTS: The male/female ratio was 1.6:1 in the paediatric group and 3:1 in the adult group. Five children (38%) and four adults (25%) had complete BD. Mean duration of follow-up for both groups was 4.7 years. The children had more acute exacerbations (4.1+/-2.7 vs2.3+/-1.5, P=0.054). Treatment in both groups included systemic steroids and immunosuppressive agents. In children, mean initial visual acuity in the affected eyes (n=22) was 0.6+/-0.7 logMAR (range, 0-2.2). It decreased during exacerbations in 15 eyes (68%; mean, 1.6+/-0.8 logMAR), severely reduced (worse than 1 logMAR) in 11 eyes (50%; mean, 2.0+/-0.45 logMAR), and improved significantly in 12 of 13 promptly treated eyes (92%; 6/12 or better in 11; mean 0.2+/-0.4 logMAR, P<0.001). The visual outcome pattern was similar in the adults. CONCLUSIONS: Uveitis in juvenile BD is characterized by frequent exacerbations of explosive nature with profoundly reduced visual acuity. Similar disease pattern was observed in children and adults, as well as in patients with complete or incomplete disease. Early diagnosis, even before all systemic criteria are fulfilled, is important because early aggressive therapy can achieve long-term useful visual acuity.

Intralesional and sub-Tenon's infusion of corticosteroids for treatment of refractory periorbital and orbital capillary haemangioma.

PURPOSE: To evaluate the effect of combined intralesional and sub-Tenon's administration of corticosteroids for the treatment of refractory periocular and orbital capillary haemangioma in a retrospective, non-comparative study. METHODS: Seven infants with resistant periorbital and orbital capillary haemangioma who attended our tertiary centre from 2000 to 2005 were treated with an intralesional injection of a mixture of betamethasone 6 mg/cc and triamcinolone 10 mg/cc, by body weight, together with sub-Tenon's infusion of betamethasone 6 mg/cc and triamcinolone 40 mg/cc of a volume of 1 cc, close to the orbital lesion, in the same session. Visual axis, proptosis, pre- and post-treatment changes in four refractive parameters, and parental satisfaction were evaluated. RESULTS: None of the babies had proptosis or visual axis obstruction after treatment. Mean spherical power decreased by 22.7% (P=0.06). Mean spherical equivalent decreased in 34%, but the difference was not statistically significant (P=0.09). No early or late ocular side effects were observed. Mean intraocular pressure results were normal before and immediately after treatment, and during the follow-up period. Parental satisfaction score during follow-up was 9/10. Mean time to improvement was 96.43+/-58.3 days. CONCLUSIONS: Combined local corticosteroid administration by posterior sub-Tenon's infusion and intralesional injection in babies with extensive capillary haemangioma is associated with a satisfactory anatomical and functional outcome and there were no ophthalmic side effects.

Combined propofol sedation with sub-Tenon's lidocaine/mercaine infusion for strabismus surgery in adults.

AIMS: To evaluate the safety and efficacy of propofol sedation combined with sub-Tenon's anaesthesia for strabismus surgery in adults. METHODS: Thirty-two consecutive patients aged 31-85 years underwent strabismus surgery under general (n=16) or local (n=16) anaesthesia. In the local anaesthesia (study) group, sedation was induced with a loading dose of midazolam, fentanyl, and propofol, followed by continuous infusion of propofol, 3-6 mg/k/h to deep sedation. A nasal tube was inserted to prevent airway obstruction. Sub-Tenon's anaesthesia included infusion of a 3-4 ml mixture (50 : 50) of lidocaine 2%/mercaine 0.5%. General anaesthesia consisted of premedication with midazolam, followed by fentanyl, esmeron-bromate, propofol, and tracheal intubation. Duration of surgery and anaesthesia, intraoperative oculocardiac reflex and arrhythmias, time to discharge, postoperative pain, nausea and vomiting, and patient and surgeon satisfaction were evaluated. RESULTS: The local anaesthesia group had a significantly shorter operative and anaesthesia time, fewer episodes of oculocardiac reflex or arrythmia/bradycardia requiring treatment, fewer early or late episodes of nausea and vomiting, and less pain. The patients and surgeon in this group reported higher satisfaction. CONCLUSION: Propofol sedation with local sub-Tenon's injection of lidocaine/mercaine is recommended for the induction and maintenance of anaesthesia during unilateral or bilateral strabismus surgery in adults. The method is quick and effective, without systemic or ocular side effects.

Xenobiotic-inducible expression of murine glutathione S-transferase Ya subunit gene is controlled by an electrophile-responsive element.

Glutathione S-transferase (GST) Ya subunit gene expression is induced in mammalian tissues by two types of chemical agents: (i) planar aromatic compounds (e.g., 3-methylcholanthrene, beta-naphthoflavone, and 2,3,7,8-tetrachlorodibenzo-p- dioxin) and (ii) electrophiles (e.g., trans-4-phenyl-3-buten-2-one and dimethyl fumarate) or compounds easily oxidized to electrophiles (e.g., tert-butylhydroquinone). To study the mechanism of this induction, we have introduced deletions in the 5' flanking region of a mouse GST Ya subunit gene, fused it to the coding sequence for chloramphenicol acetyltransferase (CAT) activity, and transfected the Ya-CAT genes for expression into hepatoma cells. We show that a single cis-regulatory element, between nucleotides -754 and -713 from the start of transcription, is responsible for the induction by both planar aromatic and electrophilic compounds. Using murine hepatoma cell mutants defective in either the Ah-encoded aryl hydrocarbon receptor (BPrc1 mutant) or in cytochrome P1-450 gene (c1 mutant), we show that induction by planar aromatic but not by electrophilic inducers requires a functional Ah receptor and cytochrome P1-450 activity. From this it is concluded that Ya gene activation by planar aromatic compounds involves metabolism of these inducers by the phase I xenobiotic-metabolizing cytochrome P1-450 system into electrophilic compounds, which is consistent with a recently proposed model [Prochaska, H. J. & Talalay, P. (1988) Cancer Res. 48, 4776-4782]. Therefore, the regulatory sequence of the Ya gene should be considered an electrophile-responsive element (EpRE) activated exclusively by inducers containing an electrophilic center. An EpRE-containing 41-bp oligonucleotide ligated at the -187 site of the Ya gene promoter confers upon it an increase in basal activity and xenobiotic inducibility. The basal activity augments with the number of EpRE copies. DNase I protection patterns show the protection of the EpRE domain by a nuclear factor(s) that becomes more abundant upon exposure of Hepa 1c1c7 cells to tert-butylhydroquinone.

Two adjacent AP-1-like binding sites form the electrophile-responsive element of the murine glutathione S-transferase Ya subunit gene.

An electrophile-responsive element (EpRE) in the 5' flanking region of the mouse glutathione S-transferase Ya subunit gene was recently found to be responsible for the induction of gene expression by xenobiotics that contain or acquire by metabolism an electrophilic center. We now find that this EpRE is composed of two adjacent 9-base-pair motifs related in sequence to the AP-1 binding site, a transcriptional enhancer originally identified as the phorbol 12-myristate 13-acetate (PMA) response element and known to be regulated by the binding of protein products of c-jun and c-fos genes. Synthetic oligonucleotides representing each of the AP-1-like binding sites of the EpRE and the AP-1 site consensus sequence were prepared and assayed for their enhancer activity and inducibility by tert-butylhydroquinone, beta-naphthoflavone, and PMA. Single AP-1-like sequences showed a lower enhancer activity than an AP-1 consensus sequence and no inducibility. Two adjacent AP-1-like sites were found to act synergistically and to confer inducibility beyond that observed for a single AP-1 consensus sequence. Examination of the PMA-responsive region of a number of genes shows the presence of adjacent AP-1-like sites and indicates that the structure of the EpRE found in the Ya gene may occur more generally and may be important in regulating the magnitude of the electrophilic response. The present study demonstrates the binding and transactivation of the EpRE by Jun and Fos and indicates that the AP-1 site is part of the EpRE. The induction by PMA or tert-butylhydroquinone appears to be independent of protein kinase C activity since it is not affected by inhibitors of this enzyme.

Efficacy of diclofenac versus dexamethasone for treatment after strabismus surgery.

OBJECTIVE: To compare the efficacy of topical diclofenac sodium 0.1% versus dexamethasone 0.1% on the conjunctival healing process and on intraocular pressure (IOP) after strabismus surgery. DESIGN: A randomized clinical trial. PARTICIPANTS: Forty consecutive pediatric patients who underwent strabismus surgery. INTERVENTION: The patients were assigned before surgery to receive topical diclofenac 0.1% (study group, 20 patients) or dexamethasone 0.1% (control group, 20 patients) from immediately after surgery to up to 4 weeks after surgery (both combined with chloramphenicol 0.2%, polymyxin B sulfate 2500 U). MAIN OUTCOME MEASURES: Between-group comparison of five parameters: patient discomfort, conjunctival chemosis, inflammation, gap, and intraocular pressure (IOP) at 1, 2, and 4 weeks after surgery. RESULTS: At postoperative week 2, the diclofenac-treated group showed significantly less patient discomfort and less conjunctival inflammation, edema, and gap than the dexamethasone group (P: = 0.003, P: = 0.04, P: = 0.02, P: = 0. 001, respectively). At week 4, the study patients continued to show less discomfort and conjunctival gap (P: = 0.02). The dexamethasone group showed a significant change in IOP between the preoperative and the fourth postoperative week (P: = 0.001 in the right eye, P: = 0.0005 in the left eye) and an increased prevalence of higher IOP during the fourth postoperative week (P: = 0.01 in the right eye, P: = 0.02 in the left eye). Thirty-eight percent of the dexamethasone group showed an increase in IOP to more than 21 mmHg during the four postoperative weeks. No increase in IOP was noted in the diclofenac group. CONCLUSIONS: Topical diclofenac is superior to dexamethasone for each of the five postoperative parameters examined. Its maximal effect occurred at 2 weeks after surgery, without an increase in IOP or in local subconjunctival hemorrhage.