Epistaxis due to traumatic intracavernous aneurysm: case report

A patient who noted the onset of repetitive arterial epistaxis and progressive unilateral visual impairment 2 months after a blunt head injury was found to have a traumatic aneurysm of the cavernous portion of internal carotid artery (ICA). The epistaxis resolved and his vision recovered following a trapping procedure. This case and a review of previously reported cases emphasize the importance of early cerebral angiography in patients with post-traumatic epistaxis and visual failure.

Synthesis and immunosuppressive activities of conformationally restricted cyclosporin lactam analogues

Cyclosporin A (CsA, 1), an immunosuppressive cyclic undecapeptide, is known to adopt predominantly a single conformation in chloroform solution, characterized in part by a type II' beta-turn encompassing Abu-Sar-MeLeu-Val (residues 2-5). In order to evaluate whether this beta-turn is bound by the receptor, we previously had prepared a conformationally restricted beta-turn analogue, (delta-lactam) CsA (2), which was found to retain only weak immunosuppressive activity, a result that could indicate that steric hindrance between receptor and the lactam atoms in 2 diminished activity or that the type II' beta-turn is not a feature in the bioactive conformation of CsA. In an attempt to distinguish between these two possibilities, we have synthesized two new CsA analogues, (gamma-lactam) CsA (3) and (des-N-methyl-lactam) CsA (4), which contain less sterically demanding conformational restrictions. The immunosupressive activity of each analogue (4-13% and 7-17%, respectively, relative to CsA), measured in an assay that determined the inhibition of concanavalin A stimulated thymocytes, is essentially equipotent with that of the delta-lactam. The chemical shifts and temperature dependencies of the protons in analogues 3 and 4 are very similar to the corresponding protons in CsA and in 2, which suggest that the solution conformations of the small lactam analogues are very similar to that of the delta-lactam 2. The synthesis of the lactam components and the corresponding CsA derivatives is described. Reduction in the size of the lactam ring does not lead to enhanced immunosuppressive activity.

Characterization of the major brain osmolytes that accumulate in salt-loaded rats

Previous studies demonstrated an accumulation of "idiogenic osmoles" in the brain with chronic salt loading. Amino acids are known to constitute a portion of these solutes, but the balance of the solutes has yet to be fully characterized. In the present study, 1H-nuclear magnetic resonance (NMR) spectroscopy and biochemical assays of rat brain were used to identify and quantify changes in organic solutes in two different animal models of hypernatremia: hypertonic salt loading and water deprivation. Five days of salt loading increased plasma sodium concentration (PNa) to 165 meq/l and 3 days of water deprivation increased PNa to 151 meq/l, compared with 141 meq/l in controls. Amino acids, methylamines, and polyols were all significantly higher in salt-loaded animals compared with controls. Specifically, higher contents of glutamine (+65%), glutamate (+27%), myo-inositol (+36%), phosphocreatine + creatine (PCr + Cr) (32%), glycerophosphorylcholine (GPC) (+75%), and choline (+114%) were observed. Sorbitol and betaine, osmolytes known to accumulate in the hypertonic inner medulla, were present in low amounts in the brain and were unchanged with salt loading. In contrast to the results with salt loading, no accumulation of brain organic solutes was detected after 3 days of water deprivation. Based on these findings, we propose that amino acids, methylamines, and polyols function as osmoregulatory solutes in the brains of salt-loaded rats in a manner similar to that observed in other biological systems, whereas 3 days of water deprivation is an insufficient stimulus for their accumulation.

Chorioretinal scarring following the Faden operation. A retrospective study of 100 procedures

Following reports of a high incidence of chorioretinal scarring related to the Faden Procedure, a retrospective study was carried out at Moorfields Eye Hospital. One hundred unselected Faden procedures were followed up with orthoptic and fundoscopic examination. Our indications and technique for performing this operation are described. A 7% incidence of chorioretinal scarring was noted; this compares well with previously published figures for conventional squint surgery and this operation should therefore be considered safe.

Acoustic neurinoma presenting as intratumoral bleeding

The authors report a case of acoustic neurinoma presenting as intratumoral bleeding. This is the tenth reported occurrence. The literature is reviewed. All cases that have been reported have appeared with sudden onset of headache, vomiting, and decreased levels of consciousness. Aneurysm rupture, an arteriovenous malformation, or other vascular anomalies are suspected first. Preexisting unilateral hearing impairment is a valuable clue to differential diagnosis. Contrast-enhanced computed tomographic scans and cerebral angiograms are important tools for correct diagnosis. The tumor size (greater than 2 cm) and the thin, dilated vessels within the tumor are considered as pathogenetic factors for bleeding. When neurological status is not stable, placement of a ventriculoperitoneal shunt followed by urgent extirpation of the tumor is indicated.

The effects of strabismus surgery on anterior segment circulation

Anterior segment circulation was assessed in 35 adults one day after squint surgery by clinical observation and low-dose fluorescein iris angiography. Seventeen patients had primary vertical rectus muscle surgery and all showed angiographic evidence of ischaemia. No ischaemia was found in the 15 patients who had secondary vertical rectus muscle surgery, or any horizontal rectus muscle surgery. The staged group had intermediate findings between the above two. Age, dysthyroid eye disease and type of conjunctival incision did not correlate with fluorescein iris angiographic sector-filling delay on the first post-operative day. The time taken for the sector with delay to fill becomes less during the first two post-operative weeks. Redistribution of iris filling persists, however. This data suggest that the safe interval before further muscle surgery can be done is shorter than has previously been assumed. Since the anterior ciliary arteries do not reform into canals the probable mechanism of redistribution of blood flow is from the long posterior ciliary arteries and increased capacity of the collateral circulation.

Cystic meningioma--a case report

A case of cystic meningioma is presented. The cyst in this particular case is within the tumor. Preoperatively, the diagnosis has been confused with astrocytoma, hemangioblastoma and neuroblastoma. Retrospectively, we conclude that careful evaluation of CT scan and angiogram will lead to accurate diagnosis.

Treatment of sixth nerve palsy in adults with combined botulinum toxin chemodenervation and surgery

This study reports the results of treating unrecovered sixth nerve palsy in adults with a combination of botulinum toxin and surgery. Twenty-two adults, 11 with unilateral and 11 with bilateral unrecovered sixth nerve palsy, were treated with injections of botulinum toxin to the contracted medial rectus followed by transposition surgery to the vertical rectus muscles. This management technique produced a satisfactory reduction in esotropia, averaging 46 prism diopters (PD), comparable with that achieved by conventional surgery in other series. The advantages of this form of treatment are discussed.

Hepatocellular carcinoma presenting as intracranial metastasis

The authors describe two cases of hepatocellular carcinoma presenting with the initial manifestations of an intracranial mass lesion without any symptoms or signs suggestive of the primary hepatic site of the tumor. The only clue of hepatic dysfunction was mild elevation of the SGOT and SGPT. The diagnosis could not be made until operation. It is unusual for the initial clinical presentation to be related to intracranial metastasis without evidence of hepatic involvement. Measurement of the serum alpha-fetoprotein and liver ultrasound examination are the most helpful screening tools for diagnosing hepatocellular carcinoma. The literature of hepatoma with cranial metastasis is reviewed.

Botulinum toxin A-induced protective ptosis in corneal disease

Botulinum toxin A produces a temporary, flaccid ptosis when injected into the levator palpebrae superioris muscle. The resulting protective ptosis was used to aid healing in 21 cases of indolent ulceration, and, prophylactically, in 4 cases of neuroparalytic keratitis. Of the indolent ulcers, 90% healed completely. In all but one case, the cornea was covered completely by the lid and complete ptosis was produced in 75% of cases in an average of 3.6 days, lasting for 16 days on average before recovery began. Recovery of levator function was complete in 8.5 weeks on average. Superior rectus underaction was seen in 68% of cases but this recovered completely in all cases in an average of 6 weeks. Impression cytology showed a trend toward normal conjunctival morphology as healing progressed.

Surgical management of nystagmus

The indications and techniques for the management of nystagmus are described and discussed. Surgical treatment is of value in patients with consistent head posture. Guidelines for surgery are given.

Botulinum toxin A induced protective ptosis

Botulinum Toxin A injected into the levator palpebrae superioris produces a flaccid ptosis of the upper lid and provides a safe and effective protection for the cornea to aid healing in indolent ulceration or as prophylaxis when there is fifth or seventh cranial nerve damage. Fifteen patients have received this treatment. Levator paresis, producing ptosis for a mean of 2-3 weeks and recovering in a mean of 8.1 weeks was successfully produced in all patients and complete corneal healing was produced in 80% of patients. The major side effect was weakness of the superior rectus muscle which occurred in 80% of cases and lasted a mean of 6 weeks.

Studies on the biosynthesis of the alpha-glucosidase inhibitor acarbose: valienamine, a m-C7N unit not derived from the shikimate pathway

Feeding experiments with Actinoplanes sp. SN223/29 showed that 3-amino-5-hydroxy-[7-13C]benzoic acid is not incorporated into acarbose (I). The valienamine moiety of I is thus not derived in the same way, from the shikimate pathway, as the m-C7N units in the ansamycin, mitomycin and ansamitocin antibiotics. Feeding experiments with [U-13C3]-glycerol followed by analysis of I by multiple quantum NMR spectroscopy support this conclusion and point to formation of the valienamine moiety by cyclization of a heptulose phosphate which arises from a triose phosphate via successive transfer of two 2-carbon fragments by transketolase, as proposed by Pape and co-workers.

The diagnosis and surgical management of acquired bilateral superior oblique palsy

Thirty-four patients with surgically treated bilateral superior oblique palsy are presented. The patients are divided into three groups: Symmetrical palsies, Asymmetrical palsies, A group in whom the bilaterality was initially masked. Bilaterality should be suspected in all cases of traumatic IVth nerve paresis, and particularly in cases with a large 'V' pattern, excyclo deviation of more than 10 degrees on down-gaze and when right hypertropia switches to left hypertropia on lateral down-gaze. Bilateral Harada-Ito procedures alone 'cured' 11 of 17 patients (65 per cent) in groups 1 and 2, and is the operation of choice in acute bilateral superior oblique palsy. Cyclo deviation was reduced by a mean of 5.5 degrees in the primary position and by 6-10 degrees in down-gaze. Patients initially managed with other surgery had a more complicated surgical course and required more operations. Seven patients who initially demonstrated only gross fusion recovered good fusion after Harada-Ito surgery.

Management of ipsilateral ptosis with hypotropia

Thirty-one patients presented for surgical correction of unilateral hypotropia of the globe and blepharoptosis. The hypotropia and pseudoptosis were corrected by Knapp procedures. The Bell's phenomenon was thereby improved, allowing safe correction of the true ptosis, generally by an anterior levator resection whose magnitude depended on measured levator function.

Further studies on the biosynthesis of chlorothricin

Feeding experiments with [U-13C3]- and (2R)-[1-2H2]glycerol showed that glycerol is incorporated intact into carbon atoms 22, 23 and 24 of the aglycone of chlorothricin. C-1 of glycerol gives rise to C-22 with retention of one atom of deuterium, which occupies the H-22R position. A mechanism for the assembly of the aglycone is proposed which invokes phosphoenolpyruvate as the direct precursor of the 3-carbon moiety and a Baeyer-Villiger oxidation as the mode of formation of the macrocyclic lactone functionality. A feeding experiment with [1,2-13C2]succinate suggests that the propionate units of the aglycone polyketide are formed entirely via the methylmalonyl-CoA mutase reaction. The formation of the two 2,6-dideoxy-D-rhamnose moieties of chlorothricin from glucose was shown to involve replacement of the 2-hydroxyl group of the sugar by hydrogen with inversion of configuration at C-2. This contrasts with the retention stereochemistry observed earlier for the analogous formation of the 2,6-dideoxyhexose moiety of the antibiotic granaticin.

Elevating the hypotropic globe

Twelve consecutive cases are reviewed of unilateral hypotropia due to various causes. In most of them the presenting complaint was of ipsilateral blepharoptosis. Some patients had undergone previous ineffective surgery. The surgical techniques employed and the results obtained are discussed, with emphasis on the necessity to test for inferior rectus restriction. Some interesting sensory results are also noted.

Paralytic strabismus: the role of botulinum toxin

Five adults with acute extraocular muscle palsies followed by limited recovery of muscle function were treated with injections of botulinum toxin A to the ipsilateral antagonist of the affected muscle. Three were cases of unilateral sixth nerve palsy, one of bilateral sixth nerve palsy, and one of third nerve palsy. After a period of paralysis, during which the strabismus was overcorrected, the injected muscle recovered and binocular sensory and motor functions were restored and have been maintained for periods of up to 21 months. The treatment is a safe and effective alternative to surgery, particularly in cases in which a general anaesthetic is not advisable.

Treatment of strabismus in adults with botulinum toxin A

Eighty-five adults with horizontal concomitant strabismus were treated with an injection of a low dose of botulinum toxin A (BTXA) into the lateral or medial rectus muscle. The ocular deviation was reduced by an average of 60% independently of its size and whether or not surgery had previously been performed. The change was temporary, however, except in those cases with binocular functions, when fusion was re-established. Repeated low dose injections can maintain the improvement, but at higher doses, although larger reductions are produced, temporary local side effects--ptosis and vertical strabismus--are common. The technique is simple, well tolerated, and has no systemic side effects.

Strabismus in childhood

Strabismus is a common childhood disorder which is underdiagnosed and undertreated. A detectable squint at any age is abnormal and should be investigated to exclude significant ophthalmological or systemic disease. Early detection and treatment will enable normal and near-normal binocular functions to be achieved in many children.