A major review of antimetabolites in glaucoma therapy

Antimetabolites have been used in combination with filtering surgery to improve surgical results for more than 10 years. Based on research published since the introduction of antimetabolites right up to date, we discuss the various forms of antimetabolites that have been used, including drugs and irradiation. Among the drugs used, mitomycin C and 5-fluorouracil are the most prominent. We discuss the background of these agents, the progress in the use of antimetabolites and the research done on these drugs. These agents have been used both intra-operatively and perioperatively. We discuss the indications for their use, their mode of action, the techniques of usage, their variations as well as the complications and the treatment of complications.

Risk factors for failures of trabeculectomies performed without antimetabolites

AIMS

To assess the risk profile for the failure of trabeculectomies in a large group of patients who were selected to be operated on without the use of antimetabolites. This was done in an effort to find subgroups of patients who may not need antimetabolites for primary procedures.

METHODS

Consecutive patients scheduled for routine trabeculectomies were operated during a 4 year period and were followed up for at least 6 months postoperatively. Patients were regularly examined in the glaucoma unit and by their local ophthalmologists. Pre- and postoperative data were evaluated and success rates determined.

RESULTS

709 eyes of 566 patients were operated on; 534 eyes of 534 patients (94.4%) were finally evaluated. The mean follow up was 27.9 (SD 13.6) months with a range of 6-62 months. Success rates for complete surgical success ranged from 59% in the best group with pigmentary dispersion syndrome to 0% in the worst group with neovascular glaucoma. Success rates of patients with POAG, pseudoexfoliation, chronic angle closure, pigmentary dispersion syndrome, and dysgenetic glaucoma were similar. Failure rates ranged from 11% in the best group (pseudoexfoliation) to 80% in the worst group (neovascular glaucoma). Failure rates were high in complicated forms of glaucoma such as traumatic (30%), buphthalmus (40%), and uveitic (50%). For repeat trabeculectomies, the failure rate was 49% (20 of 41 eyes). The mean time until failure ranged from 2.7 months (traumatic) to 15.5 months (pigmentary dispersion syndrome) and was 4.9 months for repeat trabeculectomies.

CONCLUSION

Trabeculectomy performed in selected groups of patients has a favourable outcome without the use of antimetabolites. It may be possible to avoid antimetabolites in these groups of patients for primary procedures.

Clinical, serologic, and parasitologic follow-up after long-term allopurinol therapy of dogs naturally infected with Leishmania infantum

Canine leishmaniasis usually is treated with antimony compounds, but frequent relapses, adverse effects, high costs, and development of resistance to long-term antimonial therapy emphasize the importance of searching for alternative antileishmanial drugs. Allopurinol was used at a dosage of 10 mg/kg/day PO to treat 10 dogs naturally infected with Leishmania infantum for a period of 2-24 months. Nine dogs recovered within 2-6 months of chemotherapy, and no relapses were observed during the treatment of up to 20 months. However, 3 of 4 dogs relapsed after treatment was discontinued. These dogs again recovered clinically when therapy was resumed. Parasite-specific immunoglobulin concentrations (IgG2) were high in all dogs before therapy and remained high even in clinically cured dogs during or after therapy. On the other hand, specific IgG1 reactions, which have been shown to be detectable in symptomatic animals, persisted in 7 dogs for long periods after clinical recovery. Three of these dogs relapsed within 2-4 weeks after interrupting therapy. However, 1 dog with no detectable specific IgG1 reaction at the end of therapy did not relapse in the following 4 months. Parasites could be detected in 8 of 9 dogs after clinical improvement by in vitro cultivation or polymerase chain reaction (PCR) testing of lymph node aspirates. In 4 of these dogs, parasites also were detected in blood samples by PCR. Hence, these clinically cured dogs must be regarded as reservoirs of Leishmania and allopurinol cannot be recommended in endemic areas.

Combined effect of Interceed and 5-fluorouracil on delayed adjustable strabismus surgery

AIMS/BACKGROUND

To discover a more reliable method of performing delayed suture adjustment as a basis to investigate whether delayed adjustment actually provides more stable results. In order to prevent the formation of postoperative adhesions and delay the time of adjustment, an animal study was performed to determine the combined effect of physical barriers, Viscoat and Interceed, and a pharmacological agent, 5-fluorouracil (5-FU).

METHODS

38 rabbit eyes were divided into three groups. After recession of the superior rectus muscle (SRM), 5-FU was applied beneath and over the SRM in group 5-FU. Group I-f had Interceed and 5-FU and group I-fv, Interceed, 5-FU, and Viscoat. Delayed adjustment was performed once on each SRM at 1, 2, and 3 weeks postoperatively. The possible length and the necessary force to adjust as well as the degree of adhesions were recorded.

RESULTS

5-FU delayed the adjustment for up to 1 week after surgery in three out of four eyes. Combined use of Interceed and 5-FU could delay the adjustment for up to 1 week after surgery in three out of five eyes. Addition of Viscoat could delay the adjustment for up to 1 week after surgery in four out of five eyes. Adjustment was possible on only one of four eyes thereafter.

CONCLUSIONS

Combined use of Interceed, 5-FU, and Viscoat could delay the adjustment in rabbits until 1 week postoperatively.

Determination of the activity of pyrimethamine, trimethoprim, sulfonamides, and combinations of pyrimethamine and sulfonamides against Sarcocystis neurona in cell cultures

Equine protozoal myeloencephalitis (EPM) is a neurologic syndrome in horses from the Americas and is usually caused by infection with the apicomplexan parasite, Sarcocystis neurona. The activities of pyrimethamine, trimethoprim, sulfachloropyridazine, sulfadiazine, sulfadimethoxine, sulfamethoxazole, sulfamethazine, and sulfathiazole were examined against developing S. neurona merozoites in bovine turbinate cell cultures. A microtiter plate host cell lesion based assay was used to determine the effects of agents on developing merozoites. A cell culture flask assay was used to determine if selective concentrations of the agents killed or only inhibited development of S. neurona. Pyrimethamine was coccidiocidal at 1.0 microg/ml and trimethoprim was coccidiocidal at 5.0 microg/ml. None of the sulfonamides had activity when used alone at 50.0 or 100.0 microg/ml. Combinations of sulfonamides (5.0 or 10.0 microg/ml) with 0.1 microg/ml pyrimethamine demonstrated improved activity.

Glaucoma surgery: are there new perspectives in perioperative pharmacology?

The literature directed at perioperative pharmacologic advances in relation to glaucoma filtration surgery is reviewed. The successful use of subconjunctival anesthesia demonstrates a new alternative in preoperative glaucoma surgical anesthesia. The intraoperative use of the antimetabolites mitomycin C and 5-fluorouracil in both traditional filtration and glaucoma drainage implantation surgery has been expanded. The use of the antifibrinolytic agents urokinase and recombinant tissue plasminogen activator adds a new and controversial dimension to postoperative pharmacologic therapy.

Fornix-based versus limbal-based conjunctival flaps in initial trabeculectomy with postoperative 5-fluorouracil: four-year follow-up findings

PURPOSE

To evaluate the safety and efficacy of fornix-based conjunctival flap versus limbal-based flap in initial trabeculectomy with postoperative 5-fluorouracil.

METHODS

29 patients (58 eyes) with bilateral primary open-angle glaucoma (POAG) were included in the study. Patients were randomly assigned to have a fornix-based conjunctival flap in one eye and a limbal-based flap in the other, followed by subconjunctival injection of 5-fluorouracil.

RESULTS

Mean intraocular pressure (IOP) 2 years after treatment was 12.9 +/- 12.25 mmHg in eyes with fornix-based conjunctival flaps and 13.1 +/- 16.81 mmHg in eyes with limbal-based conjunctival flaps. At 4 years, mean IOP was 14.7 +/- 9.61 mmHg in eyes with fornix-based conjunctival flaps and 15.1 +/- 7.29 mmHg in eyes with limbal-based conjunctival flaps. Cumulative success at 4 years (IOP < 21 mmHg) was 89.6% in eyes with fornix-based conjunctival flaps versus 86.2% in eyes with limbal-based conjunctival flaps with medications. Cystic leaking blebs occurred in two cases, both with limbal-based flaps.

CONCLUSION

The efficacy of limbal- and fornix-based conjunctival flaps in initial trabeculectomy with postoperative 5-fluorouracil was not significantly different; however, in this study cystic leaking blebs were encountered only in eyes with limbal-based conjunctival flaps.

Adenovirus-mediated combined suicide gene and interleukin-2 gene therapy for the treatment of established tumor and induction of antitumor immunity

The antitumor effect of the combined transfer of a suicide gene and a cytokine gene was evaluated in the present study. Adenoviruses expressing Escherichia coli cytosine deaminase (AdCD) and adenoviruses expressing murine interleukin-2 (AdIL-2) were utilized for the treatment of established tumors. The mice were inoculated s.c. with FBL-3 erythroleukemia cells and 3 days later received an intratumoral injection of AdCD in the presence or absence of AdIL-2 followed by intraperitoneal 5-fluorocytosine (5-FC) administration. The results demonstrated that tumor-bearing mice treated with AdCD/5-FC in combination with AdIL-2 showed more potent inhibition of tumor growth and survived much longer than did mice treated with AdCD/5-FC, AdIL-2, adenovirus expressing beta-galactosidase/5-FC or phosphate-buffered saline. The tumor mass showed obvious necrosis and inflammatory cell infiltration, and more CD4+ and CD8+ T cells infiltrating the tumor after combined therapy. The splenic natural killer and cytotoxic T lymphocyte activities increased significantly in the mice after combined therapy with AdCD/5-FC/AdIL-2. Our results demonstrate that therapy combining a suicide gene and IL-2 gene can inhibit the growth of established tumors in mice significantly and induce antitumor immunity of the host efficiently.

Enhanced plasma cholesterol lowering effect of retrovirus-mediated LDL receptor gene transfer to WHHL rabbit liver after improved surgical technique and stimulation of hepatocyte proliferation by combined partial liver resection and thymidine kinase--ganciclovir treatment

In this study we report an improved method for in vivo gene transfer to liver. Repeated injections of Moloney murine leukemia virus-derived retroviruses containing LDL receptor cDNA were given to the portal vein in combination with a 10% partial liver resection and stimulation of hepatocyte proliferation by plasmid/liposome-mediated thymidine kinase gene transfer and ganciclovir treatment. The method was used for the treatment of LDL receptor deficiency in Watanabe heritable hyperlipidemic rabbits. We demonstrate an increase in hepatocyte proliferation index by thymidine kinase and ganciclovir treatment from 0.9 to 1.35% and a maximum of 35% decrease in total plasma cholesterol level 2-3 months after the gene transfer. A 20% decline was still present after a 52-week follow-up period. A 50% decrease was also observed in plasma triglycerides. Liver function tests indicated a transient increase in plasma alkaline phosphatase level up to 12 weeks after the gene transfer. In situ PCR and RT-PCR analyses indicated that the transgene was present in periportal areas and was transcribed to mRNA 1 week after the gene transfer. Because of the relatively simple and controllable technique we suggest that repeated retrovirus injections via a portal vein catheter together with the limited partial liver resection and plasmid/liposome-mediated thymidine kinase gene transfer-ganciclovir treatment may be used to improve the results of retrovirus-mediated liver gene therapy.

Intercellular delivery of thymidine kinase prodrug activating enzyme by the herpes simplex virus protein, VP22

We demonstrate that fusion proteins consisting of the herpes simplex virus (HSV) transport protein VP22 linked in frame to HSV thymidine kinase (tk) retain the ability to be transported between cells. In vivo radiolabelling experiments and in vitro assays show that the fusion proteins also retain tk activity. When transfected COS cells, acting as a source of the VP22-tk chimera, were co-plated on to gap junction-negative neuroblastoma cells, ganciclovir treatment induced efficient cell death in the recipient neuroblastoma cell monolayer. No such effect was observed with COS cells transfected with tk alone. Tumours established in mice with neuroblastoma cell lines expressing VP22-tk regressed upon administration of ganciclovir. Furthermore tumours established from 50:50 mixtures of VP22-tk transduced and nontransduced cells also regressed while no significant effect was observed in similar experiments with cells transduced with tk alone. VP22 mediated transport may thus have application in a clinical setting to amplify delivery of the target protein in enzyme-prodrug protocols.

Adenoviral vectors capable of replication improve the efficacy of HSVtk/GCV suicide gene therapy of cancer

A major obstacle to the success of gene therapy strategies that directly target cancer cells is the poor vector distribution within solid tumors. To address this problem, we developed an E1b 55 kDa attenuated, replication-competent adenovirus (Ad.TKRC) which expresses the herpes simplex-1 thymidine kinase (HSVtk) gene to sensitize tumors to ganciclovir (GCV). Efficacy of this combined strategy was tested in nude mice with subcutaneous human A375 melanoma and ME180 cervical carcinomas. Intratumoral injection of a replication-defective adenoviral vector expressing HSVtk (Ad.TK) followed by GCV treatment resulted in doubling of the survival time of mice bearing A375 tumors and 20% long-term survival of mice with ME180 tumors. Treatment of tumors with Ad.TKRC without GCV resulted in a similar antitumor effect, confirming that the replicating vector has an oncolytic effect. When GCV was initiated 3 days after Ad.TKRC injection, survival of mice with each tumor type was greatly prolonged, with 60% of animals with ME180 tumors surviving for over 160 days. These results confirm that both the oncolysis caused by a replicating virus and suicide/prodrug gene therapy with HSVtk/GCV have potent antitumor effects. When combined, these two approaches are complementary resulting in a significantly improved treatment outcome.

Cooperative therapeutic effects of androgen ablation and adenovirus-mediated herpes simplex virus thymidine kinase gene and ganciclovir therapy in experimental prostate cancer

Adenovirus-mediated transduction of the herpes simplex thymidine kinase gene (HSV-tk) in conjunction with ganciclovir (GCV) has been shown to result in significant growth suppression and to enhance survival in a model of mouse prostate cancer. However, this therapeutic activity is not sustained, because in most cases tumors eventually regrow and ultimately cause the death of the host. Androgen ablation, an inducer of apoptosis in prostate cells which is used widely as palliative therapy in patients with prostate cancer, was combined with HSV-tk plus GCV using an androgen-sensitive mouse prostate cancer cell line. The combination of castration and HSV-tk plus GCV led to markedly enhanced tumor growth suppression in both subcutaneous and orthotopic models compared with either treatment alone and resulted in an enhanced survival in which combination-treated animals lived twice as long as controls in the subcutaneous model and over 50% longer than controls in the orthotopic model. Further analysis of apoptotic activity demonstrated high levels of apoptosis only in combined androgen ablation and HSV-tk plus GCV-treated tumors after 14 days of growth in an androgen-depleted environment and 8 days after HSV-tk plus GCV therapy. At this time, the apoptotic index, but not the percent of necrotic tissue, was significantly higher for combination therapy-treated tumors relative to control-treated tumors or either treatment alone. These data indicate that the therapeutic effects of androgen ablation and HSV-tk plus GCV are cooperative and that increased apoptosis may, in part, underlie these activities.

Effective and safe gene therapy for colorectal carcinoma using the cytosine deaminase gene directed by the carcinoembryonic antigen promoter

We have recently isolated carcinoembryonic antigen (CEA) promoter regions consisting of 419 bp and 204 bp from CEA-producing human colorectal carcinoma (CRC). We constructed CEA419/CD and CEA204/CD retroviruses carrying the bacterial cytosine deaminase (CD) gene directed by the CEA promoter regions. pCD2 retroviruses carrying the CD gene directed by the retrovirus long terminal repeat promoter were also used. CEA419/CD or CEA204/CD retrovirus-infected CRC cells were found to be susceptible to 5-fluorocytosine (5-FC), while non-CRC cells infected with the same retroviruses were not. CD-transduced CRC xenografts in nude mice were sensitive to 5-FC treatment, resulting in arrest of tumor growth. When mice with intraperitoneally disseminated CRCs were given intraperitoneal injections of CEA419/CD retrovirus-producing cells followed by 5-FC treatment, significantly prolonged survival rates were observed compared with animals injected with pCD2 retrovirus-producing cells followed by 5-FC treatment. Importantly, bone marrow suppression was not observed in animals injected with CEA419/CD retrovirus-producing cells and 5-FC, while profound bone marrow suppression was observed in those injected with pCD2 retrovirus-producing cells and 5-FC. These results indicate that effective and safe in vivo gene therapy for advanced CRC may be feasible by transferring the CD gene controlled by the CEA promoter followed by 5-FC treatment.

Concurrent activation of hippocampal glycine and polyamine sites of the N-methyl-D-aspartate receptor synergistically reverses working memory deficits in rats

Intrahippocampal administration of the non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist MK-801 (0.18 microg/side) significantly increased the number of errors in the working memory task with a three-panel runway setup. The increase in working memory errors by intrahippocampal MK-801 was significantly attenuated by concurrent infusion of D-cycloserine (1.0 microg/side) or spermidine (10 microg/side), agonists of the glycine and polyamine modulatory sites on the NMDA receptor/channel complex, respectively. Combined injection of the behaviorally ineffective doses of 0.1 microg/side D-cycloserine and 0.32 microg/side spermidine synergistically reduced intrahippocampal MK-801-induced increase in working memory errors. The combination of D-cycloserine and spermidine also synergistically attenuated the increase in working memory errors resulting from intrahippocampal injection of the muscarinic acetylcholine receptor antagonist scopolamine (3.2 microg/side). These results suggest that positive modulation of the NMDA receptor/channel through activation of the glycine and polyamine sites can synergistically compensate deficiency of hippocampal NMDA and muscarinic receptor-mediated neurotransmission involved in working memory function.

Occlusive ligature and standardized fenestration of a Baerveldt tube with and without antimetabolites for early postoperative intraocular pressure control

OBJECTIVE

To determine the effectiveness of a surgical modification for a nonvalved aqueous tube shunt in controlling intraocular pressure (IOP) in the early postoperative period. The effect of antimetabolite use on IOP also was studied.

DESIGN

A retrospective study of consecutive patients who underwent modified Baerveldt 350-mm2 implant with varied, nonrandomized, exposure to antimetabolites.

PARTICIPANTS

Fifty-one eyes of 46 patients with uncontrolled glaucoma were examined.

INTERVENTION

Identical surgical modification of a Baerveldt 350-mm2 tube was performed in all cases and consisted of placement of an occlusive 7-0 polyglactin suture just anterior to the plate followed by a through-and-through penetration of the tube just anterior to the occlusive ligature with a standardized 15 degrees blade. Seventeen eyes were not exposed to antimetabolite, while 2 groups of 17 eyes had 3 minutes' episcleral exposure to either 5-fluorouracil 50 mg/ml or mitomycin C 0.4 mg/ml at the location corresponding to the fenestration. The Tenon's layer and conjunctiva were not exposed because of concerns regarding conjunctival erosion over the device.

MAIN OUTCOME MEASURE

Intraocular pressure and number of antiglaucoma medications required were analyzed.

RESULTS

For the group, mean IOP before surgery and on postoperative days 1, 4, 10, 21, 42, 63, 84, and 112 was (in millimeters of mercury) 34.6, 20.1, 17.0, 17.2, 22.0, 17.3, 18.7, 17.4, and 15.6, respectively. There was an elevation of IOP at day 21 relative to fibrotic blockage of the fenestration before suture autolysis. This was temporized with antiglaucoma medication until suture autolysis occurred or treated with laser suture lysis (8 eyes). On day 1, hypotony occurred in 3 (6%) eyes whereas IOP greater than 30 mmHg was observed in 13 (26%) eyes. By day 10, the frequency had decreased to one (2.1 %) eye and three (6.4%) eyes, respectively. The use of antimetabolites did not result in lower IOP or less medication needed for any group at any interval (analysis of variance).

CONCLUSION

This modification of a nonvalved glaucoma tube shunt device provides adequate IOP control in the early postoperative period with a low rate of hypotony and surgical complications. If elevation of IOP occurs before suture autolysis, it generally is well controlled by antiglaucoma medications or laser suture lysis. Antimetabolite exposure did not influence early postoperative IOP in this study.

[Implantation of controlled-release 5-FU for the prevention of secondary cataract: preliminary study]

To assess the efficacy of a control drug release implant coated with 5-Fu placed in the capsular bag for the prevention of the secondary cataract.

Treatment of chronic viral hepatitis

Interferon-alpha therapy has proved effective for up to 40% of patients with adult-acquired chronic hepatitis B virus (HBV) infection and for 20-25% of those with chronic hepatitis C virus (HCV) infection. Nucleoside analogues, such as lamivudine and famciclovir, are showing promise as antiviral agents for chronic HBV and the combination of interferon-alpha and ribavirin is proving to be successful therapy for 40-50% of patients with chronic HCV. In this article we review current therapy and discuss future strategies of the therapy of chronic viral hepatitis.

Traditional therapies for the treatment of condylomata acuminata (genital warts)

The evaluation of therapies for condylomata acuminata (genital warts) is imprecise because it is not possible to distinguish between relapse (reappearance of previously treated warts) and reinfection (appearance of new warts in a new location). Published trials use diverse criteria for patient selection, therapeutic response and follow-up period. A further complication is that current treatments aim to clear visible lesions, which is no proof of cure as human papillomavirus may persist in a latent state. Within these limitations, the advantages and disadvantages of current therapies are reviewed, including first-line therapies such as podophyllin solution, podophyllotoxin alcohol solution or cream, cryotherapy with liquid nitrogen, laser therapy (both carbon dioxide and NdYag), and trichloracetic acid. Second-line therapies, such as electrosurgery, excision, 5-fluorouracil and interferons, are also reviewed. In general, all available treatments for genital warts are more or less unsatisfactory, with recurrence rates of 30-70% at 6 months follow-up periods.

Leptospirosis in an urban setting: case report and review of an emerging infectious disease

Leptospiosis is a common zoonosis affecting most mammals. Leptospirosis has protean manifestations ranging from a flu-like illness to fulminant hepatic and renal failure culminating in death. Although the diagnosis is often not considered upon presentation, the literature suggests that leptospirosis is a reemerging infectious disease in urban centers throughout the industrialized world. It will be incumbent upon Emergency Physicians to include this spirochetal disease in the differential diagnosis of febrile patients with appropriate risk factors and symptomatology. We present the case of a 36 year-old woman who presented to the Emergency Department with fever and hypotension. We review the literature on leptospirosis with specific focus on risk factors and pathogenesis, clinical manifestations, diagnosis, treatment, and outcome.

Gene therapy of central nervous system tumors

Recently, remarkable advances have been achieved in molecular and genetic researches of different kinds of general diseases, as well as in basic and clinical studies using gene therapy for central nervous system diseases. For brain tumors, clinical trials have been already started in more than 10 clinical protocols and more than 100 patients with malignant brain tumors. Nevertheless, there are still major issues that remain to be resolved for achieving better clinical results, such as delivery system of genetic material, regulatory methods of the intracellular expression of the transgene, antitumor efficacy, and tumor selectivity. In this paper, molecular genetic studies and the current state of gene therapy for neurological diseases, especially brain tumors, are described, and the future direction of this fascinating approach is discussed.