Surgical interventions for age-related cataract

BACKGROUND

Cataract accounts for 50% of blindness globally and remains the leading cause of visual impairment in all regions of the world, despite improvements in surgical outcomes (WHO 2005). This number is expected to rise due to an aging population and increase in life expectancy. Although cataracts are not preventable, their surgical treatment is one of the most cost-effective interventions in healthcare.

OBJECTIVES

To compare the effects of different surgical interventions for age-related cataract.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE up to July 2006, NRR Issue 3 2005, the reference lists of identified trials and we contacted investigators and experts in the field for details of published and unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTS).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and discrepancies were resolved by discussion. Where appropriate, risk ratios, odds ratios and weighted mean differences were summarised after assessing heterogeneity between the studies.

MAIN RESULTS

We identified 17 trials that randomised a total of 9627 people. Phacoemulsification gave a better visual outcome than extracapsular surgery but similar average cost per procedure in Europe but not in poorer countries. Extracapsular surgery with posterior chamber lens implant and ICCE with or without an anterior chamber intraocular lens (IOL) implant gave acceptable visual outcomes but extracapsular surgery had less complications. Manual small incision surgery provides better visual outcome than ECCE but slightly inferior unaided visual acuity compared to phacoemulsification.

AUTHORS' CONCLUSIONS

This review provides evidence from seven RCTs that phacoemulsification gives a better outcome than ECCE with sutures. We also found evidence that ECCE with a posterior chamber lens implant provides better visual outcome than ICCE with aphakic glasses. The long term effect of posterior capsular opacification (PCO) needs to be assessed in larger populations. The data also suggests that ICCE with an anterior chamber lens implant is an effective alternative to ICCE with aphakic glasses, with similar safety. Phacoemulsification provides the best visual outcomes but will only be accessible to the poorer countries if the cost of phacoemulsification and foldable IOLs decrease. Manual small incision cataract surgery provides early visual rehabilitation and comparable visual outcome to PHACO. It has better visual outcomes than ECCE and can be used in any clinic that is currently carrying out ECCE with IOL. Further research from developing regions are needed to compare the cost and longer term outcomes of these procedures e.g. PCO and corneal endothelial cell damage.

A comment on the quantitative significance of aerobic methane release by plants

A recent study by Keppler et al. (2006; Nature 439, 187-191) demonstrated CH₄ emission from living and dead plant tissues under aerobic conditions. This work included some calculations to extrapolate the findings from the laboratory to the global scale and led various commentators to question the value of planting trees as a greenhouse mitigation option. The experimental work of Keppler et al. (2006) appears to be largely sound, although some concerns remain about the quantification of emission rates. However, whilst accepting their basic findings, we are critical of the method used for extrapolating results to a global scale. Using the same basic information, we present alternative calculations to estimate global aerobic plant CH₄ emissions as 10-60 Mt CH₄ year^-1. This estimate is much smaller than the 62-236 Mt CH₄ year^-1 reported in the original study and can be more readily reconciled within the uncertainties in the established sources and sinks in the global CH₄ budget. We also assessed their findings in terms of their possible relevance for planting trees as a greenhouse mitigation option. We conclude that consideration of aerobic CH₄ emissions from plants would reduce the benefit of planting trees by between 0 and 4.4%. Hence, any offset from CH₄ emission is small in comparison to the significant benefit from carbon sequestration. However, much critical information is still lacking about aerobic CH₄ emission from plants. For example, we do not yet know the underlying mechanism for aerobic CH₄ emission, how CH₄ emissions change with light, temperature and the physiological state of leaves, whether emissions change over time under constant conditions, whether they are related to photosynthesis and how they relate to the chemical composition of biomass. Therefore, the present calculations must be seen as a preliminary attempt to assess the global significance from a basis of limited information and are likely to be revised as further information becomes available.

Antioxidant vitamin and mineral supplements for slowing the progression of age-related macular degeneration

BACKGROUND

It has been proposed that antioxidants may prevent cellular damage in the retina by reacting with free radicals that are produced in the process of light absorption.

OBJECTIVES

The objective of this review was to assess the effects of antioxidant vitamin or mineral supplementation, or both, on the progression of age-related macular degeneration (AMD).

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2005, Issue 4); MEDLINE (1966 to January 2006); SIGLE (1980 to March 2005); EMBASE (1980 to January 2005); NRR (2005, Issue 4); AMED (1985 to January 2006); and PubMed (24 January 2006 covering last 60 days), reference lists of identified reports and the Science Citation Index. We contacted investigators and experts in the field for details of unpublished studies.

SELECTION CRITERIA

We included randomised trials comparing antioxidant vitamin or mineral supplemention (alone or in combination) to a control intervention in people with AMD.

DATA COLLECTION AND ANALYSIS

The author extracted data and assessed trial quality. Where appropriate, data were pooled using a random-effects model unless three or fewer trials were available in which case a fixed-effects model was used.

MAIN RESULTS

Eight trials were included in this review. The majority of people were randomised in one trial (AREDS in the USA) that found a beneficial effect of antioxidant (beta-carotene, vitamin C and vitamin E) and zinc supplementation on progression to advanced AMD (adjusted odds ratio 0.68, 99% confidence interval 0.49 to 0.93). People taking supplements were less likely to lose 15 or more letters of visual acuity (adjusted odds ratio 0.77, 99% confidence interval 0.58 to 1.03). Hospitalisation for genito-urinary problems was more common in people taking zinc and yellowing of skin was more common in people taking antioxidants. The other trials were, in general, small and the results were inconsistent.

AUTHORS' CONCLUSIONS

The evidence as to the effectiveness of antioxidant vitamin and mineral supplementation in halting the progression of AMD comes mainly from one large trial in the USA. The generalisability of these findings to other populations with different nutritional status is not known. Further large, well-conducted randomised controlled trials in other populations are required. Long-term harm from supplementation cannot be ruled out. Beta-carotene has been found to increase the risk of lung cancer in smokers; vitamin E has been associated with an increased risk of heart failure in people with vascular disease or diabetes.

Effects of water availability, nitrogen supply and atmospheric CO2 concentrations on plant nitrogen natural abundance values

The relative effects of soil N, water supply and elevated atmospheric CO₂ on foliar δ¹⁵N values were examined. Phalaris arundinacea L. (Holdfast) and Physalis peruviana L. (Cape Gooseberry) were grown for 80 d with three water availability treatments, two atmospheric CO₂ concentrations and four N supply rates. Elevated CO₂ increased total plant biomass and N for each treatment and decreased allocation to roots, leaf N concentrations and stomatal conductance. Leaves had less negative leaf δ¹³C values under low water supply associated with decreased stomatal conductance and increased leaf N concentration, which decreased the ratio of intercellular to ambient CO₂ concentration. The δ¹⁵N value of the supplied nitrate (4.15‰) was similar to the value for Phalaris leaves (4.11‰), but Cape Gooseberry leaves were enriched (6.52‰). The effects of elevated CO₂ on leaf δ¹⁵N values were small, with Phalaris showing no significant change, while Cape Gooseberry showed a significant (P < 0.05) decline of 0.42 ‰. Variation in δ¹⁵N values was unrelated to stomatal conductance, transpiration, differential use of N forms or denitrification. Plants with low foliar N concentrations tended to be depleted in ¹⁵N. We suggest that changes in N allocation alter foliar δ¹⁵N values under different CO₂ and water treatments.

Photosynthesis within isobilateral Eucalyptus pauciflora leaves

Adult Eucalyptus pauciflora leaves are vertically displayed. They have multiple palisade cell layers beneath both surfaces, interrupted by numerous oil glands. Here, we characterized light absorption, chlorophyll, photosynthetic capacity and CO2 fixation profiles through these leaves. Multiple chlorophyll fluorescence images of leaves viewed in cross-section were made by applying light from different directions. 14CO2 labelling, followed by paradermal cryosectioning, was used to measure profiles of photosynthesis. Photosynthetic capacity peaked 75 microm into the mesophyll beneath each surface and was lowest in the centre of the 600-microm-thick leaf. Predictions by a multilayer model using Beer's law matched the observed profiles of 14C fixation. When constrained to the horizontal, a vertically acclimated leaf gains only 79% of the daily photosynthesis achieved by a horizontally acclimated leaf. However, it outperforms the horizontally acclimated leaf when both are oriented vertically. Each half of the observed profile of photosynthetic capacity closely matches the profile of light absorption through the leaf with unilateral illumination to that surface. Derivation of biochemical parameters from gas exchange measured under unilateral illumination would underestimate the real photosynthetic capacity of these leaves by 21%.

Phosphorus availability and elevated CO2 affect biological nitrogen fixation and nutrient fluxes in a clover-dominated sward

The response of biological nitrogen fixation (BNF) to elevated CO(2) was examined in white clover (Trifolium repens)-dominated swards under both high and low phosphorus availability. Mixed swards of clover and buffalo grass (Stenotaphrum secundatum) were grown for 15 months in 0.2 m2 sand-filled mesocosms under two CO2 treatments (ambient and twice ambient) and three nutrient treatments [no N, and either low or high P (5 or 134 kg P ha(-1)); the third nutrient treatment was supplied with high P and N (240 kg N ha(-1))]. Under ambient CO2, high P increased BNF from 410 to 900 kg ha(-1). Elevated CO2 further increased BNF to 1180 kg ha(-1) with high P, but there was no effect of CO2 on BNF with low P. Allocation of N belowground increased by approx. 50% under elevated CO2 irrespective of supplied P. The results suggest that where soil P availability is low, elevated CO2 will not increase BNF, and pasture quality could decrease because of a reduction in aboveground N.

Construction costs, chemical composition and payback time of high- and low-irradiance leaves

The effect of irradiance on leaf construction costs, chemical composition, and on the payback time of leaves was investigated. To enable more generalized conclusions, three different systems were studied: top and the most-shaded leaves of 10 adult tree species in a European mixed forest, top leaves of sub-dominant trees of two evergreen species growing in small gaps or below the canopy in an Amazonian rainforest, and plants of six herbaceous and four woody species grown hydroponically at low or high irradiance in growth cabinets. Daily photon irradiance varied 3-6-fold between low- and high-light leaves. Specific leaf area (SLA) was 30-130% higher at low light. Construction costs, on the other hand, were 1-5% lower for low-irradiance leaves, mainly because low-irradiance leaves had lower concentrations of soluble phenolics. Photosynthetic capacity and respiration, expressed per unit leaf mass, were hardly different for the low- and high-light leaves. Estimates of payback times of the high-irradiance leaves ranged from 2-4 d in the growth cabinets, to 15-20 d for the adult tree species in the European forest. Low-irradiance leaves had payback times that were 2-3 times larger, ranging from 4 d in the growth cabinets to 20-80 d at the most shaded part of the canopy of the mixed forest. In all cases, estimated payback times were less than half the life span of the leaves, suggesting that even at time-integrated irradiances lower than 5% of the total seasonal value, investment in leaves is still fruitful from a carbon-economy point of view. A sensitivity analysis showed that increased SLA of low-irradiance leaves was the main factor constraining payback times. Acclimation in the other five factors determining payback time, namely construction costs, photosynthetic capacity per unit leaf mass, respiration per unit leaf mass, apparent quantum yield, and curvature of the photosynthetic light-response-curve, were unimportant when the observed variation in each factor was examined.

28,000 Cases of age related macular degeneration causing visual loss in people aged 75 years and above in the United Kingdom may be attributable to smoking

BACKGROUND

Age related macular degeneration (AMD) causing visual impairment is common in older people. Previous studies have identified smoking as a risk factor for AMD. However, there is limited information for the older population in Britain.

METHODS

Population based cross sectional analytical study based in 49 practices selected to be representative of the population of Britain. Cases were people aged 75 years and above who were visually impaired (binocular acuity <6/18) as a result of AMD. Controls were people with normal vision (6/6 or better). Smoking history was ascertained using an interviewer administered questionnaire.

RESULTS

After controlling for potentially confounding factors, current smokers were twice as likely to have AMD compared to non-smokers (odds ratio 2.15, 95% CI 1.42 to 3.26). Ex-smokers were at intermediate risk (odds ratio 1.13, 0.86 to 1.47). People who stopped smoking more than 20 years previously were not at increased risk of AMD causing visual loss. Approximately 28,000 cases of AMD in older people in the United Kingdom may be attributable to smoking.

CONCLUSION

This is the largest study of the association of smoking and AMD in the British population. Smoking is associated with a twofold increased risk of developing AMD. An increased risk of AMD, which is the most commonly occurring cause of blindness in the United Kingdom, is yet another reason for people to stop smoking and governments to develop public health campaigns against this hazard.

Faster Rubisco is the key to superior nitrogen-use efficiency in NADP-malic enzyme relative to NAD-malic enzyme C4 grasses

In 27 C4 grasses grown under adequate or deficient nitrogen (N) supplies, N-use efficiency at the photosynthetic (assimilation rate per unit leaf N) and whole-plant (dry mass per total leaf N) level was greater in NADP-malic enzyme (ME) than NAD-ME species. This was due to lower N content in NADP-ME than NAD-ME leaves because neither assimilation rates nor plant dry mass differed significantly between the two C4 subtypes. Relative to NAD-ME, NADP-ME leaves had greater in vivo (assimilation rate per Rubisco catalytic sites) and in vitro Rubisco turnover rates (k(cat); 3.8 versus 5.7 s(-1) at 25 degrees C). The two parameters were linearly related. In 2 NAD-ME (Panicum miliaceum and Panicum coloratum) and 2 NADP-ME (Sorghum bicolor and Cenchrus ciliaris) grasses, 30% of leaf N was allocated to thylakoids and 5% to 9% to amino acids and nitrate. Soluble protein represented a smaller fraction of leaf N in NADP-ME (41%) than in NAD-ME (53%) leaves, of which Rubisco accounted for one-seventh. Soluble protein averaged 7 and 10 g (mmol chlorophyll)(-1) in NADP-ME and NAD-ME leaves, respectively. The majority (65%) of leaf N and chlorophyll was found in the mesophyll of NADP-ME and bundle sheath of NAD-ME leaves. The mesophyll-bundle sheath distribution of functional thylakoid complexes (photosystems I and II and cytochrome f) varied among species, with a tendency to be mostly located in the mesophyll. In conclusion, superior N-use efficiency of NADP-ME relative to NAD-ME grasses was achieved with less leaf N, soluble protein, and Rubisco having a faster k(cat).

Radiotherapy for neovascular age-related macular degeneration

BACKGROUND

Radiotherapy has been proposed as a treatment to prevent new vessel growth in people with neovascular age-related macular degeneration (AMD).

OBJECTIVES

The aim of this review was to examine the effects of radiotherapy on neovascular AMD.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group trials register) on The Cochrane Library Issue 2, 2004, MEDLINE (1966 to May 2004), EMBASE (1980 to June 2004) and LILACS (Latin American and Caribbean Health Sciences Literature Database) (May 2004). We also wrote to investigators of trials included in the review to ask if they were aware of any other studies.

SELECTION CRITERIA

We included all randomised controlled trials in which radiotherapy was compared to another treatment, sham treatment, low dosage irradiation or no treatment in people with subfoveal choroidal neovascularisation secondary to AMD.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted the data. Relative risks were combined using a random effects model. The percentage of the variability in effect estimates that was due to heterogeneity, rather than sampling error, was estimated using I2.

MAIN RESULTS

Eleven trials randomising a total of 1078 people were included in this review. All trials used a similar method of delivering the radiotherapy treatment (external beam). Dosage ranged from 7.5 to 24 Gy. Most trials found effects (not always significant) that favoured treatment. However, there was considerable inconsistency in the results between trials (I2 > 50%). As only 11 trials were included in the review and only some of these trials provided data for each outcome our ability to determine the causes of the heterogeneity between trials was limited. Subgroup analyses did not reveal any statistically significant interactions although with small numbers of trials in each subgroup (range two to four) this was not surprising. There was some indication that trials with no sham irradiation reported a greater effect of treatment as did trials with a greater percentage of participants with classic choroidal neovascularisation.

REVIEWERS' CONCLUSIONS

This review currently does not provide evidence that external beam radiotherapy is an effective treatment for neovascular AMD. If further trials are to be considered to evaluate radiotherapy in AMD then adequate masking of the control group must be considered. Given the recent evidence that most lesions are amenable to treatment with photodynamic therapy if identified at a small lesion size, trials evaluating radiotherapy against photodynamic therapy are warranted.

A simple new equation for the reversible temperature dependence of photosynthetic electron transport: a study on soybean leaf

The temperature response of J_max, the irradiance-saturated potential rate of photosynthetic electron transport in the absence of Rubisco limitation, has usually been modelled by a complicated, modified Arrhenius type of equation. Light saturation can be difficult to achieve and reduces the precision of fluorescence measurements. Consequently, we calculated the rate of electron transport at 1200 μmol photosynthetically active radiation (PAR) quanta m^-2 s^-1 from chlorophyll fluorescence measurements on intact soybean leaves [Glycine max (L.) Merr] as temperature increased from 15 to 43°C with 1250 μmol mol^-1 ambient [CO₂]. Electron transport rate was maximal around 37°C and the decline in rate following further increases in leaf temperature to 43°C was found to be completely reversible immediately upon return to lower temperatures. We report a convenient, new equation for the temperature dependence of the rate of electron transport under high irradiance:...

Causes of visual impairment in people aged 75 years and older in Britain: an add-on study to the MRC Trial of Assessment and Management of Older People in the Community

BACKGROUND

Visual impairment and blindness are common in older people in Britain. It is important to know the causes of visual impairment to develop health service and research priorities. The authors aimed to identify the causes of visual impairment in people aged 75 years and older in Britain.

METHODS

In the MRC Trial of the Assessment and Management of Older People in the Community, trial nurses tested visual acuity in everyone aged 75 years and older in 53 general practices. For all visually impaired patients in 49 of the 53 medical practices, data regarding the cause of vision loss were extracted from the general practice medical notes. Additional follow up questionnaires were also sent to the hospital ophthalmologist to confirm the cause of vision loss. Visual impairment was defined as a binocular acuity of less than 6/18.

RESULTS

There were 1742 (12.5%) people visually impaired in the 49 participating practices. Of these, 450 (26%) achieved a pinhole visual acuity in either eye of 6/18 or better. In these people, the principal reason for visual loss was considered to be refractive error. The cause of visual loss was available for 976 (76%) of the remaining 1292 visually impaired people identified. The main cause of visual loss was age related macular degeneration (AMD); 52.9% (95% confidence interval 49.2 to 56.5) of people had AMD as a main or contributory cause. This was followed by cataract (35.9%), glaucoma (11.6%), myopic degeneration (4.2%), and diabetic eye disease (3.4%).

CONCLUSIONS

A substantial proportion of visual impairment in our sample of older people in Britain can be attributed to remediable causes-refractive error and cataract. There is considerable potential for visual rehabilitation in this age group. For the large proportion with macular degeneration, low vision services will be important.

Prevalence of visual impairment in people aged 75 years and older in Britain: results from the MRC trial of assessment and management of older people in the community

AIMS

To measure the prevalence of visual impairment in a large representative sample of people aged 75 years and over participating in the MRC trial of assessment and management of older people in the community.

METHODS

53 practices in the MRC general practice research framework. Data were obtained from 14 600 participants aged 75 years and older. Prevalence of visual impairment overall (binocular visual acuity <6/18) which was categorised separately into low vision (binocular visual acuity <6/18-3/60) or blindness (binocular visual acuity of <3/60). The prevalence of binocular acuity <6/12 was presented for comparison with other studies. Visual acuity was measured using Glasgow acuity charts; glasses, if worn, were not removed.

RESULTS

Visual acuity was available for 14 600 people out of 21 241 invited (69%). Among people with visual acuity data, 12.4% overall (1803) were visually impaired (95% confidence intervals 10.8% to 13.9%); 1501 (10.3%) were categorised as having low vision (8.7% to 11.8%), and 302 (2.1%) were blind (1.8% to 2.4%). At ages 75-79, 6.2% of the cohort were visually impaired (5.1% to 7.3%) with 36.9% at age 90+ (32.5% to 41.3%). At ages 75-79, 0.6% (0.4% to 0.8%) of the study population were blind, with 6.9% (4.8% to 9.0%) at age 90+. In multivariate regression, controlling for age, women had significant excess risk of visual impairment (odds ratio 1.43, 95% confidence interval 1.29 to 1.58). Overall, 19.9% of study participants had a binocular acuity of less than 6/12 (17.8% to 22.0%).

CONCLUSION

The results from this large study show that visual impairment is common in the older population and that this risk increases rapidly with advancing age, especially for women. A relatively conservative measure of visual impairment was used. If visual impairment had been defined as visual acuity of <6/12 (American definition of visual impairment), the age specific prevalence estimates would have increased by 60%.

Antioxidant vitamin and mineral supplements for age-related macular degeneration

BACKGROUND

It has been proposed that antioxidants may prevent cellular damage in the retina by reacting with free radicals produced in the process of light absorption.

OBJECTIVES

The objective of this review is to assess the effects of antioxidant vitamin and/or mineral supplementation on the progression of age-related macular degeneration.

SEARCH STRATEGY

The Cochrane Controlled Trials Register - CENTRAL/CCTR, which contains the Cochrane Eyes and Vision Group specialised register (Cochrane Library Issue 3 2001), MEDLINE (1966 to August 2001), EMBASE (1980 to September 2001), the Science Citation Index, and the reference lists of relevant articles were searched. Investigators of included studies were contacted for further information.

SELECTION CRITERIA

Randomised trials comparing an antioxidant vitamin and/or mineral supplement (alone or in combination) to control in people with age-related macular degeneration are included in this review.

DATA COLLECTION AND ANALYSIS

The reviewer extracted data and assessed trial quality. Due to the variable methods of collecting and presenting outcome data, no statistical summary measure was calculated.

MAIN RESULTS

Seven trials, which randomised 4119 people with signs of age-related macular degeneration, are included in this review. One unpublished trial of zinc supplementation (170 participants) is awaiting assessment. The majority of people (88%) were randomised in one trial that was conducted in a relatively well-nourished American population. This trial found a modest beneficial effect of antioxidant and zinc supplementation on progression to advanced age-related macular degeneration (odds ratio 0.72, 99% confidence interval 0.52 to 0.98). People supplemented with antioxidants and zinc were less likely to lose 15 or more letters of visual acuity (equivalent to a doubling of the visual angle) (odds ratio 0.79, 99% confidence interval 0.60 to 1.04). The other six trials in this review were small and the results were inconsistent.

REVIEWER'S CONCLUSIONS

The evidence as to the effectiveness of antioxidant vitamin and mineral supplementation in halting the progression of age-related macular degeneration is dominated by one large trial in a relatively well-nourished American population that showed modest benefit in people with moderate to severe signs of the disease. There is no evidence at present that people with early signs of the disease should take supplementation, however, current studies are underpowered to answer that question. The generalisability of these findings to other populations with different nutritional status is not known. Further large well-conducted randomised controlled trials in other populations are required.

Surgical interventions for age-related cataract

BACKGROUND

Cataract is the major cause of global blindness, accounting for 40 to 80% of all blindness in developing countries. The number of people blind from cataract is expected to rise due to the changing age distribution and increasing life expectancy. There is currently no proven intervention to prevent cataract and surgery is the only form of treatment.

OBJECTIVES

The objective of this review is to compare the effects of different surgical interventions for age-related cataract.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register - CENTRAL/CCTR, which contains the Cochrane Eyes and Vision Group specialised register (Cochrane Library Issue 3 2001), MEDLINE (1966 to August 2001), EMBASE (1980 to September 2001), the reference lists of identified trials, and we contacted investigators and experts in the field for details of published and unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials evaluating surgical treatment for people with age-related cataract.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and discrepancies were resolved by discussion. Where appropriate, relative risks, odds ratios and weighted mean differences were summarised after assessing heterogeneity between the studies. We used a fixed effect model due to the low number of trials in each comparison.

MAIN RESULTS

We identified six trials that randomised a total of 7828 people. Phacoemulsification gave a better visual outcome than extracapsular surgery and gave a similar average cost per procedure in one trial conducted in the UK. Extracapsular surgery with posterior chamber lens implant and intracapsular surgery with or without an anterior chamber intraocular lens implant gave acceptable visual outcomes at 12 to 24 months after surgery. In three large trials in south Asia, best-corrected visual acuity of less than 6/60 ranged from 0.5 to 4%. Higher rates of poor outcome were observed in a multicentre study with 19 surgeons compared to a single-centre study with two surgeons.

REVIEWER'S CONCLUSIONS

This review provides evidence from one randomised controlled trial that phacoemulsification gives a better visual outcome than extracapsular extraction with sutures. However, this trial was conducted in a developed country specialised hospital setting and extrapolation to other settings must be made with caution. This review also found evidence that extracapsular cataract extraction with a posterior chamber lens implant provides better visual outcome than intracapsular extraction with aphakic glasses. This finding is also based on the results of a single trial. The long term effects of posterior capsular opacification need to be assessed in larger populations. The data in the review suggest that intracapsular extraction with an anterior chamber lens implant is an effective alternative to intracapsular extraction with aphakic glasses, with similar safety. Further data from developing regions are needed to compare all aspects of intraocular lens surgery with the three main surgical procedures - intracapsular extraction with an anterior chamber lens, extracapsular surgery with a posterior chamber lens with or without sutures.

Outcome of infants with bronchopulmonary dysplasia who receive extracorporeal membrane oxygenation therapy

BACKGROUND/PURPOSE

Extracorporeal membrane oxygenation (ECMO) is an accepted therapy for acute respiratory failure but more recently has been used in infants with bronchopulmonary dysplasia (BPD) and superimposed acute pulmonary insults. The purpose of this study was to review the outcomes of such infants.

METHODS

Charts of infants at The Children's Hospital of Philadelphia (CHOP) who had a diagnosis of BPD before ECMO were reviewed. In addition, to obtain survival data in a larger population, the Extracorporeal Life Support Organization (ELSO) Registry was searched for infants with BPD before ECMO.

RESULTS

Of 204 patients who received noncardiac ECMO at CHOP, 9 had BPD before ECMO. Of 7 survivors, 4 were still ventilator dependent at 9 to 39 months of corrected age. Developmentally, 4 had significant global delays, whereas 3 had significant language and motor delays with average to mildly delayed cognitive abilities. The ELSO Registry search showed 76 patients with BPD before ECMO, with a 78% survival.

CONCLUSIONS

The survival rate of infants with BPD who receive ECMO is comparable to, or better than, the survival rates in most other ECMO populations. However, there appears to be a high risk of severe pulmonary and neurodevelopmental sequelae.

Pharmacological assessment of the role of the glycine transporter GlyT-1 in mediating high-affinity glycine uptake by rat cerebral cortex and cerebellum synaptosomes

Two distinct types of glycine transporter, GlyT-1 and GlyT-2, have been characterised. GlyT-1 and GlyT-2 are known to be differentially expressed amongst CNS areas, but direct functional evidence for their relative contributions to high-affinity glycine uptake by brain tissues is lacking. In the present study, we have used the selective GlyT-1 inhibitor N[3-(4"-fluorophenyl)-3-(4"-phenylphenoxy)propyl]sarcosine (NFPS) to investigate the role of GlyT-1 in mediating glycine uptake. HEK293 cells expressing human GlyT-1c or GlyT-2 showed high levels of Na(+)-dependent glycine uptake, with K(m) values of 117+/-13 and 200+/-22 microM, respectively. NFPS potently inhibited uptake in GlyT-1c cells (IC(50) value 0.22+/-0.03 microM), being around 500-fold more potent than glycine or sarcosine, but had no effect on uptake in GlyT-2 cells (IC(50) >10 microM). Efflux of pre-loaded [3H]-glycine from GlyT-1c cells was increased by glycine or sarcosine, whereas NFPS had no effect on its own but blocked the effects of glycine or sarcosine. These results confirm that NFPS is a potent, selective and non-transportable GlyT-1 inhibitor. Rat cortex and cerebellum synaptosomes also showed a high-affinity Na(+)-dependent component of glycine uptake, with affinities similar to those observed for uptake in GlyT-1c or GlyT-2 cells. In cortex synaptosomes, NFPS and sarcosine produced the same maximal inhibition of uptake as glycine itself. However, in cerebellum synaptosomes, the maximal inhibition produced by NFPS and sarcosine was only half that produced by glycine. In both tissues NFPS was around 1000-fold more potent than glycine or sarcosine. Overall, our findings indicate that high-affinity glycine uptake in cerebral cortex occurs predominantly via GlyT-1. However, in cerebellum, only a part of the high-affinity uptake is mediated by GlyT-1, with the remaining NFPS-insensitive component most likely mediated by GlyT-2.

Regulation of sodium currents through oxidation and reduction of thiol residues

Changes in redox state are involved in several physiological and pathophysiological processes. Previous experiments have demonstrated that nitric oxide can function as a reactive oxygen species, inhibiting neuronal sodium currents by nitrosylation of thiol residues. We hypothesized that nitric oxide and thiol oxidizers similarly modulate voltage-dependent sodium currents. Voltage-dependent sodium currents were studied with the whole-cell patch-clamp technique in NB41A3 neuroblastoma cells. The nitric oxide donor 3-(2-hydroxy-2-nitroso-1-propylhydrazino)-1-propanamine did not affect sodium currents. In contrast, the thiol oxidizers thimerosal and 4,4'-dithiopyridine significantly inhibited sodium currents. The effect of thimerosal persisted after washout, but could be fully reversed by the reducing agent dithiothreitol. Reduced glutathione did not restore the sodium current amplitude when given extracellularly, while intracellular glutathione prevented the inhibitory effect of thimerosal. Pretreatment with the alkylating agent N-ethylmaleimide blocked the inhibitory action of thimerosal. Thiol oxidation caused a shift in the voltage dependence of fast and slow inactivation to more hyperpolarized potentials without concomitant effects on the voltage dependence of activation. Mercaptoethanol and reduced glutathione enhanced sodium currents by shifting the voltage dependence of inactivation to depolarized potentials. These results demonstrate that the oxidation and reduction of thiol residues alters the properties of voltage-sensitive sodium channels and may play an important role in the regulation of membrane excitability.

Postoperative astigmatism after intracapsular cataract surgery: results of a randomised controlled trial in Nepal

PURPOSE

Postoperative astigmatism following intracapsular cataract extraction with or without anterior chamber intraocular lens implantation is reported as an outcome from a randomised controlled trial.

METHODS

Five hundred and two of 1002 eyes randomised to intracapsular cataract extraction with anterior chamber intraocular lens (ICCE/AC IOL) and 417 of 998 eyes to intracapsular cataract extraction with aphakic spectacles (ICCE/AS) were seen for objective refraction one year after surgery. The prevalence and axis of astigmatism were evaluated using univariate analysis. Logistic regression was used to compare the postoperative astigmatism between the groups.

RESULTS

Acceptable astigmatism (-0.5 to 0.0 DCyl) in the AC IOL group was found in 60 (12.0%) patients (95% CI 9.1%-14.9%) and in the aphakic spectacles group (AS) in 69 (16.5%) patients (95% CI 12.9%-20.1%), moderate astigmatism (-1.0 to-1.5 DCyl) was found in 153 (30.4%) patients (95% CI 26.4-34.6%) in ACIOL group and in 288 (69.1%) patients (95% CI 64.6%-73.6%) in AS group; and large astigmatism (-2.0 to - 8.0 D Cyl) was found in 289 (57.6%) patients (95% CI 53.1%-61.6%) in ACIOL group and in 60 (14.4%) patients (95% CI 11.0% 17.8%) in AS group. Large astigmatism was approximately four times more common in the ICCE/AC IOL group compared to ICCE/AS group. In both groups, most patients had "against-the-rule" astigmatism, 446 (88.8%) (95%CI 86.0%-91.6%) in AC IOL group and 348 (83.5%) (95%CI 79.9%-87.1%) in AS group.

CONCLUSION

Astigmatism is common after intracapsular cataract extraction. Insertion of an anterior chamber IOL increases the risk of astigmatism.

Risk factors for age-related macular degeneration

There is an increasing body of evidence as to the risk factors for age-related macular degeneration. Age and genetic make-up are the most important risk factors identified to date. Over the next decade, the different genes that are involved in the development of age-related macular degeneration will be identified. There is reasonably consistent evidence that smoking cigarettes results in increased risk of the disease. The question as to whether antioxidant vitamin and mineral supplementation prevents or delays the development of the disease will be resolved as the results of large ongoing trials become available in the next few years. Currently, there is conflicting evidence as to their benefits and some indication as to possible harm. Other risk factors such as alcohol consumption, oestrogen replacement and lifetime light exposure require further study. The study of the epidemiology of age-related macular degeneration would be facilitated by a greater standardization of methods. Studies with large numbers of late stage disease are needed in order to provide the power to investigate moderate risks. This may either be achieved by adding on macular degeneration studies to large cohort studies already in place, or by pooling data from smaller studies.