Oxygen tension in the rabbit lens and vitreous before and after vitrectomy

Trends and factors related to outcomes for primary rhegmatogenous retinal detachment surgery in a large asian tertiary eye center

PURPOSE

To describe trends and outcomes of vitreoretinal surgery for primary rhegmatogenous retinal detachment in a large Asian tertiary eye center.

METHODS

Retrospective review of 1,530 eyes with primary retinal detachment between 2005 and 2011 managed at the Singapore National Eye Center by one of the following: scleral buckling (SB), pars plana vitrectomy (PPV), and combined SB and PPV (SB + PPV). Anatomical and functional outcomes were assessed.

RESULTS

There was a trend toward PPV and PPV + SB as the primary reattachment procedure from 2005 to 2011. The primary anatomical success rate for PPV (78.6%) was worse than that for SB (88.8%) or SB + PPV (89.0%, P = 0.000). Final anatomical success rates were similar for all 3 procedures: SB 97.7%, PPV 95.2%, and SB + PPV 96.4%. Better functional success was achieved in the SB group (86.1%) than both the PPV (72.5%) and SB + PPV groups (77.5%, P = 0.000), partly attributable to the less complex nature of retinal detachments in the SB group. Older age and proliferative vitreoretinopathy were related to the poor functional outcomes in both phakic and pseudophakic eyes.

CONCLUSION

There was an increasing trend toward PPV and PPV + SB as the primary retinal reattachment surgery from 2005 through to 2011. High rates of anatomical and functional outcomes were achieved with SB, PPV, and SB + PPV, proliferative vitreoretinopathy and older age were negatively correlated with the functional success in both phakic and pseudophakic eyes.

Methylglyoxal induces endoplasmic reticulum stress and DNA demethylation in the Keap1 promoter of human lens epithelial cells and age-related cataracts

Age-related cataracts are a leading cause of blindness. Previously, we have demonstrated the association of the unfolded protein response with various cataractogenic stressors. However, DNA methylation alterations leading to suppression of lenticular antioxidant protection remains unclear. Here, we report the methylglyoxal-mediated sequential events responsible for Keap1 promoter DNA demethylation in human lens epithelial cells, because Keap1 is a negative regulatory protein that regulates the Nrf2 antioxidant protein. Methylglyoxal induces endoplasmic reticulum stress and activates the unfolded protein response leading to overproduction of reactive oxygen species before human lens epithelial cell death. Methylglyoxal also suppresses Nrf2 and DNA methyltransferases but activates the DNA demethylation pathway enzyme TET1. Bisulfite genomic DNA sequencing confirms the methylglyoxal-mediated Keap1 promoter DNA demethylation leading to overexpression of Keap1 mRNA and protein. Similarly, bisulfite genomic DNA sequencing shows that human clear lenses (n = 15) slowly lose 5-methylcytosine in the Keap1 promoter throughout life, at a rate of 1% per year. By contrast, diabetic cataractous lenses (n = 21) lose an average of 90% of the 5-methylcytosine regardless of age. Overexpressed Keap1 protein is responsible for decreasing Nrf2 by proteasomal degradation, thereby suppressing Nrf2-dependent stress protection. This study demonstrates for the first time the associations of unfolded protein response activation, Nrf2-dependent antioxidant system failure, and loss of Keap1 promoter methylation because of altered active and passive DNA demethylation pathway enzymes in human lens epithelial cells by methylglyoxal. As an outcome, the cellular redox balance is altered toward lens oxidation and cataract formation.

Preliminary study on retinal vascular and oxygen-related changes after long-term silicone oil and foldable capsular vitreous body tamponade

Silicone oil has been the only long-term vitreous substitute used in the treatment of retinal detachment since 1962 by Cibis. Nevertheless, its effects on retinal vascular morphology and oxygen supply to the retina are ambiguous in current research. We previously invented a foldable capsular vitreous body (FCVB) to use as a new vitreous substitute in the treatment of severe retinal detachment, but its effects on the retinal vessel were unknown. Therefore, in this study, a standard three-port pars plana vitrectomy (PPV) was performed on the right eye of each rabbit and then silicone oil and FCVB were injected into the vitreous cavity as vitreous substitutes. After 180 days of retention, the retinal vascular morphology did not display any distinct abnormalities, and hypoxia-induced factor-1alpha (HIF-1α) and vascular endothelial growth factor (VEGF) did not vary markedly during the observation period in silicone oil tamponade- and FCVB-implanted eyes. This study may suggest that silicone oil and FCVB tamponade in rabbit eyes did not cause retinal vascular pathologic changes or retinal hypoxia for 180 days.

The effect of pars plan vitrectomy on oxygen saturation in retinal vessels--a pilot study

PURPOSE

  To determine the effect of pars plana vitrectomy (PPV) on oxygen saturation in retinal vessels.

METHODS

  We performed a prospective consecutive interventional case series of 20 eyes of 20 patients with macular hole or epiretinal membrane. We performed automatic retinal oximetry (Oxymap Inc., Reykjavik, Iceland) in each patient 24 hr prior to and 45 days (range 42-49) after PPV (classic 20G or sutureless 23G). We analysed oxygen saturations in retinal arteries and veins. Vessel segments of first or second degree were selected. The same segment was analysed before and after PPV. Oximetry data were compared by paired two-tailed t-test.

RESULTS

  Pars plana vitrectomy did not alter arterial haemoglobin saturation with oxygen (98±2% prior to the surgery and 98±3% after the procedure, p=0.549). The mean venous haemoglobin saturation with oxygen increased after vitrectomy from 63±10% to 66±8% (p=0.012).

CONCLUSIONS

  Oxygen saturation is higher in retinal veins after pars plana vitrectomy. Further studies are needed to unveil the mechanism of how vitrectomy affects oxygen metabolism in the retina.

Nd:YAG Capsulotomy after Phacoemulsification in Vitrectomized Eyes: Effects of Pars Plana Vitrectomy on Posterior Capsule Opacification

To compare the progression of posterior capsule opacification (PCO) in patients who required Nd:YAG laser capsulotomy following either combined cataract surgery with pars plana vitrectomy (PPV; C-CV), sequential cataract surgery after PPV (S-CV), or cataract surgery alone (CA). The medical records of 321 patients (408 eyes) who underwent Nd:YAG capsulotomy were retrospectively evaluated. The CA group had a significantly longer time interval from cataract surgery to capsulotomy than that of both the CV group (P = 0.006) and the S-CV (P = 0.013) and C-CV (P = 0.042) subgroups when age-matched comparisons were used. CV patients who implanted a hydrophobic acrylic IOL had shorter time intervals than those of CA patients (P = 0.028). CV patients had larger hazard of earlier capsulotomy than CA patients (hazard ratio (HR) = 1.337; 95% confidence interval (CI) 1.100–1.625; P = 0.004). C-CV and S-CV patients both had larger hazard than CA patients in earlier capsulotomy (HR = 1.304; 95% CI = 1.007–1.688; P = 0.044, HR = 1.361; 95%  CI = 1.084–1.709; P = 0.008, resp.). PCO progresses more rapidly in patients undergoing combined or sequential cataract surgery and PPV than in patients undergoing CA.

Progression of nuclear sclerosis based on changes in refractive values after lens-sparing vitrectomy in proliferative diabetic retinopathy

Background

Nuclear sclerosis (NS) based on the Emery–Little classification and refractive values after lens-sparing vitrectomy was compared between proliferative diabetic retinopathy (DR) patients and nondiabetic patients.

Methods

Progression of NS based on the Emery–Little classification and changes in refractive values were compared between 13 proliferative DR patients (14 eyes, DR group) and 14 nondiabetic patients (14 eyes, non-DR group) who underwent lens-sparing vitrectomy. All patients revealed grade I NS based on the Emery–Little classification. Mean patient age and refractive value just after surgery were 56.07 years and −0.33 diopters (D) in the DR group, and 57.06 years and −0.96 D in the non-DR group.

Results

The Emery–Little classification in the DR group at 6 and 24 months postoperative were grade I (13 eyes)/grade II (one eye) and grade I (eleven eyes)/grade II (three eyes), respectively. Mean refractive values in the DR group at 6, 12, and 24 months postoperative were +0.28 D, +0.27 D, and +0.37 D, respectively. The Emery–Little classification in the non-DR group at 6 and 24 months (or preoperative for patients undergoing cataract surgery) were grade I (five eyes)/grade II (eight eyes) and grade I (zero eyes)/grade II (eight eyes)/grade III (five eyes), respectively. The mean refractive value in the non-DR group at 6 months postoperative was −3.20 D. All eyes exhibited myopic changes and progression of NS.

Conclusion

The findings of this study show that the progression of NS postvitrectomy is mild, even for DR patients 50 years of age or older, thus suggesting the need to reconsider the indications for simultaneous cataract surgery with vitrectomy.

[Pathogenesis of cataract after vitrectomy]

Cataract is the most common complication after vitrectomy. At first posterior subcapsular, it evolves into a nuclear type. A better understanding of the pathophysiologic mechanisms could help to develop strategies to prevent this complication. The main causative factors are oxidative stress, as evidenced by the persistence of an elevated partial pressure of oxygen in the lens after vitrectomy and the ionic changes in the lens. Mechanical factors may also be implicated: direct contact by gas tamponade or by silicone oil leads to desiccation cataract. The key of prevention of the formation of these cataracts is based on the reduction of oxidative stress.

Electrophoretic deposition as a new approach to produce optical sensing films adaptable to microdevices

We report the fabrication of optical oxygen sensor films using electrophoretic deposition (EPD) of poly(styrene-co-maleic anhydride) nanoparticles containing the oxygen-sensitive dye platinum(ii) meso-tetra(pentafluorophenyl)porphine. Compared to other deposition methods, the EPD is simple and allows easy control over deposition, which is crucial for the implementation of optical sensing films in microdevices. By optimizing the synthesis of the functional nanoparticles, anodic EPD can be performed. The amount of deposited particles can be tuned by varying either the electrical potential or the deposition time. The sensing phases were characterized using a phase-modulation technique showing a Stern-Volmer constant (kSV1) between 45 and 52 bar(-1) for gas and of 20.72 bar(-1) in the aqueous phase without leaching of the particles from the surface. The small thickness of the layers lead to short response times (<0.4 s). This is the first time that polymeric optical sensing films have been obtained by EPD from dispersions of oxygen sensing nanoparticles.

Preretinal partial pressure of oxygen gradients before and after experimental pars plana vitrectomy

PURPOSE

To evaluate preretinal partial pressure of oxygen (PO2) gradients before and after experimental pars plana vitrectomy.

METHODS

Arteriolar, venous, and intervascular preretinal PO2 gradients were recorded in 7 minipigs during slow withdrawal of oxygen-sensitive microelectrodes (10-μm tip diameter) from the vitreoretinal interface to 2 mm into the vitreous cavity. Recordings were repeated after pars plana vitrectomy and balanced salt solution (BSS) intraocular perfusion.

RESULTS

Arteriolar, venous, and intervascular preretinal PO2 at the vitreoretinal interface were 62.3 ± 13.8, 22.5 ± 3.3, and 17.0 ± 7.5 mmHg, respectively, before vitrectomy; 97.7 ± 19.9, 40.0 ± 21.9, and 56.3 ± 28.4 mmHg, respectively, immediately after vitrectomy; and 59.0 ± 27.4, 25.2 ± 3.0, and 21.5 ± 4.5 mmHg, respectively, 2½ hours after interruption of BSS perfusion. PO2 2 mm from the vitreoretinal interface was 28.4 ± 3.6 mmHg before vitrectomy; 151.8 ± 4.5 mmHg immediately after vitrectomy; and 34.8 ± 4.1 mmHg 2½ hours after interruption of BSS perfusion. PO2 gradients were still present after vitrectomy, with the same patterns as before vitrectomy.

CONCLUSION

Preretinal PO2 gradients are not eliminated after pars plana vitrectomy. During BSS perfusion, vitreous cavity PO2 is very high. Interruption of BSS perfusion evokes progressive equilibration of vitreous cavity PO2 with concomitant progressive return of preretinal PO2 gradients to their previtrectomy patterns. This indicates that preretinal diffusion of oxygen is not altered after vitrectomy. The beneficial effect of vitrectomy in ischemic retinal diseases or macular edema may be related to other mechanisms, such as increased oxygen convection currents or removal of growth factors and cytokines secreted in the vitreous.

Oxidative responses induced by pharmacologic vitreolysis and/or long-term hyperoxia treatment in rat lenses

PURPOSE

The aim of the study was to investigate the protective effects of intact vitreous gel on the lens after pharmacologic vitreolysis and hyperoxia exposure in rats in vivo.

METHODS

Eyes of Sprague-Dawley rats were induced to posterior vitreous detachment (PVD) by pharmacologic vitreolysis, and the rats with and without PVD were treated with hyperoxia 3 h per day for 5 months. Lens transparency was monitored by a slit-lamp biomicroscope. A series of biochemical measurements were made in extracts of the lens cortex and nucleus. Ascorbate levels were measured in the aqueous and vitreous humors.

RESULTS

No significant differences in lens transparency or morphology were observed in all groups, and no significant biochemical changes were observed in the cortex or nucleus of lenses of the PVD group. In the lens nucleus, the values of water-soluble protein concentration in PVD + hyperoxia group were lower than that of the PVD group. The levels of water-soluble proteins, glutathione (GSH) and ascorbate decreased in the hyperoxia group with an intact vitreous body. Vitreolysis enhanced the effect of hyperoxia, decreasing soluble protein, GSH and ascorbate below the levels seen in eyes with vitreolysis alone. The levels of antioxidants and soluble proteins were lower in the lens nucleus, and the effects of vitreolysis plus hyperoxia were more significant in the nucleus. Hyperoxia and hyperoxia plus vitreolysis reduced catalase activity and increased oxidized GSH to a greater extent in the lens cortex, although these treatments increased protein-GSH mixed disulfides in both regions. Long-term hyperoxia also lowered ascorbate levels in the vitreous and aqueous humors, an effect that was enhanced by vitreolysis.

CONCLUSIONS

Exposure to excess molecular oxygen produces significant oxidative damage to the lens, especially the lens nucleus. These effects were enhanced by pharmacologic vitreolysis, indicating that intact vitreous gel protects the lens from oxidative damage.

Hypoxia impairs visual acuity in snapper (Pagrus auratus)

We investigated the effect of environmental hypoxia on vision in snapper (Pagrus auratus). Juvenile snapper inhabit estuarine environments where oxygen conditions fluctuate on a seasonal basis. Optomotor experiments demonstrated that visual acuity is impaired by environmental hypoxia, but not until levels approach the critical oxygen tension (P crit) of this species (around 25% air-saturated seawater). In 100, 80, and 60% air-saturated seawater, a positive optomotor response was present at a minimum separable angle (M SA) of 1°. In 40% air-saturated seawater, vision was partially impaired with positive responses at M SAs of 2° and above. However, in 25% air-saturated seawater, visual acuity was seriously impaired, with positive responses only present at M SAs of 6° and above. Snapper were found to possess a choroid rete, facilitating the maintenance of high ocular oxygen partial pressures (PO2) during normoxia and moderate hypoxia (PO2, between 269 and 290 mmHg). However, at 40 and 25% water oxygen saturation, ocular PO2 was reduced to below 175 mmHg, which is perhaps linked to impairment of visual acuity in these conditions. The ability to preserve visual function during moderate hypoxia is beneficial for the maintenance of a visual lifestyle in the fluctuating oxygen environments of estuaries.

Long-term intraocular pressure changes after combined phacoemulsification, intraocular lens implantation, and vitrectomy

PURPOSE

To observe long-term changes in intraocular pressure (IOP) after a combined phacoemulsification, intraocular lens implantation, and vitrectomy procedure.

METHODS

This was a retrospective case series at a single hospital. Of 105 consecutive cases that received combined phacoemulsification, intraocular lens implantation, and vitrectomy for macular hole or epiretinal membrane, 85 eyes (patients) were followed up for 1 year or longer. The IOP of both eyes in the subjects who had surgery in one eye was measured at baseline and at 1, 3, 6, 12, 24, 36, 48, and 60 months postoperatively. The IOP of the treated eye was compared with the fellow eye and with the baseline value at each follow-up visit.

RESULTS

Intraocular pressure in the operated eyes at 3 months after surgery was significantly lower than that at baseline and than that in the respectively fellow eyes (P < 0.001, paired-t test with Bonferroni correction). The IOP subsequently returned to the baseline value or was the same as that of the fellow eye within 3 months of the observation time point. Only two treated eyes had elevated IOP exceeding 21 mmHg after 6 months postoperatively.

CONCLUSIONS

The change in the IOP after phacovitrectomy may be limited, and care when using this procedure because some eyes show increased IOP compared to the fellow eye after a long period.

Protein misfolding and aggregation in cataract disease and prospects for prevention

The transparency of the eye lens depends on maintaining the native tertiary structures and solubility of the lens crystallin proteins over a lifetime. Cataract, the leading cause of blindness worldwide, is caused by protein aggregation within the protected lens environment. With age, covalent protein damage accumulates through pathways thought to include UV radiation, oxidation, deamidation, and truncations. Experiments suggest that the resulting protein destabilization leads to partially unfolded, aggregation-prone intermediates and the formation of insoluble, light-scattering protein aggregates. These aggregates either include or overwhelm the protein chaperone content of the lens. Here, we review the causes of cataract and nonsurgical methods being investigated to inhibit or delay cataract development, including natural product-based therapies, modulators of oxidation, and protein aggregation inhibitors.

Low glucose under hypoxic conditions induces unfolded protein response and produces reactive oxygen species in lens epithelial cells

Aging is enhanced by hypoxia and oxidative stress. As the lens is located in the hypoglycemic environment under hypoxia, aging lens with diabetes might aggravate these stresses. This study was designed to examine whether low glucose under hypoxic conditions induces the unfolded protein response (UPR), and also if the UPR then generates the reactive oxygen species (ROS) in lens epithelial cells (LECs). The UPR was activated within 1 h by culturing the human LECs (HLECs) and rat LECs in <1.5 mM glucose under hypoxic conditions. These conditions also induced the Nrf2-dependent antioxidant-protective UPR, production of ROS, and apoptosis. The rat LECs located in the anterior center region were the least susceptible to the UPR, whereas the proliferating LECs in the germinative zone were the most susceptible. Because the cortical lens fiber cells are differentiated from the LECs after the onset of diabetes, we suggest that these newly formed cortical fibers have lower levels of Nrf2, and are then oxidized resulting in cortical cataracts. Thus, low glucose and oxygen conditions induce the UPR, generation of ROS, and expressed the Nrf2 and Nrf2-dependent antioxidant enzymes at normal levels. But these cells eventually lose reduced glutathione (GSH) and induce apoptosis. The results indicate a new link between hypoglycemia under hypoxia and impairment of HLEC functions.

Functions of cholesterol and the cholesterol bilayer domain specific to the fiber-cell plasma membrane of the eye lens

The most unique feature of the eye lens fiber-cell plasma membrane is its extremely high cholesterol content. Cholesterol saturates the bulk phospholipid bilayer and induces formation of immiscible cholesterol bilayer domains (CBDs) within the membrane. Our results (based on EPR spin-labeling experiments with lens-lipid membranes), along with a literature search, have allowed us to identify the significant functions of cholesterol specific to the fiber-cell plasma membrane, which are manifest through cholesterol-membrane interactions. The crucial role is played by the CBD. The presence of the CBD ensures that the surrounding phospholipid bilayer is saturated with cholesterol. The saturating cholesterol content in fiber-cell membranes keeps the bulk physical properties of lens-lipid membranes consistent and independent of changes in phospholipid composition. Thus, the CBD helps to maintain lens-membrane homeostasis when the membrane phospholipid composition changes significantly. The CBD raises the barrier for oxygen transport across the fiber-cell membrane, which should help to maintain a low oxygen concentration in the lens interior. It is hypothesized that the appearance of the CBD in the fiber-cell membrane is controlled by the phospholipid composition of the membrane. Saturation with cholesterol smoothes the phospholipid-bilayer surface, which should decrease light scattering and help to maintain lens transparency. Other functions of cholesterol include formation of hydrophobic and rigidity barriers across the bulk phospholipid-cholesterol domain and formation of hydrophobic channels in the central region of the membrane for transport of small, nonpolar molecules parallel to the membrane surface. In this review, we provide data supporting these hypotheses.

Vitreoretinal influences on lens function and cataract

The lens is composed of a thin metabolically active outer layer, consisting of epithelial and superficial fibre cells. Lying within this outer shell are terminally differentiated, metabolically inactive fibre cells, which are divided into an outer cortex and central nucleus. Mature fibre cells contain a very high protein concentration, which is important for the transparency and refractive power of the lens. These proteins are protected from oxidation by reducing substances, like glutathione, and by the low-oxygen environment around the lens. Glutathione reaches the mature fibre cells by diffusing from the metabolically active cells at the lens surface. With age, the cytoplasm of the nucleus becomes stiffer, reducing the rate of diffusion and making nuclear proteins more susceptible to oxidation. Low pO(2) is maintained at the posterior surface of the lens by the physical and physiological properties of the vitreous body, the gel filling the space between the lens and the retina. Destruction or degeneration of the vitreous body increases exposure of the lens to oxygen from the retina. Oxygen reaches the lens nucleus, increasing protein oxidation and aggregation and leading to nuclear cataract. We suggest that maintaining low pO(2) around the lens should prevent the formation of nuclear cataracts.

Deficiency of Prdx6 in lens epithelial cells induces ER stress response-mediated impaired homeostasis and apoptosis

The multifunctional cytoprotective protein peroxiredoxin 6 (Prdx6) maintains cellular homeostasis and membrane integrity by regulating expression of intracellular reactive oxygen species (ROS) and phospholipid turnover. Using cells derived from targeted inactivation of Prdx6 gene or its depletion by RNA interference or aging, we showed that Prdx6 deficiency in cells evoked unfolded protein response (UPR), evidenced by increased expression or activation of proapoptotic factors, CHOP, ATF4, PERK, IRE-α and eIF2-α and by increased caspases 3 and 12 processing. Those cells displayed enhanced and sustained expression of endoplasmic reticulum (ER) stress-related chaperon proteins, Bip/glucose-regulated protein 78, calnexin, and calreticulin. Under cellular stress induced by hypoxia (1% O(2) or CoCl(2) treatment) or tunicamycin, Prdx6-deficient cells exhibited aberrant activation of ER stress-responsive genes/protein with higher expression of ROS, and died with apoptosis. Wild-type cells exposed to tunicamycin or hypoxia remained relatively insensitive with lower expression of ROS and ER-responsive genes than did Prdx6-deficient cells, but upregulation of ER stress responsive proteins or chaperones mimicked the UPR response of Prdx6-deficient or aging cells. Expression of Prdx6 blocked ER stress-induced deleterious signaling by optimizing physiologically aberrant expression of ER stress responsive genes/proteins in Prdx6-deficient cells or cells facing stressors, and rescued the cells from apoptosis. These findings demonstrate that impaired homeostasis and progression of pathogenesis in Prdx6-deficient lens epithelial cells or in aging cells should be blocked by a supply of Prdx6. The results provide a new molecular basis for understanding the etiology of several age-associated degenerative disorders, and potentially for developing antioxidant Prdx6-based therapeutics.

Vitreous substitutes: a comprehensive review

Vitreoretinal disorders constitute a significant portion of treatable ocular disease. Advances in vitreoretinal surgery have included the development and characterization of suitable substitutes for the vitreous. Air, balanced salt solutions, perfluorocarbons, expansile gases, and silicone oil serve integral roles in modern vitreoretinal surgery. Vitreous substitutes vary widely in their properties, serve different clinical functions, and present different shortcomings. Permanent vitreous replacement has been attempted with collagen, hyaluronic acid, hydroxypropylmethylcellulose, and natural hydrogel polymers. None, however, have proven to be clinically viable. A long-term vitreous substitute remains to be found, and recent research suggests promise in the area of synthetic polymers. Here we review the currently available vitreous substitutes, as well those in the experimental phase. We classify these compounds based on their functionality, composition, and properties. We also discuss the clinical use, advantages, and shortcomings of the various substitutes. In addition we define the ideal vitreous substitute and highlight the need for a permanent substitute with long-term viability and compatibility. Finally, we attempt to define the future role of biomaterials research and the various functions they may serve in the area of vitreous substitutes.

Quadruple therapy leads to a sustained improvement of vision in patients with wet age-related macular degeneration

AIM

To investigate the efficacy of a combined intravitreal therapy with prior photodynamic therapy (PDT) in patients with wet age-related macular degeneration.

METHODS

Fifty-two patients (mean age: 72.7 years) with predominantly classic choroidal neovascularization received low-fluence PDT (42 J/cm2 for 72 s), followed 24 h later by a 0.4-ml core pars plana vitrectomy with intravitreal injection of dexamethasone (0.8 mg) and bevacizumab (1.25 mg). The best-corrected visual acuity (BCVA; 6 m Snellen), central macular thickness (optical coherence tomography), intraocular pressure and the need for retreatment were assessed.

RESULTS

BCVA changed significantly (vs. baseline) at 3 months (+0.11), 9 months (+0.19) and 14 months (+0.16). At the end of the follow-up period, BCVA had improved by > 0.1 in the majority of the patients (72.9%), and the mean central retinal thickness had decreased by -44.3% (-211 μm). The retreatment rate was 25%. No increase in intraocular pressure or other adverse event was reported.

CONCLUSIONS

The pharmacological effects of the drugs, the low-fluence PDT, and the physiological effects of the therapy may have contributed to the sustainability of the therapeutic benefits.

Comparison of two probe designs for determining intraocular oxygen distribution

INTRODUCTION

Alterations in intraocular oxygen levels are important contributors to, or indications of, ocular disease. Polarographic electrodes and fibre-optic sensors (optodes) have been used to measure oxygen and to map the distribution of oxygen in animal models and in human eyes. A recent study reported the use of a commercial electrode to compare oxygen distribution in the vitreous of patients undergoing vitrectomy related to central retinal vein occlusion, macular hole or preretinal membrane. The results of this study were at variance with previous measures of oxygen distribution in the human vitreous using polarographic or optical sensors. To resolve this discrepancy, the present study compared measurements made in vitro or in animal eyes, using the electrode employed in the previous study or a fibre-optic sensor of a different design.

STUDY DESIGN

Comparative in vitro and in vivo measurements.

RESULTS

In vitro, the two devices reported similar levels of oxygen, although the electrode consistently detected levels above the calculated values. In rabbit eyes, the electrode had a slow response time and was unable to detect oxygen gradients that were readily measured by the smaller optode. When the electrode was inserted into an eye of similar size to the human eye, the reference thermistor measured the temperature outside the eye, not in the vitreous.

CONCLUSIONS

The design of the electrode used in the previous study makes it unsuitable for measurements of oxygen distribution in the eye.

Lipids and the ocular lens

The unusually high levels of saturation and thus order contribute to the uniqueness of human lens membranes. In addition, and unlike in most biomembranes, most of the lens lipids are associated with proteins, thus reducing their mobility. The major phospholipid of the human lens is dihydrosphingomyelin. Found in significant quantities only in primate lenses, particularly human ones, this lipid is so extremely stable that it was reported to be the only lipid remaining in a frozen mammoth 40,000 years after its death. Unusually high levels of cholesterol add peculiarity to the composition of lens membranes. Beyond the lateral segregation of lipids into dynamic domains known as rafts, the high abundance of cholesterol in the human lens leads to the formation of patches of pure cholesterol. Changes in human lens lipid composition with age and disease as well as differences among species are greater than those observed for any other biomembrane. The relationships among lens membrane composition, structure, and lipid conformation reviewed in this article are unique to the mammalian lens and offer exciting insights into lens membrane function. This review focuses on findings reported over the last two decades that demonstrate the uniqueness of mammalian lens membranes regarding their morphology and composition. Because the membranes of human lenses do undergo the most dramatic changes with age and cataractogenesis, the final sections of this review address our current knowledge of the unusual composition and organization of adult human lens membranes with and without opacification. Finally, the questions that still remain to be answered are presented.

Vitrectomy may prevent the occurrence of diabetic macular oedema

PURPOSE

This study aimed to demonstrate that vitrectomy may prevent the occurrence of diabetic macular oedema (DMO).

METHODS

Three patients with diabetes type 1 underwent vitrectomy in one eye to treat complications of proliferative diabetic retinopathy.

RESULTS

During follow-up, all patients suffered unilateral macular oedema in the non-vitrectomized eye as a result of general metabolic changes. In two of these patients, the DMO resolved with management of the underlying medical condition.

CONCLUSIONS

These case reports suggest the vitreous may play a role in the occurrence of DMO associated with general risk factors. Further studies are needed to increase understanding of the mechanisms involved in the development and progression of DMO.

Iron, the retina and the lens: a focused review

This review is focused on iron metabolism in the retina and in the lens and its relation to their respective age-related pathologies, macular degeneration (AMD) and cataract (ARC). Several aspects of iron homeostasis are considered first in the retina and second in the lens, paying particular attention to the transport of iron through the blood-retinal barrier and through the lens epithelial cell barrier, to the immunochemistry of iron-related proteins and their expression in both the retina and the lens, and to the nature of the photochemical damage caused by UV light on both tissues. A comparative overview of some iron related parameters (total iron, transferrin (Tf), transferrin saturation and total iron binding capacity), in plasma and ocular tissues and fluids of three animal species is also presented. Based on results selected from the literature reviewed, and our own results, a scheme for the overall circulation of iron within and out of the eye is proposed, in which, (i) iron is pumped from the retina to the vitreous body by a ferroportin/ferroxidase-mediated process at the endfeet of Müller cells, (ii) vitreal Tf binds this iron and the complex diffuses towards the lens, (iii) the iron/Tf complex is incorporated into the lens extracellular space probably at the lens equator and moves to the epithelial-fiber interface, (iv) upon interaction with Tf receptors of the apical pole of lens epithelial cells, the iron/Tf complex is endocytosed and iron is exported as Fe(3+) by a ferroportin/ferroxidase-mediated process taking place at the basal pole of the epithelial cells, and (v) Fe(3+) is bound to aqueous humor Tf and drained with the aqueous humor into systemic blood circulation for recycling. The proposed scheme represents an example of close cooperation between the retina and the lens to maintain a constant flow of iron within the eye that provides an adequate supply of iron to ocular tissues and secures the systemic recycling of this element. It does not discount the existence of additional ways for iron to leave the eye through the blood-retinal barrier. In this review both AMD and ARC are recognized as multifactorial diseases with an important photoxidative component, and exhibiting a remarkable similitude of altered local iron metabolism. The epidemiological relationship between ARC and ferropenic anemia is explained on the basis that hepcidin, the hormone responsible for the anemia of chronic inflammation, could paradoxically cause intracellular iron overload in the lens by interfering with the proposed ferroportin/ferroxidase-mediated export of iron at the basal side of the anterior lens epithelium. Other authors have suggested that a similar situation is created in the retina in the case of AMD.

Effects of vitrectomy on age-related macular degeneration

PURPOSE

To determine whether vitrectomy alters the long-term progression of age-related macular degeneration (AMD).

DESIGN

Retrospective case-control study.

PARTICIPANTS

Forty-four eyes of 22 patients with AMD who underwent vitrectomy in 1 eye were included in the study. The progression of AMD at follow-up in the 22 eyes that underwent vitrectomy was compared with the 22 fellow, nonvitrectomized eyes.

METHODS

The charts and photographs of subjects with Age-Related Eye Disease Study category 3 AMD in both eyes who previously underwent vitrectomy surgery for an epiretinal membrane or macular hole were reviewed. Subjects were excluded if they had had a vitrectomy in both eyes, had <2 years of follow-up, had previous choroidal neovascularization (CNV), retinal detachment, diabetic retinopathy, angioid streaks, high myopia, vascular occlusions, or extensive macular scarring in either eye, or insufficient hospital records or photographs to determine the extent of AMD. Clinical notes throughout the follow-up interval were reviewed. Two vitreoretinal specialists independently graded pre- and postvitrectomy fundus photographs of all eyes in a masked fashion.

MAIN OUTCOME MEASURES

The development or progression of geographic atrophy of the retinal pigment epithelium and the development of CNV.

RESULTS

Twenty-two patients were included. The average follow up interval was 5.5 years (range, 2-15). Choroidal neovascularization developed in 5 control eyes and in 2 vitrectomized eyes, and atrophy developed in 7 control and 4 vitrectomized eyes. The difference between vitrectomized eyes and fellow eyes for the combined end points of RPE geographic atrophy or CNV was significant (P = 0.02).

CONCLUSIONS

In this pilot study, we did not detect that vitrectomy increased the progression of AMD. In fact, it was associated with a reduced progression to geographic atrophy or CNV. Additional studies are needed to confirm or refute this association.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Retinal Oximetry Using Intravitreal Illumination

PURPOSE

To demonstrate spectroscopic retinal oximetry measurements on arteries and veins in swine using intravitreal illumination. Retinal arterial and venous saturations are measured for a range of inspired O2 levels after pars plana vitrectomy.

METHODS

Pars plana vitrectomy and intravitreal manipulations were performed on two female American Yorkshire domestic swine. Light from a scanning monochromator was coupled into a fiberoptic intraocular illuminator inserted into the vitreous. The retinal vessels were illuminated obliquely, minimizing vessel glints. Multispectral images of the retinal vasculature were obtained as the swine's arterial blood oxygen saturation was decreased from 100% to 67% in decrements of approximately 10%. Retinal vessel spectra were used to calculate oxygen saturation in selected arteries and veins. Arterial oxygen saturations were calibrated using blood gas analysis on blood drawn from a Swan-Ganz catheter placed in the femoral artery.

RESULTS

Oblique illumination of retinal vessels using an intravitreal fiberoptic illuminator provided a substantial reduction in the central vessel glint usually seen in fundus images, thus simplifying the analysis of spectral data. The vessel shadows were displaced from the vessel image simplifying the light paths in the eye. Using a full spectral analysis simplified by the light path reductions, we calculated retinal vessel saturations. The reduction of glint allowed for increased accuracy in measuring retinal vessel spectral optical density. Abnormally low retinal venous oxygen saturations were observed shortly after pars plana vitrectomy.

CONCLUSIONS

Retinal oximetry using intravitreal illumination has been demonstrated. As a research tool, intravitreal illumination addresses several difficulties encountered when performing retinal oximetry with transcorneal illumination.

The gel state of the vitreous and ascorbate-dependent oxygen consumption: relationship to the etiology of nuclear cataracts

OBJECTIVE

To investigate the rate and mechanism of oxygen consumption by the vitreous.

METHODS

Oxygen consumption was measured with a microrespirometer. Vitreous ascorbate was measured spectrophotometrically and by gas chromatography-mass spectrometry. Vitreous degeneration was related to the rate of oxygen consumption and ascorbate concentration in samples obtained during vitrectomy.

RESULTS

Prolonged exposure to oxygen or treatment with ascorbate oxidase eliminated oxygen consumption by the vitreous. Adding ascorbate restored oxygen consumption. Oxygen consumption persisted after boiling or treating the vitreous with the chelating agents EDTA and deferoxamine. In patients undergoing retinal surgery, liquefaction of the vitreous and previous vitrectomy were associated with decreased ascorbate concentration and lower oxygen consumption.

CONCLUSIONS

Ascorbate in the vitreous decreases exposure of the lens to oxygen. The catalyst for this reaction is not known, although free iron may contribute. The gel state of the vitreous preserves ascorbate levels, thereby sustaining oxygen consumption. Vitrectomy or advanced vitreous degeneration may increase exposure of the lens to oxygen, promoting the progression of nuclear cataracts.

CLINICAL RELEVANCE

Determining how the eye is protected from nuclear cataracts should suggest treatments to reduce their incidence.

Measurement of PO2 during vitrectomy for central retinal vein occlusion, a pilot study

INTRODUCTION

In this pilot study the effects of vitrectomy on PO(2) in the vitreous cavity in CRVO were investigated.

STUDY DESIGN

Prospective, controlled, interventional study.

METHOD

Six patients with ischaemic CRVO in one eye (undergoing vitrectomy for radial optic neurotomy, RON) and six with either macula hole or membrane were included. An oxygen probe was inserted before removal of the vitreous (pre-vitrectomy) and after removal of the vitreous (post-vitrectomy). In the patients with CRVO, measurements were taken before RON was performed. Oxygenation recordings (PO(2)) were taken in the mid-vitreous cavity and the preretinal vitreous.

RESULTS

Mean age was 65 years. In controls, pre-vitrectomy, the mean PO(2) adjacent to the retina (15.0 mmHg S.D.5.7) was significantly less than mid-cavity (33.7 mmHg S.D.12.8). Similarly in CRVO, the pre-vitrectomy pre-retinal PO(2) (8.1 mmHg S.D. 3.5), was significantly less than mid-cavity (19.8 mmHg S.D.7.3). The mean PO(2) was significantly less in the eyes with CRVO than in control eyes. Post-vitrectomy, the PO(2) was significantly greater than pre-vitrectomy at both recording sites in the controls mid-cavity (61.5 mmHg S.D.13.9) and pre-retinal (75.8 mmHg S.D. 9.1), and CRVO eyes mid-cavity (53.7 mmHg S.D. 17.9) and pre-retinal (59.8 mmHg S.D. 15.8).

CONCLUSION

PO(2) is reduced in the vitreous cavity in CRVO. Vitrectomy may be a method of increasing oxygen availability to the retina.

Presence of crystalline lens as a protective factor for the late development of open angle glaucoma after vitrectomy

PURPOSE

To evaluate the late development of open angle glaucoma (OAG) after vitrectomy and to compare the rate of postvitrectomy OAG development in phakic and pseudophakic eyes.

METHODS

Retrospective case series of 101 eyes of 101 patients who had vitrectomy for idiopathic epiretinal membrane or idiopathic macular hole with a follow-up duration of more than 6 months. Eligible patients were assessed for new development of OAG during the follow-up period. Patients were separated into two groups based on the lens status at the end of the vitrectomy for statistical analysis using Kaplan-Meier survival analysis with log-rank test and Cox regression analysis.

RESULTS

The mean follow-up duration was 51 months (range, 6-80 months). Of the 101 eyes, 8 (7.9%) eyes developed OAG during the follow-up period. Phakic eyes were less likely to develop OAG after vitrectomy compared with pseudophakic eyes, with 2% and 13%, respectively (log-rank test, P = 0.025). The result remained statistically significant after adjustment for age, refractive error and the use of gas tamponade (adjusted odds ratio = 0.09, P = 0.038).

CONCLUSION

The presence of the crystalline lens may be protective against the late development of OAG after vitrectomy.

A rabbit model to study biochemical damage to the lens after vitrectomy: effects of N-acetylcysteine

The purpose of the present study was to determine whether the biochemical effects of vitrectomy can be studied in rabbits and to assess the possible protective effects of N-acetylcysteine on the lens following vitrectomy. Twenty-four New Zealand rabbits (2.3-2.4 kg) were divided into three groups of eight each. Left eyes underwent vitrectomy surgery. Unoperated right eyes served as controls. Equal numbers of treated eyes were not injected, injected with 20 mM N-acetylcysteine, or 100 mM N-acetylcysteine immediately after vitrectomy. Lens transparency was monitored by slit-lamp biomicroscopy pre- and post-vitrectomy. A series of biochemical measurements were performed on lenses five months after vitrectomy. No significant differences in lens transparency or structure were observed in the three groups of lenses. However, vitrectomy was associated with significantly decreased activity of Na(+)-K(+)-ATPase and catalase. Compared with the group not treated with N-acetylcysteine, catalase activity was increased significantly in the group treated with 20 mM N-acetylcysteine. The level of glutathione and the activities of Na(+)-K(+)-ATPase and glutathione reductase were also higher in the two N-acetylcysteine-treated groups than in the untreated group, although these differences did not reach statistical significance. For all measured parameters, the effect of 20 mM N-acetylcysteine appeared to be better than 100 mM N-acetylcysteine, although these differences were not statistically significant. From these results, we gather that vitrectomy is associated with long-term decreases in enzyme activity in the lens. Injection of N-acetylcysteine into the vitreous cavity protects against some of these changes. Antioxidants like N-acetylcysteine may slow or prevent post-vitrectomy cataracts.

Enzyme-induced posterior vitreous detachment in the rat produces increased lens nuclear pO2 levels

It has been proposed that disruption of normal vitreous humor may permit O(2) to travel more easily from the retina to the center of the lens where it may cause nuclear cataract (Barbazetto, I.A., Liang, J., Chang, S., Zheng, L., Spector, A., Dillon, J.P., 2004. Oxygen tension in the rabbit lens and vitreous before and after vitrectomy. Exp. Eye Res. 78, 917-924; Harocopos, G.J., Shui, Y.B., McKinnon, M., Holekamp, N.M., Gordon, M.O., Beebe, D.C., 2004. Importance of vitreous liquefaction in age-related cataract. Invest. Ophthalmol. Vis. Sci. 45, 77-85). In the present study, we injected enzymes intravitreally into guinea pigs (which possess an avascular retina) and rats (which possess a vascular retina) to produce either vitreous humor liquefaction plus a posterior vitreous detachment (PVD) (with use of microplasmin) or vitreous humor liquefaction only (with use of hyaluronidase), and 1-2 weeks later measured lens nuclear pO(2) levels in vivo using a platinum-based fluorophore O(2) sensor (Oxford-Optronix, Ltd.). Experiments were also conducted in which the animals were allowed to breathe 100% O(2) following intravitreal injection with either microplasmin or hyaluronidase in order to investigate possible effects on O(2) exchange within the eye. Injection of guinea pigs with either of the two enzymes produced no significant differences in lens pO(2) levels 1-2 weeks later, compared to controls. However, for the rat, injection of microplasmin produced a 68% increase in O(2) level in the center of the lens, compared to the controls (5.6mm Hg increasing to 9.4mm Hg, p<0.05), with no corresponding effect observed following similar use of hyaluronidase. Treatment of guinea pigs with microplasmin dramatically accelerated movement of O(2) across the vitreal space when the animals were later allowed to breathe 100% O(2) (for example, O(2) traveled to a location directly behind the lens 5x faster than control; p<0.01); however, the effect following treatment with hyaluronidase was significantly less. When microplasmin-injected rats breathed 100% O(2), the time required for O(2) to reach the center of the lens was 3x faster than control (0.4 min compared to 1.4 min, p<0.01). The results have implication with regard to the occurrence of age-related PVD in the human, and a possible acceleration of maturity-onset nuclear cataract. In addition, enzymatic creation of a PVD to increase the rate of O(2) exchange within the vitreal space may have potential application for treatment of retinal ischemic disease.

Age-dependent control of lens growth by hypoxia

PURPOSE

The lens grows continuously throughout life, but the factors that influence the size of the adult lens are not known. Lens thickness is a significant risk factor for age-related cataract. It has been postulated that the hypoxic environment in the eye protects the lens from nuclear cataracts. The authors sought to determine whether the Po(2) in the eye regulates lens growth.

METHODS

Lens cell proliferation was determined by counting BrdU-labeled and total nuclei in the germinative zone in flatmounts of lens epithelia. Oxygen levels in the eye were altered by having rats breathe 11%, 21% (room air), or 60% oxygen. Oxygen levels in the vitreous were measured with a fiberoptic oxygen sensor.

RESULTS

The BrdU-labeling index in the germinative zone declined from approximately 3.5% at 1 month to less than 0.7% at 8 months. Raising oxygen levels in the eyes of 1-month-old animals did not alter the rate of lens cell proliferation. Elevating intraocular oxygen in animals older than 1 month increased proliferation to the more rapid rate seen at 1 month. Decreasing oxygen levels below their normally low level did not affect the BrdU-labeling index at any age. Chronic exposure to increased oxygen led to the production of more lens fiber cells and larger lenses.

CONCLUSIONS

Normal age-related decline in lens growth requires the low oxygen level normally present in the eye. Increases in lens cell number and mass may account for some of the increase in cataract risk caused by chronic exposure of the lens to elevated oxygen levels.

Oxygen permeability of the lipid bilayer membrane made of calf lens lipids

The oxygen permeability coefficient across the membrane made of the total lipid extract from the plasma membrane of calf lens was estimated from the profile of the oxygen transport parameter (local oxygen diffusion-concentration product) and compared with those estimated for membranes made of an equimolar 1-palmitoyl-2-oleoylphosphatidylcholine/cholesterol (POPC/Chol) mixture and of pure POPC. Profiles of the oxygen transport parameter were obtained by observing the collision of molecular oxygen with nitroxide radical spin labels placed at different depths in the membrane using the saturation-recovery EPR technique and were published by us earlier (J. Widomska, M. Raguz, J. Dillon, E. R. Gaillard, W. K. Subczynski, Biochim. Biophys. Acta. 1768 (2007) 1454-1465). At 35 degrees C, the estimated oxygen permeability coefficients were 51.3, 49.7, and 157.4 cm/s for lens lipid, POPC/Chol, and POPC membranes, respectively (compared with 53.3 cm/s for a water layer with the same thickness as a membrane). Membrane permeability significantly decreases at lower temperatures. In the lens lipid membrane, resistance to the oxygen transport is located in and near the polar headgroup region of the membrane to the depth of the ninth carbon, which is approximately where the steroid-ring structure of cholesterol reaches into the membrane. In the central region of the membrane, oxygen transport is enhanced, significantly exceeding that in bulk water. It is concluded that the high level of cholesterol in lens lipids is responsible for these unique membrane properties.

Maintaining transparency: a review of the developmental physiology and pathophysiology of two avascular tissues

The lens and cornea are transparent and usually avascular. Controlling nutrient supply while maintaining transparency is a physiological challenge for both tissues. During sleep and with contact lens wear the endothelial layer of the cornea may become hypoxic, compromising its ability to maintain corneal transparency. The mechanism responsible for establishing the avascular nature of the corneal stroma is unknown. In several pathological conditions, the stroma can be invaded by abnormal, leaky vessels, leading to opacification. Several molecules that are likely to help maintain the avascular nature of the corneal stroma have been identified, although their relative contributions remain to be demonstrated. The mammalian lens is surrounded by capillaries early in life. After the fetal vasculature regresses, the lens resides in a hypoxic environment. Hypoxia is likely to be required to maintain lens transparency. The vitreous body may help to maintain the low oxygen level around the lens. The hypothesis is presented that many aspects of the aging of the lens, including increased hardening, loss of accommodation (presbyopia), and opacification of the lens nucleus, are caused by exposure to oxygen. Testing this hypothesis may lead to prevention for nuclear cataract and insight into the mechanisms of lens aging. Although they are both transparent, corneal pathology is associated with an insufficient supply of oxygen, while lens pathology may involve excessive exposure to oxygen.

Two-year results of surgical removal of choroidal neovascular membranes related to non-age-related macular degeneration

PURPOSE

To present the 2-year outcomes of surgical removal of non-age-related macular degeneration (AMD)-related choroidal neovascular membranes and to evaluate any association between visual outcome and baseline clinical factors.

METHODS

Retrospective consecutive case series. All patients who had surgery for non-AMD-related choroidal neovascularisation (CNV) between November 1997 and March 2003 under the care of a single surgeon (WA) were included in the study. Baseline data including patient age, duration of subfoveal CNV, preoperative visual acuity (VA), lesion size, lesion components and aetiology were collected. The primary outcome was VA change with secondary outcomes retinal detachment, operative peripheral retinal break formation, CNV recurrence and cataract.

RESULTS

A total of 52 eyes were included in the study. The aetiology of CNV was: punctate inner choridopathy 21 (40%); idiopathic 8 (15%); pathologic myopia 6 (12%); ocular histoplasmosis syndrome 1 (2%); and other 16 (31%). The mean age of patients was 41(range 14-72) years. 24-month follow-up was available for 41 (80%) eyes. The mean logMAR equivalent baseline acuity was 1.1 and mean lesion size 1.2 disc areas. An improvement in VA >1 Snellen line was noted in 26 (63%) eyes, whereas 10 (24%) eyes remained the same (within 1 line) and 5 (12%) lost >1 line of acuity. Improvement in VA was associated with worse baseline VA (84% for eyes with VA <or=6/36 vs 31% for those with VA>6/36, p=0.001). No evidence of association between 2-year visual outcome and any other baseline factor under study was observed. Peripheral retinal breaks were noted in 5 (10%) eyes at the time of surgery, and 3 (5.8%) eyes developed postoperative retinal detachments. Persistent/recurrent CNV was noted in 17 (33%) eyes. The median time to presentation of CNV in these eyes was 27 (range 2-172) weeks. Five eyes underwent cataract surgery during the follow-up period. The mean age of these patients was significantly higher than the mean age of those who did not require cataract surgery (57 vs 37 years, p=0.014).

CONCLUSIONS

Surgical excision of non-AMD-related CNV resulted in improvement of VA in the majority of eyes. Worse presenting acuity was associated with better visual improvements.

A NOVEL METHOD TO OXYGENATE INTRAOCULAR IRRIGATION FLUIDS WITH AN IN-LINE OXYGENATOR

PURPOSE

We describe a novel method to oxygenate intraocular irrigation solutions involving an in-line oxygenator.

METHODS

Either lactated Ringer (LR) solution or balanced salt solution (BSS) was oxygenated with the FE390 Stainless In-line Oxygenation Assembly (Beer, Beer, and More Beer, Concord, CA). After running a 100-mL of solution through the in-line oxygenator, oxygen saturation was measured with a dissolved oxygen meter. A control experiment involving the oxygenator without oxygen perfusion was performed. Paired t-tests were used to compare oxygen saturation changes before and after oxygenation.

RESULTS

In comparison with the original BSS, there was an increase in oxygen saturation of 162 +/- 47% (n = 40; P < 0.05). Without oxygenation perfusion, there was only a 24 +/- 14% (n = 40) increase in oxygen levels in BSS, which was significantly lower than that in treated BSS (P < 0.05). In comparison with the original LR solution, there was an increase in oxygen saturation of 208 +/- 21% (n = 40; P < 0.05). Without oxygenation perfusion, there was only a 21 +/- 9% (n = 40) gain in oxygen saturation in the control LR solution, which was statistically lower as well (P < 0.05).

CONCLUSION

The in-line oxygenator is an efficient tool for oxygenating BSS and LR solution. It represents a potential efficient and convenient method to oxygenate irrigating solutions for vitreoretinal surgeries.

Zinc-desferrioxamine reduces damage to lenses exposed to hyperbaric oxygen and has an ameliorative effect on catalase and Na, K-ATPase activities

Our purpose was to investigate the effects of exposure to high partial pressure of oxygen on lens optical quality and on the activities of lenticular catalase and Na, K-ATPase in culture and to examine the effect of zinc-desferrioxamine (Zn-DFO) addition to cultured lenses exposed to high oxygen partial pressure on these parameters. Bovine lenses, kept in organ culture, were exposed to different combinations of partial pressure of oxygen with and without addition of Zn-DFO complex (20 microM) and examined during a 14-day period. Lens optical quality, catalase, and Na, K-ATPase activity were compared between study and control groups. Two hundred lenses were included in the present study. Decreased lenticular optical quality and decreased catalase and Na, K-ATPase activities were observed in lenses exposed to hyperbaric oxygen. Lenses exposed to normobaric oxygen showed a reduction in these parameters to a lesser degree. The damaging optical and enzymatic effects of oxygen on lenses in culture increased in magnitude along the culture period. Addition of Zn-DFO to the culture just before the exposure to hyperbaric oxygen eliminated most of the optical and enzymatic oxygen-induced damage. Addition of Zn-DFO after the first exposure demonstrated reduction in the oxidative damage induced reduction of optical quality in a time-dependent manner - the later the addition of Zn-DFO took place the smaller the protective effect observed. High oxygen load has toxic effects on bovine lenses in organ culture conditions as determined by optical parameters as well as reduction of catalase and Na, K-ATPase activities. These toxic effects can be attenuated by introducing Zn-DFO just before lenses are exposed to oxygen. The beneficial effect of Zn-DFO, applied after lenses have been exposed to hyperbaric oxygen, on the oxidative damage was time-dependent - the earlier the application the more significant the observed protective effect. The present results may indicate a possible future role for Zn-DFO as a protective agent against oxygen-induced human cataract formation.

Lower intraocular oxygen tension in diabetic patients: possible contribution to decreased incidence of nuclear sclerotic cataract

PURPOSE

To report intraocular oxygen tension in eyes of diabetic and nondiabetic patients.

DESIGN

A prospective, interventional consecutive case series.

METHODS

Oxygen was measured with an optical oxygen sensor in patients who were undergoing vitrectomy. Before turning on the infusion fluid, intraocular oxygen tension was measured in two locations: adjacent to the lens and in the mid vitreous cavity.

RESULTS

Fifty eyes from 50 patients were included in the study. Twenty-one eyes were from diabetic patients and 29 eyes were from nondiabetic patients. The mean oxygen tension adjacent to the lens was significantly lower in diabetic than in nondiabetic patients (8.4 +/- 0.7 mm Hg vs 10.7 +/- 0.8 mm Hg; P < .05). Similarly, the mean oxygen tension in the center of the vitreous cavity was lower in diabetic than in nondiabetic patients (5.7 +/- 0.7 mm Hg vs 8.5 +/- 0.6 mm Hg; P < .001). In subgroup analyses, previous panretinal photocoagulation or cataract surgery did not affect oxygen levels significantly in the vitreous of diabetic or nondiabetic patients.

CONCLUSION

Eyes from diabetic patients have significantly lower intraocular oxygen tension than in eyes from nondiabetic patients. Because oxidative damage to the lens nucleus and increased intraocular oxygen tension have been associated with nuclear sclerotic cataract, these findings may help explain recent reports of an apparent protective effect of diabetes mellitus against nuclear sclerotic cataract.

LXII Edward Jackson lecture: open angle glaucoma after vitrectomy

PURPOSE

To present data and an hypothesis for the late development of open angle glaucoma (OAG) after vitrectomy.

DESIGN

A retrospective observational case series.

METHODS

The records of 453 eyes that had undergone vitrectomy were reviewed for postoperative OAG. Eyes with confounding factors were excluded. Sixty-eight eyes of 65 patients that underwent routine vitrectomy were followed for a mean of 56.9 months (range, seven to 192 months). For the main outcome measures, patients were classified into three groups: patients with suspected glaucoma, patients in whom glaucoma developed after the operation, and patients with pre-existing glaucoma.

RESULTS

In glaucoma suspects, the mean intraocular pressure was significantly higher in the operated eye compared with the fellow eye (P = .0001). In eyes with new onset glaucoma, 23 of 34 eyes (67.6%) had it in the vitrectomized eye only. In phakic eyes, the time interval between vitrectomy and the development of glaucoma (mean, 45.95 months) was significantly longer than eyes that were nonphakic at the time of vitrectomy (mean, 18.39 months; P = .0115). When the interval between cataract surgery in phakic eyes to the development of glaucoma was compared with the interval from vitrectomy to glaucoma diagnosis in the nonphakic group, the difference was not statistically significant. In eyes with glaucoma before the operation, the mean number of antiglaucoma medications that were required to control the intraocular pressure was significantly higher in the vitrectomized eye, compared with the fellow eye (2.9 medications +/- 1.2 vs 2.0 medications +/- 1.4; P = .0215; n = 14).

CONCLUSION

There is an increased risk of OAG after vitrectomy. The presence of the lens may be protective. In established OAG before the operation, the number of antiglaucoma medications may increase after surgery. Oxidative stress is hypothesized to have a role in the pathogenesis.

Aggregation of lens crystallins in an in vivo hyperbaric oxygen guinea pig model of nuclear cataract: dynamic light-scattering and HPLC analysis

PURPOSE

The role of oxygen in the formation of lens high-molecular-weight (HMW) protein aggregates during the development of human nuclear cataract is not well understood. The purpose of this study was to investigate lens crystallin aggregate formation in hyperbaric oxygen (HBO)-treated guinea pigs by using in vivo and in vitro

METHODS

methods. Guinea pigs were treated three times weekly for 7 months with HBO, and lens crystallin aggregation was investigated in vivo with the use of dynamic light-scattering (DLS) and in vitro by HPLC analysis of water-insoluble (WI) proteins. DLS measurements were made every 0.1 mm across the 4.5- to 5.0-mm optical axis of the guinea pig lens.

RESULTS

The average apparent diameter of proteins in the nucleus (the central region) of lenses of HBO-treated animals was nearly twice that of the control animals (P < 0.001). Size distribution analysis conducted at one selected point in the nucleus and cortex (the outer periphery of the lens) after dividing the proteins into small-diameter and large-diameter groups, showed in the O2-treated nucleus a threefold increase in intensity (P < 0.001) and a doubling in apparent size (P = 0.03) of large-diameter aggregate proteins, compared with the same control group. No significant changes in apparent protein diameter were detected in the O2-treated cortex, compared with the control. The average diameter of protein aggregates at the single selected location in the O2-treated nucleus was estimated to be 150 nm, a size capable of scattering light and similar to the size of aggregates found in human nuclear cataracts. HPLC analysis indicated that one half of the experimental nuclear WI protein fraction (that had been dissolved in guanidine) consisted of disulfide cross-linked 150- to 1000-kDa aggregates, not present in the control. HPLC-isolated aggregates contained alphaA-, beta-, gamma-, and zeta-crystallins, but not alphaB-crystallin, which is devoid of -SH groups and thus does not participate in disulfide cross-linking. All zeta-crystallin present in the nuclear WI fraction appeared to be there as a result of disulfide cross-linking.

CONCLUSIONS

The results indicate that molecular oxygen in vivo can induce the cross-linking of guinea pig lens nuclear crystallins into large disulfide-bonded aggregates capable of scattering light. A similar process may be involved in the formation of human nuclear cataract.

Nonvitrectomizing vitreous surgery for epiretinal membrane long-term follow-up

PURPOSE

To report the long-term follow-up results of nonvitrectomizing vitreous surgery for idiopathic epiretinal membrane (ERM).

DESIGN

Nonrandomized comparative case series.

PARTICIPANTS

Thirty patients were followed up for at least 5 years after nonvitrectomizing vitreous surgery.

INTERVENTION

Epiretinal membranes were peeled without infusion of balanced salt solution and removal of the vitreous. The data from the fellow eye was the control data.

MAIN OUTCOME MEASURES

We examined the visual acuities (VAs), objective refractions, and slit-lamp and Scheimpflug photographs from the preoperative and the final examinations of both eyes. Quantitative assessment of the progression of nuclear sclerosis was performed by densitometry analysis using Scheimpflug photography. The recurrence rate of ERM was determined.

RESULTS

The follow-up periods ranged from 60 to 102 months (mean+/-standard deviation, 72.2+/-11.0 months). The patient ages ranged from 52 to 76 years (68.8+/-6.3 years). The final VA improved or stabilized within 2 lines in 29 of 30 eyes (96.7%). No unilateral progression of nuclear sclerosis occurred in any cases. The mean preoperative and postoperative refractions without additional surgery were -0.4+/-2.9 diopters (D) and -0.2+/-3.0 D in the operated eyes, respectively, and -0.2+/-2.5 D and 0.1+/-2.4 D, respectively, in the unoperated fellow eyes. The mean differences in the refractive error between both eyes (operated eye data minus fellow eye data) were -0.2+/-0.7 D before surgery and -0.3+/-0.8 D after surgery (P = 0.319, paired t test). The mean preoperative and postoperative nuclear densities in 16 patients were 69+/-14 nuclear density units (NDUs) and 76+/-12 NDUs in the operated eyes and 71+/-14 NDUs and 78+/-14 NDUs in the fellow eyes, respectively. The mean preoperative and postoperative differences in nuclear densities in both eyes were -2+/-2 NDUs and -2+/-5 NDUs, respectively (P = 0.836, paired t test). The ERM recurred in 10 eyes (33%), and 3 eyes underwent conventional vitrectomy combined with cataract surgery.

CONCLUSIONS

Unilateral nuclear sclerosis did not progress for at least 5 years after nonvitrectomizing vitreous surgery. The recurrence rate of ERM appeared to be higher than that after conventional vitreous surgery.

Age-related nuclear cataract—oxidation is the key

Age is by far the biggest risk factor for cataract, and it is sometimes assumed that cataract is simply an amplification of this aging process. This appears not to be the case, since the lens changes associated with aging and cataract are distinct. Oxidation is the hallmark of age-related nuclear (ARN) cataract. Loss of protein sulfhydryl groups, and the oxidation of methionine residues, are progressive and increase as the cataract worsens until >90% of cysteine and half the methionine residues are oxidised in the most advanced form. By contrast, there may be no significant oxidation of proteins in the centre of the lens with advancing age, even past age 80. The key factor in preventing oxidation seems to be the concentration of nuclear glutathione (GSH). Provided that nuclear GSH levels can be maintained above 2 mm, it appears that significant protein oxidation and posttranslational modification by reactive small molecules, such as ascorbate or UV filter degradation products, is not observed. Adequate coupling of the metabolically-active cortex, the source of antioxidants such as GSH, to the quiescent nucleus, is crucial especially since it would appear that the cortex remains viable in old lenses, and even possibly in ARN cataract lenses. Therefore it is vital to understand the reason for the onset of the lens barrier. This barrier, which becomes apparent in middle age, acts to impede the flow of small molecules between the cortex and the nucleus. The barrier, rather than nuclear compaction (which is not observed in human lenses), may contribute to the lowered concentration of GSH in the lens nucleus after middle age. By extending the residence time within the lens centre, the barrier also facilitates the decomposition of intrinsically unstable metabolites and may exacerbate the formation of H(2)O(2) in the nucleus. This hypothesis, which is based on the generation of reactive oxygen species and reactive molecules within the nucleus itself, shifts the focus away from theories for cataract that postulated a primary role for oxidants generated outside of the lens. Unfortunately, due to marked variability in the lenses of different species, there appears at present to be no ideal animal model system for studying human ARN cataract.

Thioredoxin reductase may be essential for the normal growth of hyperbaric oxygen-treated human lens epithelial cells

We have shown previously with in vivo and in vitro animal models that the lens epithelium, in contrast to the nucleus, is remarkably resistant to hyperoxia. The main purpose of this study was to investigate the mRNA response of cultured human lens epithelial cells (LECs) to challenge by a high level of hyperbaric oxygen. Cells were treated for 3 hr with 50 atm of 99% O2, and then cultured normally for various times up to 11 days. Although the cells appeared normal immediately after the O2-treatment, they failed to grow and suffered 50% cell loss, as well as significant mitochondrial damage, during normal post-culture. Growth of the cells resumed after 3 days and by day 11, the number of O2-treated cells was the same as the controls. Remarkably, the 3 hr O2-treatment produced no immediate effects on either the cellular level of GSH, or on the activities of a number of antioxidant enzymes including glyceraldehyde-3-phosphate dehydrogenase, which is generally regarded as being highly sensitive to oxidation. In contrast, the activity of thioredoxin reductase (TrxR) was severely affected by the O2, decreasing by 51% after the 3 hr exposure. O2-induced death of the cells appeared to be caused by loss of ATP since a 31% decrease in ATP level occurred immediately after the O2-treatment, in spite of a 46% increase in lactate production. Analysis with real-time PCR showed a maximum 3-6-fold increase in mRNA levels 9 hr after the 3 hr O2-exposure for the enzymes heme oxygenase-1 (HO-1), MnSOD and TrxR1 (the cytoplasmic form of TrxR). These results were confirmed with the use of one-step RT-PCR and Northern blotting. Initial upregulation of message for HO-1 occurred a few hours before any upregulation of MnSOD could be detected, suggesting that release of free iron from the degradation of heme by HO-1 may have played a role in the upregulation of the dismutase. No significant changes in mRNA levels were observed for the antioxidant enzymes catalase, CuZnSOD, glutathione reductase and glutathione peroxidase, or for the antioxidant protein thioredoxin. Recovery of TrxR activity over a 4-day period appeared to parallel the return of the cells to a normal rate of growth. The results indicate that damaging effects of hyperoxia on cultured LECs occur primarily in the mitochondria, rather than in the cytoplasm. Cells avoid O2-induced cell death, and return to a normal rate of proliferation by upregulating mRNA levels for HO-1, MnSOD and TrxR1. It appears that full activity of TrxR1, an enzyme required for the production of deoxyribonucletides for DNA synthesis, is essential for the normal growth of O2-challenged LECs.

Vitrectomy surgery increases oxygen exposure to the lens: a possible mechanism for nuclear cataract formation

PURPOSE

To report vitreous oxygen tension before, immediately after, and at longer times after vitrectomy.

DESIGN

A prospective, interventional consecutive case series.

METHODS

Oxygen was measured using an optical oxygen sensor in patients undergoing vitrectomy. Intraoperatively, oxygen measurements were taken before and after vitrectomy in two intraocular locations: adjacent to the lens and in the mid-vitreous.

RESULTS

Sixty-nine eyes underwent oxygen tension measurements at the time of vitrectomy. In baseline eyes, oxygen tension in the vitreous was low, measuring 8.7 +/- 0.6 mm Hg adjacent to the lens and 7.1 +/- 0.5 mm Hg in the mid-vitreous. The difference between the two locations was statistically significant (P < .003), indicating that vitreous gel maintains an intraocular oxygen gradient. Immediately after vitrectomy, oxygen tension in the fluid-filled eye was higher, measuring 69.6 +/-4.8 mm Hg adjacent to the lens and 75.6 +/- 4.1 mm Hg in the mid-vitreous. There was no statistically significant oxygen gradient between the two locations. The difference in oxygen tension pre- and postvitrectomy is highly statistically significant (P < .0001 lens, P < .0001 mid-vitreous). In eyes with a history of vitrectomy and previous removal of the vitreous gel, the intraocular oxygen tension was significantly higher than in eyes with a formed vitreous gel undergoing a first vitrectomy (P < .02 lens, P < .003 mid-vitreous).

CONCLUSION

Vitrectomy surgery significantly increases intraocular oxygen tension during and for prolonged periods after surgery. This exposes the crystalline lens to abnormally high oxygen and may lead to nuclear cataract formation.