Significant changes in advanced lung cancer survival during the past decade in Hungary: impact of modern immunotherapy and the COVID-19 pandemic

Objective

The approval of immunotherapy (I-O) for the treatment of late-stage non-small cell lung cancer (NSCLC) opened new perspectives in improving survival outcomes. However, survival data have not yet been provided from the period of the Covid-19 pandemic. The aims of our study were to assess and compare survival outcomes of patients with advanced LC receiving systemic anticancer treatment (SACT) before and after the approval of immunotherapy in Hungary, and to examine the impact of pandemic on survival outcomes using data from the Hungarian National Health Insurance Fund (NHIF) database.

Methods

This retrospective, longitudinal study included patients aged ≥20 years who were diagnosed with advanced stage lung cancer (LC) (ICD-10 C34) between 1 January 2011 and 31 December 2021 and received SACT treatment without LC-related surgery. Survival rates were evaluated by year of diagnosis, sex, age, and LC histology.

Results

In total, 35,416 patients were newly diagnosed with advanced LC and received SACT during the study period (mean age at diagnosis: 62.1-66.3 years). In patients with non-squamous cell carcinoma, 3-year survival was significantly higher among those diagnosed in 2019 vs. 2011-2012 (28.7% [95% CI: 26.4%-30.9%] vs. 14.45% [95% CI: 13.21%-15.69%], respectively). In patients with squamous cell carcinoma, 3-year survival rates were 22.3% (95% CI: 19.4%-25.2%) and 13.37% (95% CI: 11.8%-15.0%) in 2019 and 2011-2012, respectively, the change was statistically significant. Compared to 2011-2012, the hazard ratio of survival change for non-squamous cell carcinoma patients was 0.91, 0.82, and 0.62 in 2015-2016, 2017-2018, and 2019, respectively (p<0.001 for all cases). In the squamous cell carcinoma group, corresponding hazard ratios were 0.93, 0.87, and 0.78, respectively (p<0.001 for all cases). Survival improvements remained significant in both patient populations during the Covid-19 pandemic (2020-2021). No significant improvements were found in the survival of patients with small cell carcinoma. Platinum-based chemotherapy was the most common first-line treatment in all diagnostic periods, however, the proportion of patients receiving first- or second-line immunotherapy significantly increased during the study period.

Conclusion

3-year survival rates of NSCLC almost doubled among patients with non-squamous cell carcinoma and significantly improved at squamous cell carcinoma over the past decade in Hungary. Improvements could potentially be attributable by the introduction of immunotherapy and were not offset by the Covid-19 pandemic.

Opposite trends in incidence of breast cancer in young and old female cohorts in Hungary and the impact of the Covid-19 pandemic: a nationwide study between 2011-2020

Background

This nationwide study examined breast cancer (BC) incidence and mortality rates in Hungary between 2011-2019, and the impact of the Covid-19 pandemic on the incidence and mortality rates in 2020 using the databases of the National Health Insurance Fund (NHIF) and Central Statistical Office (CSO) of Hungary.

Methods

Our nationwide, retrospective study included patients who were newly diagnosed with breast cancer (International Codes of Diseases ICD)-10 C50) between Jan 1, 2011 and Dec 31, 2020. Age-standardized incidence and mortality rates (ASRs) were calculated using European Standard Populations (ESP).

Results

7,729 to 8,233 new breast cancer cases were recorded in the NHIF database annually, and 3,550 to 4,909 all-cause deaths occurred within BC population per year during 2011-2019 period, while 2,096 to 2,223 breast cancer cause-specific death was recorded (CSO). Age-standardized incidence rates varied between 116.73 and 106.16/100,000 PYs, showing a mean annual change of -0.7% (95% CI: -1.21%-0.16%) and a total change of -5.41% (95% CI: -9.24 to -1.32). Age-standardized mortality rates varied between 26.65-24.97/100,000 PYs (mean annual change: -0.58%; 95% CI: -1.31-0.27%; p=0.101; total change: -5.98%; 95% CI: -13.36-2.66). Age-specific incidence rates significantly decreased between 2011 and 2019 in women aged 50-59, 60-69, 80-89, and ≥90 years (-8.22%, -14.28%, -9.14%, and -36.22%, respectively), while it increased in young females by 30.02% (95%CI 17,01%- 51,97%) during the same period. From 2019 to 2020 (in first COVID-19 pandemic year), breast cancer incidence nominally decreased by 12% (incidence rate ratio [RR]: 0.88; 95% CI: 0.69-1.13; 2020 vs. 2019), all-cause mortality nominally increased by 6% (RR: 1.06; 95% CI: 0.79-1.43) among breast cancer patients, and cause-specific mortality did not change (RR: 1.00; 95%CI: 0.86-1.15).

Conclusion

The incidence of breast cancer significantly decreased in older age groups (≥50 years), oppositely increased among young females between 2011 and 2019, while cause-specific mortality in breast cancer patients showed a non-significant decrease. In 2020, the Covid-19 pandemic resulted in a nominal, but not statistically significant, 12% decrease in breast cancer incidence, with no significant increase in cause-specific breast cancer mortality observed during 2020.

Underlying reasons for post-mortem diagnosed lung cancer cases - A robust retrospective comparative study from Hungary (HULC study)

Objective

The Hungarian Undiagnosed Lung Cancer (HULC) study aimed to explore the potential reasons for missed LC (lung cancer) diagnosis by comparing healthcare and socio-economic data among patients with post-mortem diagnosed LC with those who were diagnosed with LC during their lives.

Methods

This nationwide, retrospective study used the databases of the Hungarian Central Statistical Office (HCSO) and National Health Insurance Fund (NHIF) to identify patients who died between January 1, 2019 and December 31, 2019 and were diagnosed with lung cancer post-mortem (population A) or during their lifetime (population B). Patient characteristics, socio-economic factors, and healthcare resource utilization (HCRU) data were compared between the diagnosed and undiagnosed patient population.

Results

During the study period, 8,435 patients were identified from the HCSO database with LC as the cause of death, of whom 1,203 (14.24%) had no LC-related ICD (International Classification of Diseases) code records in the NHIF database during their lives (post-mortem diagnosed LC population). Post-mortem diagnosed LC patients were significantly older than patients diagnosed while still alive (mean age 71.20 vs. 68.69 years, p<0.001), with a more pronounced age difference among female patients (difference: 4.57 years, p<0.001), and had significantly fewer GP (General Practitioner) and specialist visits, X-ray and CT scans within 7 to 24 months and 6 months before death, although the differences in GP and specialist visits within 7-24 months did not seem clinically relevant. Patients diagnosed with LC while still alive were more likely to be married (47.62% vs. 33.49%), had higher educational attainment, and had more children, than patients diagnosed with LC post-mortem.

Conclusions

Post-mortem diagnosed lung cancer accounts for 14.24% of total lung cancer mortality in Hungary. This study provides valuable insights into patient characteristics, socio-economic factors, and HCRU data potentially associated with a high risk of lung cancer misdiagnosis.

Antiproliferative Effect of 4-Thiouridylate on OCM-1 Uveal Melanoma Cells

Purpose

Brachytherapy is a well-established, effective treatment for uveal melanoma with a failure rate of 15%. The fatal consequence of unsuccessful treatments offers reason for improvement of the method. The authors propose using an apoptosis inducing agent locally, concomitantly with the well-established therapy, to sensitize the tumor cells. The authors propose a new nontoxic moderately active apoptosis inducing agent, 4-thio-uridylate (s4UMP), for this purpose.

Methods

OCM-1 uveal melanoma cells were treated with various concentrations of s4UMP and its effect was monitored by measuring the cell viability (MTT assay). The following apoptosis detecting methods were performed to reveal the mechanism of decreased cell viability: light microscopy, DNA fragmentation assay, determination of caspase 9 activity, and FACS analysis.

Results

The viability of uveal melanoma cells was decreased by 32%, 40%, and 9% after 24, 48, and 72 hours of treatment with 10 μg/mL (30 μM) S4UMP. The effect was not dose dependent; it rather followed a saturation-type inhibition and the cells at lower drug concentration recovered after 72 hours. Characteristic apoptotic cell morphology and DNA fragmentation was detected in treated cells. The caspase-9 was activated upon treatment showing maximal activity at 48 hours suggesting the induction of apoptosis. The annexin binding activity further verified the apoptogenic activity of s4UMP.

Conclusions

Uveal melanoma, more than other solid tumors, is resistant to most of the chemotherapeutic protocols as indicated by the high mortality rate of metastatic disease. The authors showed that s4UMP, a naturally occurring nucleotide, could induce apoptosis in uveal melanoma cells, suggesting a potential supplementary therapeutic application of the compound.

Comparison of Divide and Conquer and Phaco-Chop Techniques during Fluid-Based Phacoemulsification

PURPOSE

To determine whether, similar to ultrasound phaco-emulsification, applied energy and surgery time decrease using phaco-chop nucleus fragmentation method compared to divide and conquer technique using the fluid-based system.

METHODS

This prospective, comparative, randomized clinical study included patients with cataract who were randomly assigned to use either standard divide and conquer technique (25 eyes of 25 patients, Group 1) or Nagahara phaco-chop maneuver (25 eyes of 25 patients, Group 2) during fluid-based phaco-emulsification. Surgical parameters were recorded and patients were examined 1 day, 10 days, and 1 month after surgery. Statistical analyses were performed using the paired test of Wilcoxon.

RESULTS

Fluid-based time, mean fluid-based magnitude, effective fluid-based time, and the number of pulses were significantly less using phaco-chop technique compared to divide and conquer method (p<0.001). Surgery time was similar using the two nucleofractis techniques (p=0.97). Visual acuities showed no statistical differences between the two groups (p>0.05).

CONCLUSIONS

Nuclear fragmentation can be performed with Nagahara phaco-chop technique using the fluid-based system as well. The applied fluid-based energy decreases compared to divide and conquer method. However, surgery time is not reduced due to the difficulties reaching the full occlusion necessary to hold the nucleus during the chop maneuver.

The Efficacy and Safety of Timolol Maleate versus Brinzolamide Each Given Twice Daily Added to Travoprost in Patients with Ocular Hypertension or Primary Open-Angle Glaucoma

PURPOSE

To compare the efficacy and safety of timolol maleate 0.5% versus brinzolamide 1% when added to travoprost 0.004% in patients with ocular hypertension or primary open-angle glaucoma.

DESIGN

A prospective, double-masked, randomized, active-controlled, parallel comparison.

METHODS

Qualified patients at Visit 1 were placed on travoprost dosed every evening for 4 weeks and then were randomized at baseline (Visit 2) to the addition of timolol maleate or brinzolamide each given twice daily. Patients returned to clinic at Week 4 (Visit 3) for a safety visit and Week 12 (Visit 4) for an efficacy visit. At Visits 2 and 4 the intraocular pressure (IOP) was measured at 08:00, 12:00, and 16:00 hours.

RESULTS

Ninety-seven patients on brinzolamide had a baseline diurnal IOP of 21.5+/-2.2 mmHg and 95 on timolol maleate had 21.3+/-2.5 mmHg, each added to travoprost. The diurnal mean IOP at Week 12 was 18.1+/-2.7 mmHg for brinzolamide and 18.1+/-3.0 mmHg for timolol maleate (p=0.96). There was no statistical difference found between treatment groups in the absolute level of pressure, or in the reduction in IOP from baseline, at each time point or for the diurnal curve (p>0.05). There was no significant difference for any adverse event between groups (p>0.05), with the most common side effect being conjunctival hyperemia in 15/97 (16%) brinzolamide and 6/95 (6%) timolol treated patients (p=0.06).

CONCLUSIONS

This study showed that brinzolamide provides similar safety and efficacy compared to timolol maleate when added to travoprost.

Progesterone Administration Fails to Protect Albino Male Rats against Photostress-Induced Retinal Degeneration

PURPOSE

Female patients show better recovery after brain injury and lower incidence of vascular diseases before menopause. The aim of this study was to test the protective effect of female sexual hormones against photostress-induced photoreceptor apoptosis.

METHODS

Five week old male albino Sprague-Dawley rats were injected intraperitoneally with progesterone (60 mg/kg body weight) for 4 days. The control group was injected with the vehicle only (benzyl alcohol). Both groups were halved and one was stressed with light (2700 lux for 24 hours) and the other remained under the original dim cyclic light condition. For functional evaluation, baseline electroretinograms (ERGs) were recorded 7 days before light stress, with follow-up ERGs 5 days after the cessation of light exposure. Animals were sacrificed and their eyes enucleated for histology.

RESULTS

Light exposure caused pronounced decrease in the ERG a- and b-wave amplitudes compared to controls. However, in the light-stressed group, the difference in retinal function between progesterone-treated and nontreated animals was not statistically significant. The thickness of the outer nuclear layer and the length of rod outer and inner segments were significantly reduced in the light-stressed group, indicating loss of rod photoreceptor cells. Progesterone had no neuroprotective effect on rod cell structure.

CONCLUSIONS

The administration of progesterone did not prove to be protective against excessive light-caused retinal degeneration on male albino rats. The role of other sexual steroids and their interaction need to be clarified.

Randomized clinical trial of dexketoprofen/tramadol 25 mg/75 mg in moderate-to-severe pain after total hip arthroplasty

Background. The aim was to evaluate the analgesic efficacy and safety of the dexketoprofen/tramadol 25 mg/75 mg fixed-dose combination vs dexketoprofen (25 mg) and tramadol (100 mg) in moderate-to-severe acute pain after total hip arthroplasty.

Methods. This was a randomized, double-blind, parallel-group study in patients experiencing pain of at least moderate intensity on the day after surgery, compared with placebo at first administration to validate the pain model. The study drug was administered orally every 8 h throughout a 5 day period. Rescue medication, metamizole 500 mg, was available during the treatment period. The evaluation of efficacy was based on patient assessments of pain intensity and pain relief. The primary end point was the mean sum of the pain intensity difference values throughout the first 8 h (SPID₈).

Results. Overall, 641 patients, mean age 62 (range 29–80) yr, were analysed; mean (sd) values of SPID₈ were 247 (157) for dexketoprofen/tramadol, 209 (155) for dexketoprofen, 205 (146) for tramadol, and 151 (159) for placebo. The primary analysis confirmed the superiority of the combination over dexketoprofen 25 mg (P=0.019; 95% confidence interval 6.4–73) and tramadol 100 mg (P=0.012; 95% confidence interval 9.5–76). The single components were superior to placebo (P<0.05), confirming model sensitivity. Most secondary analyses supported the superiority of the combination. The incidence of adverse drug reactions was low and similar among active treatment groups.

Conclusion. The efficacy results confirmed the superiority of dexketoprofen/tramadol over its single components, even at higher doses (tramadol), with a safety profile fully in line with that previously known for these agents in monotherapy.

Clinical trial registration. EudraCT 2012-004548-31 (https://www.clinicaltrialsregister.eu/ctr-search/search?query=eudract_number:2012-004548-31);

ClinicalTrials.gov NCT01902134 (https://www.clinicaltrials.gov/ct2/show/NCT01902134?term=NCT01902134&rank=1).

Vascular endothelial growth factor levels in tears of patients with retinal vein occlusion

PURPOSE

We measured vascular endothelial growth factor (VEGF) levels in tear fluid and serum in patients with retinal vein occlusion (RVO).

PATIENTS AND METHODS

Eight patients with RVO due to secondary macular oedema were examined. VEGF levels were measured by enzyme-linked immunosorbent assay. All patients had a full ophthalmic examination (visual acuity, slit lamp biomicroscopy, perimetry, and fluorescein angiography). Central retinal thickness (CRT) was examined using optical coherence tomography (OCT). Tear and serum samples were collected and examinations were performed at diagnosis and 1 and 4 weeks later.

RESULTS

VEGF levels in the tears of RVO eyes were significantly higher than in fellow eyes at diagnosis and after both 1 and 4 weeks (paired t test, p1 = 0.01, p2 = 0.02, p3 = 0.006). We found a weak but significant positive correlation between VEGF levels in tear fluid and serum of patients with RVO (r = 0.21), while this correlation tended to be stronger between the fellow eyes and serum levels (r = 0.33).

CONCLUSION

To the best of our knowledge, we are the first to report an increased level of VEGF in the tear fluid of patients with RVO. Alterations of VEGF levels in tears may be useful for determining stages of RVO. This non-invasive and objective method may also be helpful for estimating the severity of macular oedema and efficacy of treatment.

[Acanthamoeba keratitis in patients with contact lens wear in the Department of Ophthalmology in Debrecen]

BACKGROUND

With increasing numbers of contact lens wearers, Acanthamoeba infections are also more frequent all over the world and also in Hungary. Despite improved diagnostic and therapeutic possibilities it can still cause serious visual loss. In this study the symptoms, signs, diagnostics and treatment options for Acanthamoeba keratitis (AK) in patients treated in our department are presented and compared to the literature.

PATIENTS AND METHODS

Between 2001 and 2006 a total of 11 patients were treated in our department for Acanthamoeba keratitis.

RESULTS

The mean age of the patients was 30 years and the 8 female and 3 male patients were all contact lens wearers. In six cases the right eye was affected and in five cases the left eye. Poor and improper contact lens hygiene was the cause of infection in all cases and 82% of the infections occurred in the summer period between June and September. In addition to long-term conservative treatment, perforating keratoplasty was performed in six cases. After the therapy the best visual acuity was 0.6, but 4 of the patients had a serious visual loss. Follow-up time ranged from 6 months to 5 years.

CONCLUSIONS

Early diagnosis and long-term suitable local therapy are necessary for effective recovery. If the patient wears contact lens and there is severe pain with ring infiltration in the cornea, Acanthamoeba infection should be considered and suitable therapy should be given. Immediately performed perforating keratoplasty does not lead to visual improvement. Prevention by informing the patients about adequate hygiene and use of the cleaning solutions is one of the most important tasks of contact lens specialists.

Hepatitis C virus presumably associated bilateral consecutive anterior ischemic optic neuropathy

PURPOSE

To report a case of bilateral nonarteritic anterior ischemic optic neuropathy (NAION) in a hepatitis C (HCV) infected patient and demonstrate the relationship between HCV and the development of NAION.

METHODS

Case report.

RESULTS

A 43-year-old woman with chronic HCV infection and long-term euthyroid autoimmune thyroiditis suddenly lost vision in her right eye, and 6 months later in her left eye, due to NAION. Slightly elevated levels of aminotransferases suggested liver infection activity. Anti-HCV antibody was detected; the genotype of the virus was 1b and the viral RNA level was 1.8 x 106 IU/mL. Liver biopsy proved chronic active hepatitis (Ishak score grading: 7, staging: 2). Except for the elevated levels of antithyroid antibodies and a weak antinuclear factor, the detailed laboratory examinations (thrombophilia, cryoglobulin, anticardiolipin antibodies, co-infections) revealed no other abnormalities; a causative relationship between the underlying chronic hepatitis C and bilateral NAION therefore seems probable. The patient was treated with pegylated interferon and ribavirin for 1 year and a sustained viral remission could be achieved. Her vision has neither improved nor deteriorated further.

CONCLUSIONS

This appears to be the first reported case of bilateral NAION presumably caused by HCV infection.

Erfahrungen der Umsetzung von Diagnosis Related Groups (DRG) in der ungarischen Augenheilkunde

OBJECTIVE

The aim of our investigation is to analyse the effect of the introduction of the DRG (Diagnosis Related Groups) principle on the financing of ophthalmology care including the analysis of market share of ophthalmology.

DATA AND METHODS

Data of the study derive from the financial database of the Hungarian National Health Insurance Fund Administration (OEP) containing the monthly activity reports of health care providers. The financing of acute hospital care in Hungary is based on a case-mix system called Homogeneous Disease Groups (Homogén Betegségcsoportok, HBCS). The analysis covers the period between 1995 and 2003. We used the following indicators in order to analyse the market share of ophthalmology: financial cases (patients), DRG costweights and nursing days (length of stay).

RESULTS

From the DRG costweights - serving as a base value for financing - the market share of ophthalmology was 3.3 - 3.5 % in 1995 - 1996, but decreased to 2.6 - 2.7 % in 1997 - 1998, and after a gradual increase since 1999 it went up to 3.4 % in 2002 - 2003. The market share of ophthalmology from financial cases (patients) increased from 3.1 - 3.2 % in 1995 - 1996 to 3.8 - 3.9 % in 2002 - 2003. From the total number of nursing days ophthalmology had a market share of 2.4 - 2.6 % in 1995 - 1996, which showed a further decrease to 2.2 - 2.3 % in 2002 - 2003. The average length of stay in ophthalmology decreased from 8 days (1995) to 4 days (2003).

CONCLUSION

The frequent changes of the Hungarian DRG system had a significant effect on the financing of Hungarian ophthalmology care. The continuous changes in the regulation of financing and reimbursement represent a big challenge for ophthalmology.

Cell proliferation and apoptosis in stromal corneal dystrophies

The aim of our study was to evaluate corneal cell proliferation and apoptosis in cases of granular, macular and lattice dystrophy, and to provide evidence which may help to clarify whether apoptosis is a pathogenic factor in any of these dystrophies. The study group comprised 39 eyes (from 33 patients) which had undergone penetrating keratoplasty (PK) for stromal dystrophies: these comprised 12 eyes (from 9 patients, 55.5% males) with granular dystrophy, 13 eyes (12 patients, 33.3% males) with macular dystrophy, and 14 eyes (13 patients, 61.5% males) with lattice type I dystrophy. A further 4 corneal buttons from enucleated eyes of 4 patients with choroideal melanoma served as controls. Immunocytochemical analysis of Ki67 (DNAcon Kit, DakoCytomation A/S, Glostrup, Denmark) was used for evaluation of cell proliferation. Apoptosis was detected by use of the TUNEL (terminal deoxyribonucleotidyl transferase-mediated dUTP-digoxigenin nick-end labelling) assay method (Apoptag reagent, Q-Biogene, Strasbourg, France). Statistical comparisons were made using the Mann-Whitney test. No Ki67-positive cells were detected in the study-group or control corneas. In control corneas no apoptotic activity was found. In the study group the mean (normalised) apoptotic keratocyte number was 1.1+/-1.7 in granular dystrophy and 0.5+/-1.1 in lattice type I dystrophy (p = 0.36, 0.63 respectively). Compared to the controls, the difference was statistically significant only for macular dystrophy (1.6+/-1.2; p = 0.01). Keratocyte apoptosis seems to be a concomitant or pathogenic factor in macular dystrophy. However, the pathways that are triggered to result in increased apoptotic cell death remain to be clarified.

[Initial experience with transpalpebral orbital lipectomy]

PURPOSE

The aim of this study was to evaluate the short-term effectiveness of transpalpebral orbital lipectomy.

METHOD

Using a transpalpebral approach, 2.0-6.5 ml connective tissue was removed from 50 orbits of 33 patients with mild to severe Graves' orbitopathy (25 females, 8 males) over a 5-year period. Indications for surgery comprised cosmetic correction of exophthalmos (27/33 patients), corneal damage (5/33), and rapid bilateral deterioration of visual acuity in 1 patient.

RESULTS

In 27 patients undergoing correction for aesthetic purposes no change in visual acuity ensued; in 4 of 5 keratopathy patients an improvement in visual acuity was detected. Diplopia ceased in 4 of 13 patients, diminished in 3 of 13 cases, and constantly increased in 2 of 13 cases. The high intraocular pressure returned to normal in 8 of 13 patients. The proptosis was reduced at 3.2+/-1.3 mm.

CONCLUSION

Transpalpebral orbital lipectomy is a low-risk, highly effective technique for orbital decompression in both acute and chronic cases of Graves' orbitopathy.

Antiproliferative effect of 4-thiouridylate on OCM-1 uveal melanoma cells

PURPOSE

Brachytherapy is a well-established, effective treatment for uveal melanoma with a failure rate of 15%. The fatal consequence of unsuccessful treatments offers reason for improvement of the method. The authors propose using an apoptosis inducing agent locally, concomitantly with the well-established therapy, to sensitize the tumor cells. The authors propose a new nontoxic moderately active apoptosis inducing agent, 4-thio-uridylate (s4UMP), for this purpose.

METHODS

OCM-1 uveal melanoma cells were treated with various concentrations of s4UMP and its effect was monitored by measuring the cell viability (MTT assay). The following apoptosis detecting methods were performed to reveal the mechanism of decreased cell viability: light microscopy, DNA fragmentation assay, determination of caspase 9 activity, and FACS analysis.

RESULTS

The viability of uveal melanoma cells was decreased by 32%, 40%, and 9% after 24, 48, and 72 hours of treatment with 10 microg/mL (30 microM) s4UMP. The effect was not dose dependent; it rather followed a saturation-type inhibition and the cells at lower drug concentration recovered after 72 hours. Characteristic apoptotic cell morphology and DNA fragmentation was detected in treated cells. The caspase-9 was activated upon treatment showing maximal activity at 48 hours suggesting the induction of apoptosis. The annexin binding activity further verified the apoptogenic activity of s4UMP.

CONCLUSIONS

Uveal melanoma, more than other solid tumors, is resistant to most of the chemotherapeutic protocols as indicated by the high mortality rate of metastatic disease. The authors showed that s4UMP, a naturally occurring nucleotide, could induce apoptosis in uveal melanoma cells, suggesting a potential supplementary therapeutic application of the compound.

[The role of infection control in the prevention of postoperative endophthalmitis]

INTRODUCTION

Infection control programs play an important role in the fight against nosocomial infections. They include all written protocols used and practical procedures performed before, during and after surgery. The authors describe the role of infection control in the prevention of postoperative endophthalmitis.

PATIENTS AND METHODS

Retrospective data of endophthalmitis cases following elective eye penetrating surgeries performed at the Departments of Ophthalmology of the University of Debrecen and of the Hajdú-Bihar County Hospital in the periods between 1997-2001 and 2002-2003 were evaluated. Infection control methods for prevention have been in use in both institutes since 2002.

RESULTS

The incidences of postoperative endophthalmitis before and after 2002 were 0.09 % and 0.07 %, respectively. Endophthalmitis cases in both periods occurred sporadically. Between 1997 and 2001 women accounted for 63.6 %, while they made up 80 % between 2002 and 2003; In the first period 63.6 % were older than 60 years whereas this group made up and 100 % in the second period. During the two periods accompanying chronic systemic diseases also had to be taken into consideration in 80 % and in 63.6 % of the cases, respectively. Intraoperative loss of the vitreous body was present in 27.2 % (1997-2001), and in 20 % (2002-2003) of the cases.

CONCLUSIONS

We did not find any statistically significant difference between the incidence of postoperative endophthalmitis in the two periods. We think, however, that further studies involving more patients and longer study periods will reveal a correlation between the use of infection control methods and the prevention of both sporadic and epidemic cases of endophthalmitis, therefore all available data concerning this problem should be published. Moreover, the introduction of infection control policies into clinical practice will make prevention deliberate and more effective.

A comparison of accommodation amplitudes in pseudophakic eyes measured with three different methods

PURPOSE

To compare the accommodative amplitudes with three different methods in pseudophakic eyes with different types of intraocular lenses (IOLs).

METHODS

Fifty-one pseudophakic eyes of 44 patients (age: 72.02+/-8.53 years) were studied. One of two different types of IOL were implanted (N=30, three-piece Alcon Acrysof MA60AC and N=21, one-piece Alcon Acrysof SA60AT) in-the-bag after standard phacoemulsification. The time of the examinations was 13.85+/-7.35 months postoperatively. We measured the amplitude of accommodation with three different methods: (1) subjective minus-lenses-to-blur method; (2) a new optical device (ACMaster, Carl Zeiss, Jena, Germany) using partial coherence interference (PCI) technique under physiological stimulus; and (3) objective anterior chamber depth measuring with a standard A-scan ultrasonic device (Ultrascan Imaging System, Alcon Laboratories, Forth Worth, TX, USA) before and after pharmacological relaxation of ciliary muscle.

RESULTS

We measured -0.83+/-0.63 D amplitude of accommodation with subjective minus-lenses-to-blur method. The IOL position did not change significantly during physiological accommodation effort measured with PCI method (-0.026+/-0.134 mm). The change in the IOLs position between near fixating and after ciliary muscle relaxation was -0.18+/-0.28 mm measured with ultrasound. There were no significant differences between values of one-piece and three-piece IOL groups.

CONCLUSION

The amplitude of accommodation measured by subjective and objective methods are different and are not comparable with each other. We did not observe any difference between values of examined two types of IOLs.

Corneal endothelial function after phacoemulsification using the fluid-based system compared to conventional ultrasound technique

AIM

To quantitatively assess corneal endothelial changes after phacoemulsification with the fluid-based system compared to conventional ultrasound technique.

METHODS

This prospective, randomized clinical study included patients with cataract who were randomly assigned either to have phacoemulsification with the fluid-based system (30 eyes of 30 patients--Group 1) or with traditional ultrasound (30 eyes of 30 patients--Group 2). Patients who were available at each follow-up visit (25 eyes in both groups) were enrolled in the statistical analysis. Endothelial function was evaluated by measuring central corneal thickness, central endothelial cell density (ECD), mean cell size, and coefficient of variation in cell size preoperatively, 10 days, 1 and 3 months, and 1 year after surgery. Statistical analyses were performed using two-way repeated measure ANOVA.

RESULTS

An acute, reversible increase of central corneal thickness (CCT) was found 10 days after surgery, which was similar in both groups (P=0.35). ECD decreased, whereas mean cell size increased significantly immediately after surgery. However, the impairments were finished after 1 month. The alterations were similar in both groups (ECD: P=0.99; mean cell size: P=0.85). The coefficient of variation in cell size remained stable after surgery (P=0.08), and significant difference was not found between groups (P=0.99). The endothelial cell loss (ECL) was 6.5+/-8.4% in Group 1 and 6.5+/-11.7% in Group 2 (P=0.69).

CONCLUSIONS

Corneal endothelial changes were similar using the fluid-based system compared to the traditional ultrasound technique. The fluid-based method proved to be as safe as conventional ultrasound in cataract surgery.

[Clinicopathological characteristic of keratoglobus]

BACKGROUND

This study describes the clinical, topographical, pachymetrical, and histological features of a unique corneal disorder: keratoglobus.

CASE REPORT

Ultrasound pachymetry proved that the structure of the cornea was evenly thinning towards the periphery. Histological examinations disclosed the absence of Bowman's membrane and the thinning of the stromal lamellae.

CONCLUSION

On account of the thickness of the recipient's periphery, penetrating keratoplasty proved to be a reasonable surgical procedure in this case.

[Tear examinations in primary peripheral lipid keratopathy]

The authors report a case of a bilateral peripheral lipid keratopathy, rising differential diagnostic points as well. After several year-long follow-up period the peripheral corneal opacity left the center unaffected. The diagnosis was confirmed by tear examinations which disclosed elevated level of fatty and phosphorous content compared to healthy control eyes.

The Madrid triple classification of dry eye

From the clinical point of view, there are many etiologic causes, several combinations of anatomo-pathologic manifestations, and different grades of severity of Dry Eye diseases in the dysfunctional tear film syndrome. The dacryologist doctor must recognize these three parameters, quantify them, and establish the most appropriate treatment. The present triple classification has been elaborated for this purpose. First, there is an etiologic distribution in ten groups: age-related, hormonal, pharmacologic, immunopathic, hyponutritional, dysgenetic, inflammatory, traumatic, neurodeprivative, and tantalic. Each of these groups comprise many variants. Second, there is an anatomo-pathologic classification named ALMEN classification from the acronym of aquodeficiency, lipodeficiency, mucodeficiency, epitheliopathy, and non-ocular exocrine affectations. Finally, there is a severity classification in five grades: subclinical (symptoms only when overexposure), mild (habitual symptoms), moderate (symptoms plus reversible signs), severe (symptoms plus permanent signs), and disabling (all the above, plus visual discapacity).

Antioxidant properties of calcium dobesilate in ischemic/reperfused diabetic rat retina

Calcium dobesilate possesses antioxidant properties and protects against capillary permeability by reactive oxygen species in the rat peritoneal cavity, but whether a similar action can take place in the diabetic rat retina is unknown. We investigated the oral treatment of diabetic rats with calcium dobesilate on the prevention of free radical-mediated retinal injury induced by ischemia/reperfusion (90 min ischemia followed by 3 min and/or 24 h of reperfusion). Streptozotocin-induced diabetic rats were orally treated with 50 and 100 mg/kg of calcium dobesilate for 10 days (n=12 in each group). In the first series of studies, calcium dobesilate was found to significantly reduce the maldistribution of ion content in diabetic ischemic/reperfused rat retina. Thus, in diabetic rats treated with 100 mg/kg/day calcium dobesilate, ischemia/reperfusion provoked: (i) 27.5% increase in retinal Na(+) content compared to 51.8% in the vehicle-treated group (P<0.05), and (ii) 59.6% increase in retinal Ca(2+) content compared to 107.1% in vehicle-treated animals (P<0.05). In the second series of studies, calcium dobesilate was found to significantly protect diabetic rat retina against inhibition of Na(+)/K(+)-ATPase and Ca(2+)/Mg(2+)-ATPase activities by ischemia/reperfusion (54% and 41% reduction, respectively, with 100 mg/kg of calcium dobesilate) and also against changes in retinal ATP, reduced glutathione (GSH), and oxidized glutathione (GSSG) contents. In the third series of experiments, rats treated with 100 mg/kg of calcium dobesilate reduced the hydroxyl radical signal intensity to 41% (measured by electron paramagnetic resonance), induced by ischemia/reperfusion in diabetic rat retina. Finally, 100 mg/kg calcium dobesilate significantly reduced retinal edema (measured by the thickness of the inner plexiform layer) in diabetic rats. In conclusion, oral treatment with calcium dobesilate significantly protected diabetic rat retina against oxidative stress induced by ischemia/reperfusion. Whether the antioxidant properties of calcium dobesilate explain, at least in part, its beneficial therapeutic effects in diabetic retinopathy deserves further investigation.

[Palliative treatment of deep penetrating tumors in the medial eyelid eyelid with carbon dioxide laser]

A deep penetrating tumor was removed from the medial lid angle with a carbon dioxide laser knife for palliative reasons. After an early recurrence, which was also removed with the laser knife, we observed a satisfactory healing per secundam intentionem. After carbon dioxide laser excision no plastic covering is necessary. This quick and easy method is especially advantageous for patients with a bad compliance.

Demonstration of increasing standard pH value of lacrimal fluid with increase of flow rate

PURPOSE

To test the hypothesis that pH value of human tears is affected by flow rate.

METHODS

After stimulation with a drop of 70% alcohol into the ipsilateral nasal cavity tears from the left eyes of 30 healthy volunteers were collected with glass capillaries while flow rate of tear secretion was registered. The pCO(2), actual and standard pH were determined in the collected samples with the Astrup method: Standard pH is defined as the pH of the sample that has been equilibrated at 37 degrees C with a gas mixture having pCO(2)=40 mmHg.

RESULTS

The flow rate correlated positively and significantly with both the standard pH value (r=0.503, p<0.01) and the pCO(2) (r=0.517, p<0.01) while there was no correlation between the actual pH and the flow rate.

CONCLUSION

Loss of CO(2) from the sample is a cause of serious uncertainty in tear pH determination. A positive flow rate-pH relationship was found for human tears when the uncertainty was removed by determination of the standard pH.

Penetrating keratoplasty for pseudophakic bullous keratopathy

Corneal decompensation after cataract surgery and intraocular lens (IOL) implantation has become the leading indication for penetrating keratoplasty during the past decade. We reviewed the clinical course and the surgical management of 212 patients with penetrating keratoplasty for pseudophakic bullous keratopathy treated at our Department during the last 15 years. Corneal transplantation for pseudophakic bullous keratopathy was successful in 76%. One third of the patients achieved a long-term visual acuity of 0.5 and more. At keratoplasty the original IOL was left in place in 129 eyes. We removed from and not replaced the IOL in 37 eyes and we performed IOL exchange in 46 eyes. The secondary IOL was an angle-supported flexible anterior chamber lens in 40 cases, and a suture fixated posterior chamber lens in 8 cases. During the penetrating keratoplasty for pseudophakic bullous keratopathy the most important question is how to manage the previously implanted intraocular lens. We have to decide whether the intraocular lens should be removed or replaced at the time of surgery. The choice of removing, retaining or replacing the intraocular lens at keratoplasty depends on the variable intraocular pathological conditions and each case requires individual evaluation.

Plasminogen activator activity in tears after excimer laser photorefractive keratectomy

PURPOSE

To quantify changes of plasminogen activator activity in tear fluid during corneal re-epithelialization after excimer laser photorefractive keratectomy (PRK).

METHODS

Tear samples were collected with glass capillaries from 77 eyes of 42 patients immediately before and immediately after PRK treatment and on postoperative days 3 and 5. In 20 patients, the contralateral eye was similarly sampled to serve as control. Plasminogen activator activity in the tear samples was measured by a spectrophotometric method using human plasminogen and chromogenic peptide substrate, D-valyl-L-leucyl-L-lysine-p-nitroanilide (S-2251).

RESULTS

In tears of all eyes that underwent PRK, the plasminogen activator activities were lower immediately after PRK than were the preoperative values. For patient eyes with normal wound healing, tear plasminogen activator activities were significantly elevated above the preoperative level on the third postoperative day and then returned to the preoperative level by the fifth postoperative day. In contrast, tear plasminogen activator activities remained low through the third postoperative day in all (six) eyes in which haze developed after 3 to 6 months. The contralateral control eyes showed no appreciable change in plasminogen activator activity over the 5-day period.

CONCLUSIONS

Plasminogen activator activity levels measured in tears of excimer laser PRK-treated eyes may serve as a predictor of wound healing. Extended low levels of plasminogen activator activity through the third postoperative day correlate with the development of corneal healing abnormalities (haze). The low plasminogen activator activity could be not only an accompanying sign but also a cause of defective corneal wound healing.

Corneal transplantation in children

Authors discuss the special problems related to childhood keratoplasties. They evaluate the results of the keratoplasties carried out in children during the past 10 years in their service. They review the concerning literature and summarize their opinion on the corneal transplantations of this age group.

Lactate dehydrogenase activity in pathological human tears obtained with glass capillaries correlates with the albumin content

Lactate dehydrogenase (LDH) activity was measured in stimulated normal human tears and in tears from patients suffering from various corneal and conjunctival disorders. In normal tears the LDH activity was below the detection level of the method used, and it was hardly detectable in tears of most of the patients. The LDH activity correlated with the serum albumin content (r = 0.745, n = 32), suggesting that its source in pathological cases could be the plasma by transudation, and not the surface epithelial cells. Based on these results, LDH activity cannot be used as a measure of epithelial cell destruction in most pathological conditions, since the tear secretion of the patients is usually stimulated due to irritation, associated with the disorder or disease.

Serious fireworks-related eye injuries

OBJECTIVE

To analyze and compare epidemiological and clinical information on serious fireworks-related eye injuries from two affiliates of the United States Eye Injury Registry.

METHOD

Retrospective review.

RESULTS

In the Eye Injury Registry of Alabama (EIRA) database, 185 of the 4150 injuries (4.4%) were caused by fireworks. In the Hungarian Eye Injury Registry database, only two of the 1245 cases (0.1%, p=0.000001) were fireworks-related. In the EIRA, 79% of patients were males and 87% were under 31 years. A bystander was injured in 67% of the cases, being an average of 23 feet away; 39% of bystanders had a final vision < or =19/200. No injured person wore eye protection. Bottle rockets caused 80% of the 185 injuries. Overall, 20% of eyes had <5/200 final visual acuity. Twenty-five percent of bottle rocket-injured eyes, compared to 64% of those injured by other devices, had > or =20/40 final vision (p=0. 000004). CONCLUSIONS. The rate of fireworks-related serious eye injuries has not decreased in Alabama in the last 16 years; most patients are young males. Since bystanders are at a measurable risk even at a distance of 100 feet, wearing eye protection is recommended to both bystanders and operators. Bottle rockets cause most of the injuries and the more severe ones, and should be the prime target for prevention. The benefit of a strict and enforced legislative ban on private fireworks displays is demonstrated by the much lower incidence figure in Hungary. Such a ban should be considered in other countries where fireworks-related eye injuries are common.

Mutation of the RB1 gene caused unilateral retinoblastoma in early Age

Fluorescence in situ hybridization (FISH) was applied for the detection of the retinoblastoma tumor-suppressor gene deletion on retinoblastoma tumor cells obtained from the unilateral tumor of a 3-month-old boy. Both retinoblastoma tumor cells and peripheral lymphocytes of the patient showed one hybridization signal per cell at the retinoblastoma-1 locus, indicating that one copy of the gene was deleted. Peripheral blood lymphocytes obtained from the patient's parents had two copies per cell for the gene. Retinoblastoma nuclear phosphoprotein expression could not be detected in the tumor tissue. No copy number alterations were detected with ten different centromeric DNA probes in the tumor cells. The deletion at the RB1 locus detected by FISH suggested that this gene alteration was heritable. The parental peripheral blood lymphocytes did not show the loss of the gene; thus the first deletion may have taken place in either of the parental germ cells. The second somatic mutation of the RB1 gene was probably under the detection limit of FISH. The second allelic alterations were detected by using the polymerase chain reaction for all exons of the retinoblastoma gene.

Expression of betaig-h3 is lower than normal in keratoconus corneas but increases with scarring

PURPOSE

Keratoconus is a progressive ectatic disease of the cornea. Despite extensive clinical and laboratory investigations, its pathogenesis remains unclear. In this study, we examined the localization of betaig-h3, a recently described extracellular matrix protein in keratoconus corneas both in the absence and presence of subepithelial scarring.

METHODS

Two normal corneas and central corneal buttons of 10 patients with keratoconus were excised during perforating keratoplasty and examined, including one case with acute corneal hydrops. In one case, keratoconus was associated with Down syndrome. Immunodetection was done with an antipeptide antibody reacting with the N-terminal part of betaig-h3.

RESULTS

We found decreased betaig-h3 levels in the basal epithelial layer and keratocytes of keratoconus corneas. In the scarred corneas, however, betaig-h3 levels were increased in the basal epithelial layers and in activated keratocytes at the places of scarring. In the cornea of the patient with Down syndrome, we found an additional betaig-h3-positive zone in the anterior stroma.

CONCLUSIONS

The decreased levels of betaig-h3 corneas seem to be specific for keratoconus. Considering the putative role of betaig-h3 as a cellular-attachment protein, paucity of betaig-h3 in the corneal stroma may lead to decreased mechanical stability and contribute to the development of keratoconus.

Immunohistochemical detection of betaIG-H3 in scarring human corneas

BACKGROUND

BetaIG-H3 is a recently described extracellular matrix protein that is present in various organs. In rabbit corneas, increased betaIG (the rabbit form of betaIG-H3) mRNA levels were shown during corneal development and wound healing. In this study, we investigated the localization of betaIG-H3 protein in scarring human corneas.

METHODS

Corneal buttons obtained during keratoplasty were examined. Immunohistological detection using a polyclonal antipeptide antibody against the betaIG-H3 protein was performed on 24 pathological corneas (9 ulcerations, 8 alkali burns, 2 perforating injuries, 5 bullous keratopathy) and 2 normal corneas.

RESULTS

In normal corneas, strong staining was present in the basal layer of the epithelium and in the endothelium; the stromal fibers showed faint, uniform immunoreactivity. In all scarring corneas, the epithelium was usually thickened and all of its layers were reactive with the betaIG-H3 antibody. The cytoplasm of the stromal fibroblasts, as well as the stromal fibers around them also showed staining with the antibody. These changes were present in all scarring corneas, irrespective of the pathological process leading to scar formation.

CONCLUSION

These results prove, at the protein level, the presence of increased amounts of betaIG-H3 at the sites of scarring in human corneas.

The continuous-injection technique to reduce complications during retrobulbar anesthesia

Retrobulbar as well as peribulbar anesthesia remain relatively risky procedures; retrobulbar hemorrhage and especially globe penetration or perforation can have blinding consequences. Our continuous-injection-technique greatly reduces these risks whether used for retrobulbar or peribulbar anesthesia. If the ophthalmologist starts injecting the agent while advancing the needle, the fluid pushes tissues away, possibly preventing a hemorrhage. Since resistance against the plunger is instantaneously experienced if the needle impacts the sclera, the ophthalmologist is adequately warned before actual perforation of the sclera occurs.

Transforming growth factor-beta induced protein, betaIG-H3, is present in degraded form and altered localization in lattice corneal dystrophy type I

Lattice corneal dystrophy type I (LCDI) is an inherited autosomal dominant local amyloidosis, restricted to the corneal stroma. Comparison of electrophoretic profiles of normal and dystrophic corneas revealed a 42 kD protein, which was present only in dystrophic corneas. The N-terminal sequence of this protein showed identity to transforming growth factor-beta induced gene product (betaIG-H3). A polyclonal antiserum was raised in chicken against a synthetic peptide identical to the N-terminal portion of betaIG-H3. On immunoblots, the antiserum stained the 42 kD band, and also a 68 kD band corresponding to the reported molecular weight of the intact betaIG-H3. In normal corneas, only the 68 kD band was present. Immunohistologically, the antiserum stained corneal subepithelial regions, including subepithelial deposits, in dystrophic corneas. In normal corneas, the staining was observed only in the epithelium. These results may reflect the role of betaIG-H3 in extracellular matrix construction and/or amyloid formation.

[Epidemiology of severe eye injuries. United States Eye Injury Registry (USEIR) and Hungarian Eye Injury Registry (HEIR)]

BACKGROUND

Both in industrialized and in developing nations, the devastating impact of ocular trauma on society is increasingly recognized. Lacking standardized surveillance systems, however, comparable epidemiological information has not been available previously.

METHODS

For several years, the United States Eye Injury Registry (USEIR) and the Hungarian Eye Injury Registry (HEIR) have been collecting data on all types of serious ocular trauma, based on identical operating criteria and using standardized reporting forms. We performed a retrospective analysis comparing the two datasets, containing over 8,400 injuries from the U.S. and over 1,200 injuries from Hungary.

RESULTS

Sixty percent of patients in the U.S. and 52% of patients in Hungary were less than 30 years of age, with an at least 80% male preponderance in both registries. The home was the most frequent place of injury in both countries (USEIR: 41%, HEIR: 35%); industrial premises represented no more than 14%. Guns were responsible for 12% of cases in the USEIR (HEIR, 1%). Champagne corks were identified as a unique and relatively common source of eye injury in Hungary (1.4%, as opposed to 0.07% in the U.S.). In the USEIR, 16% of injuries were caused by assault (HEIR, 24%; chi-square value = 36.7, p < 0.0000001). The enucleation rate was 12% in the U.S. and 1% in Hungary.

CONCLUSIONS

The different findings in the two countries identify certain areas for the implementation of preventive measures (supplying champagne bottles with warning labels and a coordinated fight against violence in Hungary, stricter fireworks legislation in the U.S., public awareness for home injuries in both countries, etc.). Based on the encouraging results from this study, we plan to continue our efforts using modified reporting forms and an upgraded software. We invite additional countries to adopt the USEIR model.

Comparison of different keratometers with the EyeSys videokeratoscope

We compared the accuracy and the reproducibility of the measurements using a Haag-Streit, a Shin-Nippon, and a Carl Zeiss keratometer and an EyeSys videokeratoscope. Two investigators performed 20 measurements on 3 calibrated steel balls and 5 measurements on 22 normal corneas with all instruments. Calculating the accuracy of the measurements the limits of the 95% confidence intervals of the bias were determined. The accuracy was better than +/-0.1D for the keratometers, whereas it was better than +/-0.25D for the EyeSys videokeratoscope. The coefficient of reproducibility (1.96 x standard deviation) on test balls and corneas was smaller than 0.25D in the case of the Shin-Nippon and Carl Zeiss keratometers and the EyeSys videokeratoscope whereas it was between 0.25-0.5D in the case of the Haag-Streit keratometer. The Carl Zeiss keratometer was the best with respect to the accuracy and reproducibility of the measurements. Paired t-test was used to find possible significant differences between the results of the two investigators, but only clinically insignificant differences were found.

Changing concept and modern techniques in cataract surgery

Until the middle of the 80-ies the routine method of cataract surgery was intracapsular extraction (ICCE). Approximately 10 years ago the so called extracapsular cataract extraction (ECCE) started to become more and more widely used. After extracapsular cataract extraction had come into general use, it became possible to implant the IOL behind the iris, into the left in place capsular bag of the original lens. We usually perform extracapsular cataract extraction with posterior chamber lens (PCL) implantation as a routine procedure. In the last few years phacoemulsification started to gain acceptance. During this operation one breaks the nucleus of the lens into pieces with the help of ultrasound, and this way it is possible to remove both the nucleus and the cortex of the lens through a small wound. The first step in learning phacoemulsification is to be able to create a perfectly round hole on the anterior capsule (capsulorhexis). Besides using various manual techniques we introduced diathermal capsulotomy for capsulorhexis. This latter procedure is becoming more and more popular as it is safe, easy to perform, and gives excellent result.

Excimer laser photorefractive keratectomy with different ablation zones

In this study we would like to introduce the excimer laser, and to demonstrate our results and complications by using different ablation zones during photorefractive keratectomy (PRK) in the correction of myopia and astigmatismus. In 1996 we performed photorefractive keratectomy on 100 myopic eyes of 52 patients (28 females, 24 males). Mean age was 26.21 years (ranged from 19 to 54 years). The preoperative refraction ranged from -1.0 D to -18.0 Diopters. The diameter of the ablation zones were between 5 and 6.5 mm. We evaluated the results and the complications of the surgeries of 100 eyes which were performed with Schwind keratom F excimer laser. After 2 days, 1 week, 1 month, 3 months, and 6 months postoperatively we tested the best uncorrected and corrected visual acuities, and performed intraocular pressure measurement, slit lamp examination as well as corneal topography. The postoperative refractions were between +/- 0.5 to +/- 1.0 Diopters. After six months postoperatively the slit lamp examination showed that 80% of the patients had no corneal haze while 20% had stage I (Hanna) corneal haze. The smaller the diameter of the ablation zone was, the more pronounced the corneal haze and the night-glare were. The photorefractive excimer laser keratectomy is judged to be a safe method, although it might have some side-effects. The different ablation zones of this treatment means an important modification, that not only allows the method to meet the individual requirements, but reduces the chance of the complications as well. Based on the authors' experiences PRK for moderate myopia with large diameter ablation zones appears more predictable than than with smaller ablation zone diameters.

New indications for and technics in vitreoretinal surgery

Vitreoretinal surgery has become a widely used ophthalmic surgical procedure since the late sixties. However, it remained an intensively developing field of surgical interventions, and indications still become wider and wider. The procedure starts with the removal of vitreous body, blood or inflammatory material from the vitreous cavity. After this, the given retinal disease, such as retinal detachment, macular hole, proliferative diabetic retinopathy, intraocular foreign body, etc. can be properly treated in situ. For that purpose a number of fine intraocular instruments, fluids, gases can be used. While the anatomical success rate can be up to 95%, the final visual outcome, due to the fact that the retina is not rarely seriously damaged, is less enthusiastic. However, a great number of previously untreatable vitreoretinal diseases can be managed in this way, nowadays.

Results of contact beta-irradiation of choroidal melanomas

Between the end of 1986 and the end of October 1996 81 patients suffering from choroidal melanoma were irradiated at the Department of Ophthalmology University Medical School of Debrecen. The irradiations were performed with Ruthenium-106 beta ray emitting scleral plaques (ophthalmic applicators). The radioactive plaques were implanted surgically, fixed by episcleral sutures onto the sclera covering the base of the tumour, and removed by another operation when sufficient time for irradiation had elapsed. For the treatment of tumours in the vicinity of the optic nerve special plaques were used with a notch for the nerve. Precise localisation of the tumours was established by intraoperative ultrasonography and transillumination. The mean follow up period was 3.5 years after the irradiation. Tumour regression was recorded by fluorescein angiography, ultrasonography and fundus photography. In 75 cases (92.5%) the treatment was successful. Additional laser photocoagulation was performed after irradiation in 26 cases. The irradiation by Ruthenium-106 scleral plaques of choroidal melanomas proved to be an effective treatment in cases of small and medium sized choroidal melanomas in our practice and the results are similar to those of the largest radiotherapy centers of Europe.

Scleral reinforcement in progressive myopia and intraoperative ultrasound control of the cadaver fascia lata strip

Scleral reinforcement (sustentaculum sclerae) is one of the operations against myopia. During the progression of myopia the eye grows. The chorioretinal layer can only moderately follow the expansion of the sclera, and mostly this is the cause of the complications that can cause permanent visual acuity decrease. The aim of the operation is to strengthen the posterior part of the sclera by implantation of a cadaver fascia lata strip, that slows down or stops the expansion of the eyeball, and this way prevents the development of complications. At our Department we perform the Snyder-Thompson technique. Between 1984 and 1994 343 operations were performed at our Department. We followed up the changes of the axial lengths by ultrasound (A-mode) examinations. The axial length decreased in 43.7% remained unchanged in 22.2% and increased in 34.1% of the cases. We controlled the location of the strip intra- and postoperatively with B-mode ultrasound. Nowadays scleral reinforcement is still the only possibility to stop or slow down the expansion of the eyeball in cases of progressive high myopia.

Different opening techniques in cataract surgery

A retrospective study on the different opening techniques in cataract surgery at our Department in 1996 was carried out. In our everyday practice fornix based conjunctival flap and sclerocorneal oblique or vertical-oblique approach with a center at 12 o'clock was performed. In the case of hemorrhagic diathesis and secondary ACL implantation the corneal approach was preferred. After glaucomatous filtration surgery the incision was made temporally in some cases.

Keratoprosthesis. Implantation of artificial corneas

Keratoprosthesis (implantation of artificial, plastic cornea) is indicated in severe cases with corneal leucoma (non-transparent, cicatrized cornea) in which keratoplasty (corneal transplantation) is not possible or has repeatedly failed. In the past 40 years we implanted 37 artificial corneas (7 Cardona type, 29 Konstantinov type, 1 Fjodorov type). The visual acuity increase was temporary (lasting from a few weeks to a few months) in 25 patients. The visual acuity was at least 0.2 three years following the implantation of keratoprosthesis in 12 patients. One patient had 1.0 vision 10 years after surgery. Our results indicate that the implantation of artificial corneal is still an "ultimum refugium", an operation that can be justified only in monocular patients, in eyes that cannot be and/or had unsuccessfully been operated on with repeated keratoplasties. The visual improvement is temporary, but in some cases may last for several years. Still this is the only procedure by which useful vision can be provided, for shorter or longer time intervals, for patients suffering from corneal blindness (nontransparent cornea in otherwise functioning eye) whose only eye cannot be treated with corneal transplantation. Keratoprosthesis with better biocompatibility, better fixation techniques, and wider visual fields have to be developed before the implantation of artificial cornea can be looked upon as a surgical procedure with which full optical rehabilitation can be achieved.

Changing techniques and indications for lamellar keratoplasty

In recent decades, the number of lamellar keratoplasties (LKs) being performed worldwide has been gradually decreasing. However, new technical procedures have been developed and microsurgeons must consider modified indications for lamellar grafting. In the period 1946-1995, in the Department of Ophthalmology University Medical School of Debrecen, Hungary 3889 consecutive keratoplasties were performed of which 608 were LKs. In the period 1946-1960 special surgical material (biosutures) was used without operating microscopes and the leading indication for LK was corneal scar (leukomas). Between 1961 and 1979 with the development of microsurgical procedures (10/0 nylon sutures, operating microscope), the LK technique became more advanced. In the period 1979-1995 precision lamellar grafting could be performed with the widely available improved modern techniques. Changing indications for LK were noted in the second period and this tendency has subsequently continued. Currently the main indications for LK are "immediate" keratoplasty after chemical burns, and sclerokeratoplasty against recurrent pterygia. Their observations lead the authors to conclude that the possible reasons for the changing indications of LK are the new technical procedures, the increasing knowledge, the better immunological tests and the improved postoperative therapy.