Broadening the ocular phenotypic spectrum of ultra-rare BRPF1 variants: report of two cases

INTRODUCTION

BRPF1 gene on 3p26-p25 encodes a protein involved in epigenetic regulation, through interaction with histone H3 lysine acetyltransferases KAT6A and KAT6B of the MYST family. Heterozygous pathogenic variants in BRPF1 gene are associated with Intellectual Developmental Disorder with Dysmorphic Facies and Ptosis (IDDDFP), characterized by global developmental delay, intellectual disability, language delay, and dysmorphic facial features. The reported ocular involvement includes strabismus, amblyopia, and refraction errors. This report describes a novel ocular finding in patients affected by variants in the BRPF1 gene.

METHODS

We performed exome sequencing and deep ocular phenotyping in two unrelated patients (P1, P2) with mild intellectual disability, ptosis, and typical facies.

RESULTS

Interestingly, P1 had a Chiari Malformation type I and a subclinical optic neuropathy, which could not be explained by variations in other genes. Having detected a peculiar ocular phenotype in P1, we suggested optical coherence tomography (OCT) for P2; such an exam also detected bilateral subclinical optic neuropathy in this case.

DISCUSSION

To date, only a few patients with BRPF1 variants have been described, and none were reported to have optic neuropathy. Since subclinical optic nerve alterations can go easily undetected, our experience highlights the importance of a more detailed ophthalmologic evaluation in patients with BRPF1 variant.

Microperimetry assessment in foveal hypoplasia: functional results in a series of pediatric patients

OBJECTIVE

To study the relationships of functional and morphologic retinal parameters in a series of pediatric patients with varying degrees of foveal hypoplasia (FH).

DESIGN

Monocentric observational retrospective study.

PARTICIPANTS

Among 21 pediatric patients, 16 met inclusion criteria, having FH confirmed with spectral-domain optical coherence tomography (SD-OCT) scan METHODS: Data were analyzed retrospectively. Patients able to undergo macular microperimetry (MP) and SD-OCT examinations were included in the analysis. MP and SD-OCT outcomes were compared with FH grading and best-corrected visual acuity (BCVA) using Pearson's correlation.

RESULTS

Thirty-one eyes from 16 patients (mean age 12.4 years) with different degrees of FH were analyzed. Two patients had grade 1, 7 had grade 2, 5 had grade 3, and 2 had grade 4 FH. Clinical nystagmus was present in 8 patients. The correlation between BCVA and SD-OCT data (-0.31) was lower than that found between BCVA and nystagmus (0.64), that for fixation index P1 (-0.60), as well as that for macular sensitivity (-0.63).

CONCLUSIONS

Although limited by the small sample, our study confirms the feasibility of automated MP evaluation in pediatric patients with FH. The added value of this work is the provision of data on relationships between anatomic and functional macular measurements acquired with SD-OCT, MP, and BCVA in eyes with various degrees of FH. Larger prospective studies are necessary to confirm these results.

Central retinal artery occlusion in a young child affected by COVID-19: a first case report

BACKGROUND

Central retinal artery occlusion (CRAO) is an ophthalmic emergency, and its etiology is generally ascribed to vessel occlusion by a thrombus or embolus, eventually due to a hypercoagulable state. CRAO occurrence is described even in the pediatric population, but its incidence is very rare. SARS-CoV-2 infection has a multitude of presentations, and almost any organ may be involved including the ocular district. Cases of CRAO in patients affected by COVID-19 are reported in the literature in the adult population, but not in the pediatric one.

CASE PRESENTATION

We describe the case of a six-year-old otherwise healthy girl, who presented a sudden and complete bilateral vision loss after a one-day fever. All the clinical, ophthalmological, laboratory and instrumental investigations led to the diagnosis of a right CRAO and the suspicion of a contralateral posterior optic nerve affection. These manifestations could not be ascribed to any etiological condition apart from the documented ongoing mild SARS-CoV-2 infection. Treatment with anticoagulants and steroids was tried but the visual outcome was poor during the one-month hospitalization and at the last follow-up.

CONCLUSIONS

To the best of our knowledge, this is the first report of CRAO in the course of SARS-CoV-2 infection in the pediatric age. In our review of the literature, we found few cases of CRAO in adults with COVID-19; we highlighted differences in anamnestic, clinical, and interventional aspects and therefore we tried to summarize the state of the art on this topic to facilitate further studies. Even if rare, the prognosis of CRAO is poor and the thrombolytic treatment could be effective only if rapidly administered, so the disease suspicion should be high in a patient with sudden vision loss, also in pediatric age.

Optic nerve involvement in CACNA1F-related disease: observations from a multicentric case series

BACKGROUND

Congenital Stationary Night Blindness (CSNB) constitutes a group of non-progressive retinal disorders characterized by disturbances in scotopic vision and/or by a delay in adaptation to darkness, as well as by low visual acuity, myopia, nystagmus, and strabismus. Color vision and fundus appearance tend to be normal. To date, several CACNA1F gene variants have been linked to a CSNB phenotype but only few reports have focused on the optic nerve in this disease.

MATERIALS AND METHODS

Twelve patients underwent standard ophthalmological and genetic evaluation including spectral domain optical coherence tomography (SD-OCT), full-field electroretinography (ffERG), kinetic perimetry, fundus photography, magnetic resonance imaging (MRI), and next-generation sequencing (NGS). Bilateral thinning of the peripapillary nerve fiber layer (pRNFL) and the ganglion cell complex (GCC) supported involvement of the optic nerves. MRI, when available, was assessed for gross intracranial optic pathway abnormalities.

RESULTS

All patients were shown to carry pathogenic variants in the CACNA1F gene, and all showed signs of optic nerve involvement. All patients showed a certain degree of myopic refractive error. Low average pRNFL thickness was evident in all patients. In three of them, pRNFL thickness was evaluated longitudinally and was proven to be stable over time. MRI imaging was unremarkable in all cases.

CONCLUSION

Our data support the hypothesis that CACNA1F could be related to early-onset or congenital optic nerve involvement without any signs of a progressive optic neuropathy. Even though additional data from larger cohorts and longer follow-up periods are needed to further support and confirm our findings, there is a clear significance to our findings in the preparation for future CACNA1F gene therapy trials.

X-linked retinoschisis: mutation spectrum and genotype-phenotype relationship in an Italian pediatric cohort

BACKGROUND

X-linked juvenile retinoschisis (×LRS) is an X-linked vitreoretinal degenerative disease that consists of variable phenotypes ranging from severe early-onset defects to subtle abnormalities diagnosed in elderly patients. XLRS is caused by a loss of function of the protein Retinoschisin (RS1), which is essential to preserve retinal integrity and function of photoreceptor-bipolar synapse. The literature data so far mostly agree on the absence of a clear genotype-phenotype correlation in XLRS. We reviewed clinical and molecular characteristics of a cohort of Italian pediatric XLRS patients to assess the presence of a correlation between genotype and phenotype severity.

MATERIALS AND METHODS

We retrospectively examined clinical and genetic features of a cohort of 27 XLRS patients. In this study we included patients with a diagnosis of XLRS confirmed by fundus photography, spectral domain optical coherence tomography, and molecular analysis and with an onset of less than 10 years of age. We sorted RS1 variants according to their effect of RS1 structure and function in three separate groups.

RESULTS

According to previous studies, we did not observe a conclusive genotype-phenotype correlation in our cohort; nevertheless, we noticed that patients harboring RS1 variants leading to RS1-secreted mutants show a more homogeneous phenotype, with an overall good visual acuity, compared to the other two groups.

CONCLUSIONS

Our data support the hypothesis that secretion profile of RS1 could influence the severity of the phenotype. More extensive and functional studies are needed to acquire notions in view of the opportunity of gene replacement therapy for XLRS patients.

Novel mutations in MFRP and PRSS56 are associated with posterior microphthalmos

Background: Biallelic pathogenic variants in MFRP and PRSS56 genes can be responsible for nanophthalmos (NO) or posterior microphthalmos (PM). This study describes detailed clinical and molecular findings in a series of five patients affected by PM from four unrelated families.Materials and Methods: All patients underwent a complete ophthalmological and genetic evaluation. For proper and deep phenotyping a multimodal instrumental approach was used for all cases: B-scan ultrasound, spectral domain optical coherence tomography (SD-OCT), fundus retinal imaging and anterior segment data were obtained. Molecular analysis of PRSS56 and MFRP genes was performed with Next-Generation Sequencing (NGS) methodology and segregation analysis on parents and one affected sibling was performed with Sanger sequencing.Results: A very high hyperopia of +14.00D or more was the main refractive error and macular abnormalities were identified in all patients. Axial length ranged from 15.3 mm to 17.86 mm (mean 16.58 mm) and age at first presentation ranged from 6 to 36 months (mean 18 months). Anterior chamber depth was within normal values, according to age, while total axial length was severely reduced in all patients. All our patients met the diagnostic criteria for PM. Three patients, including a pair of siblings, carried compound heterozygous mutations in the PRSS56 gene; in the other two patients, one homozygous or two compound heterozygous mutations in the MFRP gene were detected.Conclusion: Our study describes four novel mutations in the PRSS56 gene and one in the MFRP gene in patients with non-syndromic posterior microphthalmos. Proper genotype-phenotype correlation and early diagnosis could lead to good functional results.

Propranolol 0.2% Eye Micro-Drops for Retinopathy of Prematurity: A Prospective Phase IIB Study

Background: Oral propranolol reduces retinopathy of prematurity (ROP) progression, although not safely. Propranolol 0.1% eye micro-drops administered to newborns with stage 2 ROP are well-tolerated, but not sufficiently effective. Methods: A multi-center open-label trial was conducted to assess the safety and efficacy of propranolol 0.2% eye micro-drops in newborns with stage 1 ROP. The progression of the disease was evaluated with serial ophthalmologic examinations. Hemodynamic, respiratory, biochemical parameters, and propranolol plasma levels were monitored. Demographic and perinatal characteristics, co-morbidities and co-intervention incidences, together with ROP progression, were compared with a historical control group in the same centers participating in the trial. Results: Ninety-eight newborns were enrolled and compared with the historical control group. Populations were not perfectly homogeneous (as demonstrated by the differences in the Apgar score and the different incidence rate in surfactant administration and oxygen exposure). The progression to ROP stage 2 or 3 plus was significantly lower than the incidence expected on the basis of historical data (Risk Ratio 0.521, 95% CI 0.297- 0.916). No adverse effects related to propranolol were observed and the mean propranolol plasma level was significantly lower than the safety cut-off of 20 ng/mL. Unexpectedly, three newborns treated with oral propranolol before the appearance of ROP, showed a ROP that was unresponsive to propranolol eye micro-drops and required laser photocoagulation treatment. Conclusion: Propranolol 0.2% eye micro-drops were well-tolerated and appeared to reduce the ROP progression expected on the basis of a comparison with a historical control group. Propranolol administered too early appears to favor a more aggressive ROP, suggesting that a β-adrenoreceptor blockade is only useful during the proliferative phase. Further randomized placebo-controlled trials are required to confirm the current results. Clinical Trial Registration  The trial was registered at ClinicalTrials.gov with Identifier NCT02504944 and with EudraCT Number 2014-005472-29.

Refractive Outcome in Preterm Newborns With ROP After Propranolol Treatment. A Retrospective Observational Cohort Study

Background: Recent explorative studies suggest that propranolol reduces retinopathy of prematurity (ROP) progression, but the short-term effects of propranolol treatment at 1 year of corrected age have not been extensively evaluated. Methods: A multi-center retrospective observational cohort study was conducted to assess the physical development and the refractive outcome of infants with prior ROP treated with propranolol. Forty-nine infants treated with propranolol were compared with an equal number of patients who did not receive any propranolol therapy and represent the control group, with comparable anthropometrical characteristics and stages of ROP. Results: The weight, length, and head circumference at 1 year of corrected age were similar between infants who had been treated, or not, with propranolol, without any statistically significant differences. Refractive evaluation at 1 year showed spherical equivalent values decreasing with the progression of ROP toward more severe stages of the disease, together with an increasing number of infants with severe myopia. On the contrary, no differences were observed between infants who had been treated with propranolol and those who had not. Conclusion: This study confirms that the progression of ROP induces an increase of refractive errors and suggests that propranolol itself does not affect the refractive outcome. Therefore, if the efficacy of propranolol in counteracting ROP progression is confirmed by further clinical trials, the conclusion will be that propranolol might indirectly improve the visual outcome, reducing the progression of ROP.

Propranolol eye drops in patients with corneal neovascularization

RATIONALE

Studies performed in animal models of corneal neovascularization suggested the possible efficacy of a treatment with propranolol. Corneal neovascularization is one of the most feared complications of Stevens-Johnson syndrome that frequently involves ocular surface. We report the first 2 patients with severe ocular neo-vascularization treated with different degrees of success, with propranolol eye drops.

PATIENT CONCERNS

Two patients with corneal neovascularization complicating the Stevens-Johnson syndrome, not responsive to steroids and cyclosporine, were treated with propranolol eye drops.

DIAGNOSES

Corneal neovascularization was detected by ophthalmoscopic evaluation.

INTERVENTIONS

Topical treatment with propranolol eye drops at different concentrations.

OUTCOMES

Both patients reported dramatic subjective benefits (reduction of photophobia and discomfort) without adverse effects, and in the patient with a less advanced disease, an objective reduction of neovascularization and an improved visual acuity was observed.

LESSONS

This experience suggests that propranolol might be an inexpensive, safe and effective treatment in counteracting the progression of corneal neovascularization.

Study protocol: safety and efficacy of propranolol 0.2% eye drops in newborns with a precocious stage of retinopathy of prematurity (DROP-ROP-0.2%): a multicenter, open-label, single arm, phase II trial

BACKGROUND

Retinopathy of prematurity (ROP) still represents one of the leading causes of visual impairment in childhood. Systemic propranolol has proven to be effective in reducing ROP progression in preterm newborns, although safety was not sufficiently guaranteed. On the contrary, topical treatment with propranolol eye micro-drops at a concentration of 0.1% had an optimal safety profile in preterm newborns with ROP, but was not sufficiently effective in reducing the disease progression if administered at an advanced stage (during stage 2). The aim of the present protocol is to evaluate the safety and efficacy of propranolol 0.2% eye micro-drops in preterm newborns at a more precocious stage of ROP (stage 1).

METHODS

A multicenter, open-label, phase II, clinical trial, planned according to the Simon optimal two-stage design, will be performed to analyze the safety and efficacy of propranolol 0.2% eye micro-drops in preterm newborns with stage 1 ROP. Preterm newborns with a gestational age of 23-32 weeks, with a stage 1 ROP will receive propranolol 0.2% eye micro-drops treatment until retinal vascularization has been completed, but for no longer than 90 days. Hemodynamic and respiratory parameters will be continuously monitored. Blood samplings checking metabolic, renal and liver functions, as well as electrocardiogram and echocardiogram, will be periodically performed to investigate treatment safety. Additionally, propranolol plasma levels will be measured at the steady state, on the 10th day of treatment. To assess the efficacy of topical treatment, the ROP progression from stage 1 ROP to stage 2 or 3 with plus will be evaluated by serial ophthalmologic examinations.

DISCUSSION

Propranolol eye micro-drops could represent an ideal strategy in counteracting ROP, because it is definitely safer than oral administration, inexpensive and an easily affordable treatment. Establishing the optimal dosage and treatment schedule is to date a crucial issue.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02504944, registered on July 19, 2015, updated July 12, 2016. EudraCT Number 2014-005472-29.

Propranolol 0.1% eye micro-drops in newborns with retinopathy of prematurity: a pilot clinical trial

BACKGROUND

Oral propranolol reduces retinopathy of prematurity (ROP) progression, although not safely. This study evaluated safety and efficacy of propranolol eye micro-drops in preterm newborns with ROP.

METHODS

A multicenter open-label trial, planned according to the Simon optimal two-stage design, was performed to analyze safety and efficacy of propranolol micro-drops in newborns with stage 2 ROP. To this end, hemodynamic and respiratory parameters were monitored, and blood samples were collected weekly, for 3 wk. Propranolol plasma levels were also monitored. The progression of the disease was evaluated with serial ophthalmologic examinations.

RESULTS

Twenty-three newborns were enrolled. Since the fourth of the first 19 newborns enrolled in the first stage of the study showed a progression to stage 2 or 3 with plus, the second stage was prematurely discontinued. Even though the objective to complete the second stage was not achieved, the percentage of ROP progression (26%) was similar to that obtained previously with oral propranolol administration. However, no adverse effects were observed and propranolol plasma levels were significantly lower than those measured after oral administration.

CONCLUSION

Propranolol 0.1% eye micro-drops are well tolerated, but not sufficiently effective. Further studies are required to identify the optimal dose and administration schedule.

Intravitreal bevacizumab for retinopathy of prematurity as first line or rescue therapy with focal laser treatment. A case series

OBJECTIVES

Laser therapy is effective in the treatment of severe forms of retinopathy of prematurity (ROP), and aggressive posterior ROP (APROP), but always damages the retina. We report our preliminary findings in seven premature infants with complicated ROP or APROP who were treated with intravitreal bevacizumab (IVB) as first line monotherapy or rescue therapy combined with laser treatment.

METHODS

We studied retrospectively seven preterm infants, who were affected by APROP (n = 4) or pre-threshold ROP (n = 3). Infants were treated with IVB (0.625 mg; Avastin®, Roche, Basel, Switzerland) monotherapy (n = 2) when they were too sick to undergo lengthy laser treatment.

RESULTS

Monotherapy IVB (n = 3 eyes) and IVB combined with laser therapy (n = 3 eyes) of APROP cases were followed by regression of the ROP and complete peripheral vascularization. The combined therapy with IVB and laser therapy of pre-threshold ROP (5 eyes) produced a regression of neovascularization and good retinal anatomical outcome.

CONCLUSIONS

In our series, IVB was successful in treating ROP in a small cohort of extremely preterm infants with APROP or pre-threshold ROP, both as monotherapy or rescue treatment after laser therapy, without the development of ocular and systemic short- and long-term adverse effects.

Redox Processes in Polynary Copper Oxides and Copper Oxide / Mesoporous Silica Composites

Dynamic redox processes in different complex copper oxides and oxide / mesoporous silica composites are characterized. In the spinel-type CuxMn3.xO4 the atomic and electronic structures are described with respect to the reversible process Cu2+ + Mn3+ ⇒ Cu3+ + Mn4+, the crucial dynamic equilibrium for the catalytic oxidation of CO to CO2 at ambient temperatures. A comparison with the perovskite-type LaCu1-xMnxO3-δ is presented. In the K2NiF4-type La2-xSrxCu1-yRuyO4-δ the electronic structure is characterized with respect to the equilibrium Cu2+ + Ru5+ ⇒ Cu3+ + Ru4+. Analogous redox processes are characterized in composite compounds made up of copper oxides inserted in mesoporous MCM-type silica. Due to their structural order in the nanoscopic range, the investigation of these materials required multiple, complementary characterization methods, i.e. X-ray diffractometry, thermal analysis, scanning and transmission electron microscopy, magnetic measurements, XPS, and particularly X-ray absorption spectroscopy (EXAFS / XANES) measurements.

Role of the adrenergic system in a mouse model of oxygen-induced retinopathy: antiangiogenic effects of beta-adrenoreceptor blockade

PURPOSE

Oxygen-induced retinopathy (OIR) is a model for human retinopathy of prematurity (ROP). In OIR mice, this study determined whether blockade of β-adrenergic receptors (β-ARs) with propranolol influences retinal levels of proangiogenic factors, retinal vascularization, and blood-retinal barrier (BRB) breakdown.

METHODS

Propranolol was administered subcutaneously and picropodophyllin (PPP) intraperitoneally. Intravitreal injections of vascular endothelial growth factor (VEGF) were performed. Messengers of β-ARs, VEGF, its receptors, IGF-1 and IGF-1R were measured with quantitative RT-PCR. VEGF content was determined with ELISA. β-ARs, hypoxia-inducible factor (HIF)-1α, occludin, and albumin were measured with Western blot. Retinal localization of β3-ARs was determined by immunohistochemistry. Retinopathy was assessed by scoring fluorescein-perfused retinas, and plasma extravasation was visualized by Evans blue dye.

RESULTS

Hypoxia did not influence β-AR expression, except that it increased β3-AR protein with dense β3-AR immunoreactivity localized to engorged retinal tufts. Hypoxia upregulated VEGF, IGF-1, their receptors, and HIF-1α. Propranolol dose-dependently reduced upregulated VEGF and decreased hypoxic levels of IGF-1 mRNA and HIF-1α. Blockade of IGF-1R activity with PPP did not influence propranolol's effects on VEGF. Retinal VEGF in normoxic mice or VEGF in brain, lungs, and heart of the OIR mice were unaffected by propranolol. Propranolol ameliorated the retinopathy score, restored occludin and albumin, and reduced hypoxia-induced plasma extravasation without influencing the vascular permeability induced by intravitreal VEGF.

CONCLUSIONS

This is the first demonstration that β-AR blockade is protective against retinal angiogenesis and ameliorates BRB dysfunction in OIR. Although the relevance of these results to infant ROP is uncertain, the findings may help to establish potential pharmacologic targets based on β3-AR pharmacology.

Study protocol: safety and efficacy of propranolol in newborns with Retinopathy of Prematurity (PROP-ROP): ISRCTN18523491

Background

Despite new therapeutic approaches have improved the prognosis of newborns with retinopathy of prematurity (ROP), an unfavourable structural and functional outcome still remains high. There is high pressure to develop new drugs to prevent and treat ROP. There is increasing enthusiasm for anti-VEGF drugs, but angiogenic inhibitors selective for abnormal blood vessels would be considered as an optimal treatment.

In an animal experimental model of proliferative retinopathy, we have recently demonstrated that the pharmacological blockade of beta-adrenoreceptors improves retinal neovascularization and blood retinal barrier breakdown consequent to hypoxia. The purpose of this study is to evaluate the propranolol administration in preterm newborns suffering from a precocious phase of ROP in terms of safety and efficacy in counteracting the progression of retinopathy.

Methods/Design

Preterm newborns (gestational age at birth lower than 32 weeks) with stage 2 ROP (zone II-III without plus) will be randomized, according to their gestational age, to receive propranolol added to standard treatment (treatment adopted by the ETROP Cooperative Group) or standard treatment alone. Propranolol will be administered until retinal vascularization will be completely developed, but not more than 90 days. Forty-four participants will be recruited into the study. To evaluate the safety of propranolol administration, cardiac and respiratory parameters will be continuously monitored. Blood samplings will be performed to check renal, liver and metabolic balance. To evaluate the efficacy of propranolol, the progression of the disease, the number of laser treatments or vitrectomies, the incidence of retinal detachment or blindness, will be evaluated by serial ophthalmologic examinations. Visual function will be evaluated by means of behavioural standardized tests.

Discussion

This pilot study is the first research that explores the possible therapeutic role of beta blockers in ROP. The objective of this research is highly ambitious: to find a treatment simple, inexpensive, well tolerated and with few adverse effects, able to counteract one of the major complications of the prematurity. Any favourable results of this research could open new perspectives and original scenarios about the treatment or the prevention of this and other proliferative retinopathies.

Trial Registration

Current Controlled Trials ISRCTN18523491; ClinicalTrials.gov Identifier NCT01079715; EudraCT Number 2010-018737-21

Irresponsiveness of two retinoblastoma cases to conservative therapy correlates with up- regulation of hERG1 channels and of the VEGF-A pathway

Background

Treatment strategies for Retinoblastoma (RB), the most common primary intraocular tumor in children, have evolved over the past few decades and chemoreduction is currently the most popular treatment strategy. Despite success, systemic chemotherapeutic treatment has relevant toxicity, especially in the pediatric population. Antiangiogenic therapy has thus been proposed as a valuable alternative for pediatric malignancies, in particolar RB. Indeed, it has been shown that vessel density correlates with both local invasive growth and presence of metastases in RB, suggesting that angiogenesis could play a pivotal role for both local and systemic invasive growth in RB. We present here two cases of sporadic, bilateral RB that did not benefit from the conservative treatment and we provide evidence that the VEGF-A pathway is significantly up-regulated in both RB cases along with an over expression of hERG1 K⁺ channels.

Case presentation

Two patients showed a sporadic, bilateral RB, classified at Stage II of the Reese-Elsworth Classification. Neither of them got benefits from conservative treatment, and the two eyes were enucleated. In samples from both RB cases we studied the VEGF-A pathway: VEGF-A showed high levels in the vitreous, the vegf-a, flt-1, kdr, and hif1-α transcripts were over-expressed. Moreover, both the transcripts and proteins of the hERG1 K⁺ channels turned out to be up-regulated in the two RB cases compared to the non cancerous retinal tissue.

Conclusions

We provide evidence that the VEGF-A pathway is up-regulated in two particular aggressive cases of bilateral RB, which did not experience any benefit from conservative treatment, showing the overexpression of the vegf-a, flt-1, kdr and hif1-α transcripts and the high secretion of VEGF-A. Moreover we also show for the first time that the herg1 gene transcripts and protein are over expressed in RB, as occurs in several aggressive tumors. These results further stress the relevance of the VEGF-A pathway in RB and the correlation with hERG1, making aggressive and recurrent RB cases good candidates for antiangiogenesis therapies based on the targeting of VEGF-A.

Spontaneous resolution of macular edema after panretinal photocoagulation in florid proliferative diabetic retinopathy

PURPOSE

To report the evolution of diabetic macular edema (DME) after extensive panretinal photocoagulation in patients with Type 1 diabetes exhibiting florid proliferative diabetic retinopathy (FPDR).

METHODS

This retrospective observational case series comprised 17 eyes of 10 consecutive patients (8 women and 2 men). All patients exhibited FPDR combined with severe DME, and all underwent panretinal photocoagulation. The evolution of visual acuity and progression of FPDR were evaluated. The evolution of DME during follow-up was assessed by fluorescein angiography and repeated optical coherence tomography examinations.

RESULTS

At baseline, all eyes had diffuse DME. Mean logMAR visual acuity was 0.402 +/- 0.46. Mean central macular thickness was 468.23 +/- 113.63 microm. After panretinal photocoagulation, DME regressed spontaneously in all eyes after a mean follow-up of 7.1 +/- 2.68 months. Mean central macular thickness decreased to 268.12 +/-54.67 microm (t-test, P < 0.0001). Mean visual acuity improved significantly to 0.184 +/- 0.12 (t-test, P = 0.048). Diabetic macular edema only recurred in two eyes.

CONCLUSION

In DME combined with FPDR, extensive panretinal photocoagulation and glycemic control seem effective in reducing DME and improving vision. In FPDR, DME may be caused by excessive production of vascular endothelial growth factor by the unperfused retina.

Venous retinal flow reperfusion mechanisms following radial optic neurotomy with adjunctive intraocular triamcinolone in central retinal vein occlusion

Background

To evaluate retinal reperfusion, anastomosis, and compensation following radial optic neurotomy for ischemic nonperfused central retinal vein occlusion.

Methods

Prospective, non-comparative, interventional case series of 13 patients with ischemic, nonperfused central retinal vein occlusion who underwent decompression surgery with a radial optic neurotomy and adjunctive intraocular triamcinolone. Patients were followed for 1 year after surgery, and were analyzed in the preoperative and postoperative stages determining: visual acuity by ETDRS chart (LogMar) and retinal thickness with optical coherence tomography. Fluorescein angiography was performed at regular intervals to evaluate the capillary perfusion grade. Intraocular pressure was measured and fundus was examined.

Results

Visual acuity and retinal thickness improved in 10/13 (77%) patients after surgery at 1-year follow-up. Adequate retinal reperfusion was achieved in ten of the 13 eyes. Acute reperfusion occurred in six eyes within 2 weeks of surgery and a shunt vessel at the optic disk developed in four eyes within 4 months. In the remaining three eyes, retinal reperfusion was not observed by fluorescein angiography. No complications were noted in any of the patients.

Conclusion

Surgical decompression promoted mechanical reperfusion of the occluded vessel in 10/13 (77%) cases. In 6/13 patients (46%) reperfusion occurred within 2 weeks of surgery, and in 4/13 patients (31%) collateral vessels formed within 4 months.

Towards quantitative analysis of retinal features in optical coherence tomography

The purpose of this paper was to propose a new computer method for quantitative evaluation of representative features of the retina using optical coherence tomography (OCT). A multi-step approach was devised and positively tested for segmentation of the three main retinal layers: the vitreo-retinal interface and the inner and outer retina. Following a preprocessing step, three regions of interest were delimited. Significant peaks corresponding to high and low intensity strips were located along the OCT A-scan lines and accurate boundaries between different layers were obtained by maximizing an edge likelihood function. For a quantitative description, thickness measurement, densitometry, texture and curvature analyses were performed. As a first application, the effect of intravitreal injection of triamcinolone acetonide (IVTA) for the treatment of vitreo-retinal interface syndrome was evaluated. Almost all the parameters, measured on a set of 16 pathologic OCT images, were statistically different before and after IVTA injection (p<0.05). Shape analysis of the internal limiting membrane confirmed the reduction of the pathological traction state. Other significant parameters, such as reflectivity and texture contrast, exhibited relevant changes both at the vitreo-retinal interface and in the inner retinal layers. Texture parameters in the inner and outer retinal layers significantly correlated with the visual acuity restoration. According to these findings an IVTA injection might be considered a possible alternative to surgery for selected patients. In conclusion, the proposed approach appeared to be a promising tool for the investigation of tissue changes produced by pathology and/or therapy.

Sensitive detection of transitional cell carcinoma of the bladder by microsatellite analysis of cells exfoliated in urine

Transitional cell carcinoma (TCC) is the most common bladder tumor. Urine cytology can identify most high-grade tumors but sensitivity is lower if one includes lesions of all grades. Microsatellite marker alterations have been found in many tumor types including bladder cancer and have been used to detect cancer cells in body fluids including urine. The aim of our study is to further evaluate feasibility and sensitivity of microsatellite analysis to detect bladder cancer cells in urine. We studied 55 individuals: 21 with symptoms suggestive of bladder cancer, 23 patients with previous history of TCC and 11 healthy subjects. Genomic DNA was extracted from blood lymphocytes, urine sediment, bladder washings and tumor or normal bladder mucosa. Twenty highly informative microsatellite markers were analyzed for loss of heterozigosity (LOH) and microsatellite instability (MIN) by polymerase chain reaction. Microsatellite analysis of urine identified 33 of 34 (97%) patients with either primary or tumor recurrence, whereas urine cytology identified 27 of 34 (79%) patients (p = 0.0001). Detection of microsatellite abnormalities improved the sensitivity of detecting low-grade and/or stage bladder tumor: from 75-95% for grades G1-G2 and from 75-100% for pTis-pTa tumors. Bladder washings from 25 patients were also analyzed, and in all cases results were identical to those obtained from voided urine. None of the 16 patients without evidence of TCC showed LOH and/or MIN in urine samples or bladder washings. Interestingly, in a patient with persistent bladder mucosa abnormalities, microsatellite alterations were demonstrated 8 months before the histopathologic diagnosis of tumor recurrence. These results further indicate that microsatellite marker analysis is more sensitive than conventional urine cytology in detecting bladder cancer cells in urine and represents a potential clinical tool for monitoring patients with low-grade/stage TCC.

Extracorporeal shock wave lithotripsy in ureteral and kidney malformations

INTRODUCTION

Extracorporeal shock wave lithotripsy (SWL) has long been accepted worldwide in the treatment of kidney stone disease. Upper ureter calculi in ureteral and kidney malformations are rather frequent (10-25%). The aims of this retrospective study were to determine whether malformations might impair fragment expulsion.

MATERIAL AND METHODS

From 1986 to 1995, 203 patients with ureteral and kidney malformations were treated and followed up for a minimum of 1 year to a maximum of 9 years. Malformations included: ureteropelvic junction stenosis, horseshoe kidney, renal malrotation, renal ectopia, duplicated ureter, nonobstructive megaureter, medullary sponge kidney and caliceal diverticula. As pretreatment workup, all patients underwent conventional studies prior to SWL treatment: X-rays, renal ultrasound, intravenous pyelography, routine blood tests and urinalysis. All examinations were repeated at regular intervals for the first 6 months. Patients with metabolic disorders were excluded from the study. We also excluded patients with a follow-up of under 1 year. We considered three groups of patients: (1) stone-free patients at plain X-rays and ultrasound; (2) >90% elimination, i.e. stone-free patients at plain X-rays and positive at ultrasound; (3) patients with residual fragments at plain X-rays and ultrasound.

RESULTS

96 (55%) patients were in group 1 (stone free), 40 (19%) were in group 2 (>90% elimination) and 67 (26%) were in group 3 (residual). Residual stones were more frequent in patients with medullary sponge kidney (82%). In patients with renal ectopia the residual stone rate accounted for only 13% of cases.

CONCLUSIONS

There is evidence that SWL should always be offered to patients with ureteral and kidney malformations. These patients should however be considered at high risk for recurrences and so they need to be carefully followed up.

Diagnosis and therapy of the female urethral diverticula

The various diagnostic and therapeutic modalities currently in use for urethral diverticula are reviewed. Various radiographic techniques have been reported, but only voiding cystourethrography (VCUG) and positive-pressure urethrography (PPU) are currently utilized. Urethroscopy is another suitable technique for diagnosis. Various sonographic techniques have been proposed, but their sensitivity is improved only by the transvaginal approach and magnetic resonance imaging (MRI). Various treatment methods have been proposed. The standard operative approach is surgical, through the vagina. The techniques currently in use to treat urethral diverticula are the Spence procedure, the typical urethral diverticulectomy, and the Tancer partial ablation technique. A full history, and physical examination is the first step in screening. When the diagnosis is suspected ultrasound and radiological imaging is necessary. Sonography is the first non-invasive examination to be performed. In negative cases it is imperative to perform a PPU or MRI. Symptomatic and very large diverticula must be treated in the easiest way possible. The best treatment, except for complicated and infected diverticula, is excision.

Transurethral electrovaporization of the prostate vs. transurethral resection. Results of a multicentric, randomized clinical study on 150 patients

AIM OF THE STUDY

To evaluate clinical, urodynamic efficacy and safety of TURP and TVP in patients with symptoms due to obstructive benign prostatic hypertrophy with a prospective multicentric randomized study.

MATERIALS AND METHODS

150 patients with BPH, urodynamically obstructed, were randomized to receive TURP or TVP. At the end of the recruitment phase, 80 patients underwent TURP and 70 patients underwent TVP. Patients were clinically evaluated by the I-PSS score at months 0, 1, 3, 6 and 12. Preoperative evaluation included complete blood routine examination, PSA, transrectal ultrasound and pressure/flow studies. Pressure/flow studies were also performed after 3 months.

RESULTS

There was no statistical difference between groups in any of the preoperative parameters. All patients were considered urodynamically obstructed at preoperative pressure studies. As for catheter days and hospitalization days, statistical differences between TVP and TURP were found; catheter days were 2.71 days (SE 0.12) in the TURP group vs. 1.9 (SE 0.24) in the TVP group (p < 0.000). Hospitalization was 4.7 days (SE 0.22) after TURP and 3.9 days (SE 0.24) after TVP (p < 0.000). Mean preoperative I-PSS score was 18.84 and 18.19 in the TVP and TURP groups, respectively. At 3, 6 and 12 months, IPSS was 5.52 and 5.50, 3.77 and 4.94, 3.52 and 4.04 for TURP and TVP, respectively. Mean preoperative peak flow rate (PFR) was 8.78 and 7.26 ml/s for TURP and TVP, respectively; after 3, 6 and 12 months, PFR was 19.21 and 18.8, 20.77 and 20.13, 20.30 and 20.31 ml/s, respectively. After 3 months, 6 patients in the TURP group (7.5%) and 7 patients in the TVP group (10%) were borderline obstructed. 1 patient in the TVP group (1.4%) was still obstructed and underwent TURP. As for complications, 4 patients (5.7%) in the TVP group had stress urinary incontinence after 12 months vs. 1 (1.25%) in the TURP group.

DISCUSSION

The present study clearly demonstrates that TVP is as effective as TURP in relieving urinary obstruction due to BPH, it offers some advantages in terms of catheterization and hospital stay, but at the price of a higher incidence of postoperative urine incontinence. Technical improvements might solve this problem in the future, perhaps combining TVP with TURP of the apical tissue.

Abdominal sacral colpopexy with prolene mesh

The objective was to evaluate abdominal colposacropexy using Prolene mesh to correct total vaginal vault prolapse or total procidentia. Between 1994 and 1997 we performed colposacropexy on 15 patients for simple vaginal vault prolapse (in 7 cases after hysterectomy) and for total uterine prolapse in 8 cases. In these cases a simple abdominal hysterectomy was performed. We simultaneously performed colposacropexy with colposuspension according to the Burch technique for urinary stress incontinence in 6 cases. The colposacropexy technique consisted of isolating the vaginal apex and creating a retroperitoneal tunnel from the vagina to the sacral promontory. Between the vaginal cul de sac and the sacrum, a mesh of Prolene is inserted and fixed with non-absorbable sutures. The Foley catheter was removed after 4-12 days (average 5). Average follow-up was 15 months. No intraoperative complications occurred, and all patients who were sexually active have resumed normal sexual activity; no infections or rejections of the prostheses have been verified. We believe that it is very important to restore the normal anatomic support of the vaginal vault after prolapse. This strong support is assured by fixing the vaginal apex to the periosteum of the sacrum using Prolene mesh. Colposacropexy with Prolene mesh is a safe and effective technique for the surgical therapy of vaginal vault prolapse.

Management of hemorrhage after percutaneous renal surgery

Percutaneous renal surgery is routine therapy for a number of renal pathologies. It is a technique not without complications, often serious ones, of which the worst is bleeding. We reviewed our experience of the incidence, etiology, and management of this serious complication to determine a protocol of treatment that will minimize the consequences. Between 1984 and 1996, we carried out 976 percutaneous operations for reno-calix stones, pyeloureteral junction stenosis, neoplasia of the renal pelvis, diagnosis, and ureteral prostheses. In all cases, the percutaneous access was achieved through a lower calix in the posterior axillary line with the patient in a prone position. The lithotripsy was performed with ultrasound and balistic energy lithotripters. Antegrade endopyelotomy was performed according to our technique. At the end of the procedure, a nephrostomy tube was positioned, 24F for lithotripsy and 16F for endopyelotomy. The nephrostomy tube was removed after 24 to 48 hours. In this series, 146 patients (15%) presented significant perioperative bleeding. In 97 cases (10%), this complication was resolved with the repositioning of the nephrostomy tube, bedrest in a supine position, and observation, whereas in 49 cases (5%), clamping of the nephrostomy tube for 24 hours was necessary. In 56 patients (5.7%), two blood transfusions were necessary, and three patients (0.3%) had bleeding 10, 12, and 20 days after the operation, which was resolved by embolization of the lacerated vessel.

Diverticula of the female urethra

OBJECTIVE

To determine the optimum procedure for the diagnosis and therapy of diveticula of the female urethra.

PATIENTS AND METHODS

The study included 18 patients with urethral diverticula treated at the Cristo Re Hospital in Rome between 1987 and 1995. Most of the patients were suffering from cystitis (eight), dysuria (seven) and recurring urinary infections (11). Less frequently, more specific symptoms were present such as post-voiding dribbling (two) and anterior vaginal mass (three). The pre-operative evaluation included a history, physical examination, voiding and positive pressure voiding cysto-urethrography (VCUG) and urodynamic tests. A 'typical' surgical excision of the diverticula was carried out in all cases. Surgical excision was combined with cystopexis (Raz operation) in four patients with urinary stress incontinence and three with detrusor instability were treated postoperatively with anticholinergics for 3 months. The outcome was evaluated by a physical examination and urodynamic tests at 3, 6 and 12 months postoperatively; the mean (range) follow-up was 34 (2-80) months.

RESULTS

All the urethral diverticula were in the distal two-thirds of the urethra, along the posterolateral wall. The VCUG was sufficient for diagnosis in eight patients while the other 10 required a positive-pressure VCUG. Fifteen patients were evaluated; complications included a urinary tract infection for 2 months in four patients and stress incontinence for 2 months in two. There were no recurrences or urethrovaginal fistulae.

CONCLUSIONS

Diverticula in the female urethra are difficult to diagnose because the symptoms can be misleading; the positive-pressure VCUG is useful in doubtful cases. However, a detailed history and physical examination are mandatory.

Risk factors for urological prosthetic infection

We reviewed our experience of 91 procedures for implant and revision of urological prostheses from 1989 to 1996. The aim of the study was to determine the risk factors for urological prostheses. The procedures consisted of 48 implants of artificial urinary sphincters AMS 800 (35 primary implants and 13 revisions) and 43 penile prostheses (40 primary implants and 3 revisions). Simultaneous penile reconstruction was performed in 5 cases. The mean follow-up was 2 years (range 1-6 years) for artificial urinary sphincter and 1.8 years (range 1-4) for penile prostheses. Infection occurred in 7 cases (4 urinary sphincter and 3 penile prostheses). The infection rate after primary uncomplicated implant of AMS 800 was 8.5% compared to 7.6% for revision procedures (p=n.s.). The infection rate after primary implant of penile prostheses was 5% compared to 33% for revision procedures. There was a similar significant difference between the penile prostheses implant group with reconstruction of the corpora (2 out 5 patients) and the primary uncomplicated implant group (p=0.001). The risk of infection is significantly greater when penile reconstruction is required and is associated with revision operations.

Transurethral electrovaporization of the prostate with the Vaportrode VE-B. Preliminary results

Transurethral resection of the prostate (TURP) is still considered the 'gold standard' in the treatment of benign prostatic hyperplasia (BPH). However, it is possible to replace this technique in particular situations (advanced age, serious cardiovascular, respiratory and metabolic disorders).

OBJECTIVE

The aim of this study is to propose an alternative treatment to TURP with a minimal invasiveness, rapid discharge of the patient and lower costs achieving the same results as TURP. We have used electrovaporization of the prostatic tissue to investigate the outcome of electrovaporization in the treatment of patients with BPH.

METHODS

A grooved rolling electrode with a large surface contact was used (Vaportrode VE-B; Circon Acmi, USA), mounted on a common resectoscope connected to a normal high-frequency discharge unit. This concentration of high energy produces an area of high current density at the point of contact with the prostatic tissue and a consequent thermal reaction which causes the tissue temperature to rise rapidly until vaporization. In the period ranging from January 1995 to June 1995, 35 patients with BPH were treated.

RESULTS

The average maximal flow increased from 9.8 +/- 3.18 to 13.6 +/- 5.9 ml/s at 2 days and to 20.74 +/- 9.8 ml/s at 28 days (p < or = 0.01); the average symptom score decreased from 18.17 +/- 4.5 to 10.4 +/- 3.3, 28 days after surgery with an average improvement of 52% (p < or = 0.01). Voiding pressure at 28 days was 22.9 +/- 2 cm H2O (p < or = 0.01). Sixteen patients were obstructed preoperatively while 19 patients were unobstructed postoperatively and 3 were equivocal as shown in the Abrams-Griffiths nomogram. Postvoiding residual urine was 0 ml at the follow-up at 2 and 28 days. The average reduction in weight of the prostatic adenoma, measured with transrectal ultrasound and the ellipsoid formula, was 84% (range 50-90%).

CONCLUSION

We think that this technique represents an interesting alternative in the treatment of symptomatic BPH.