Local versus Systemic Therapy for Noninfectious Uveitis (NIU)

The mainstay of treatment for noninfectious uveitis (NIU) is immunosuppressant therapy. This may come in a localized form that is administered specifically to the eye or a systemic form that penetrates ocular tissues. Over the last twenty years, both local and systemic treatments have undergone advancements in pharmaceutical development. In this review, we will discuss new therapies and analyze the risks and benefits for all existing NIU therapies. Some of these therapies include topical, intravitreal, periocular, and systemic steroids, as well as systemic antimetabolites, tumor necrosis factor-α inhibitors, T-cell inhibitors, anti-CD 20 agents, interleukin-6 inhibitors, alkylating agents, and intravenous immunoglobulin.

Large Hyphema following Femtosecond Laser-assisted Cataract Surgery (FLACS) and Trabectome Resulting in Endocapsular Hematoma

Aim

To report a large hyphema following femtosecond laser-assisted cataract surgery (FLACS) and trabectome resulting in endocapsular hematoma.

Background

Hyphema has previously been described following trabectome, however, no cases have been reported following FLACS or FLACS combined with microinvasive glaucoma surgery (MIGS). We report a case of a large hyphema following FLACS combined with MIGS that resulted in an endocapsular hematoma.

Case description

A 63-year-old myopic female with exfoliation glaucoma underwent FLACS with a trifocal intraocular lens implant and Trabectome in the right eye. Significant intraoperative bleeding ensued following the trabectome and was treated with viscoelastic tamponade, anterior chamber (AC) washout, and cautery. The patient developed a large hyphema with intraocular pressure (IOP) rise that was treated with multiple AC taps, paracentesis, and eye drops. The hyphema took approximately 1 month to completely clear, leaving an endocapsular hematoma. This was treated successfully with Neodymium:Yttrium-Aluminum-Garnet (Nd:YAG) laser posterior capsulotomy.

Conclusion

Hyphema may occur with angle-based MIGS in combination with FLACS and may cause endocapsular hematoma. An increase in episcleral venous pressure during the docking and suction phase of the laser may predispose to bleeding. Endocapsular hematoma is an uncommon finding after cataract surgery and may be treated with Nd:YAG posterior capsulotomy.

How to cite this article

Chang EL, Apostolopoulos N, Mir TA, et al. Large Hyphema following Femtosecond Laser-assisted Cataract Surgery (FLACS) and Trabectome Resulting in Endocapsular Hematoma. J Curr Glaucoma Pract 2022;16(3):195-198.

Anterior Subcapsular Cataract Formation With Long-term Topical Netarsudil Treatment for Glaucoma

PURPOSE

The purpose of this study was to describe anterior subcapsular cataract development in patients on long-term topical netarsudil use.

PATIENTS AND METHODS

This clinical observational study summarizes a similar cataract pattern demonstrated in a series of patients from a single physician practice and a university-based outpatient clinic during their routine clinical follow-up visits from October 2020 to August 2021. All patients have been using topical netarsudil once daily for at least 15 months. No anterior capsular changes have been observed in any patient at the time when netarsudil was initiated.

RESULTS

Five eyes from 4 patients between the ages of 41 and 61 and 1 eye from a patient aged 84 were found to develop anterior subcapsular opacities 15 to 37 months after beginning netarsudil. These cataracts were overall small, 1 to 3 mm, round, oval or ring-shaped, central or paracentral with mild density. No other risk factors for cataract development apart from age were found in these patients.

CONCLUSION

Patients on long-term netarsudil should be monitored for potential development of anterior subcapsular cataracts.

Nocardia keratitis mimicking superior limbic keratoconjunctivitis and herpes simplex virus

Purpose

Nocardia keratitis is a rare type of infectious keratitis and may mimic other corneal diseases and lead to delay in diagnosis. This case illustrates how Nocardia often escapes accurate diagnosis due to its insidious onset, variable clinical manifestations, and unusual characteristics on cultures.

Observation

The patient presented with an epithelial defect and superior pannus and scarring, which was misdiagnosed as superior limbic keratoconjunctivitis (SLK) and herpes simplex virus (HSV) keratitis. Repeat corneal scraping cultures, smears, and conjunctival biopsy were necessary to elucidate the diagnosis. It can be effectively treated with the intravenous preparation of trimethoprim-sulfamethoxazole 80 mg/mL (brand name SEPTRA) used topically as eye drops.

Conclusion

The diagnosis of Nocardia keratitis relies on a high clinical suspicion and a prompt corneal scraping with culture. Due to its potential for rapid resolution with early therapy, it is important to isolate Nocardia early in its disease course.

Importance

Topical amikacin had been the standard of care for Nocardia keratitis for many years. However, recently there is increasing resistance of Nocardia to amikacin. SEPTRA offers an alternative therapy. Nocardia keratitis mimics other infectious and inflammatory etiologies so rapid diagnosis and treatment is critical in the prevention of long-term complications.

Thymosin beta-15 predicts for distant failure in patients with clinically localized prostate cancer-results from a pilot study

OBJECTIVES

To report the results of a pilot study on the prognostic value of a newly identified actin-binding protein, thymosin beta-15 (Tbeta15), in predicting prostate-specific antigen (PSA) and bone failure in patients with Gleason 6/10 clinically localized prostate cancer.

METHODS

Thirty-two patients (median age 70 years) with clinically localized, moderately differentiated (Gleason 6/10) prostate cancer treated by external beam radiotherapy alone (68.4 Gy) with available paraffin blocks at the Massachusetts General Hospital were evaluated for this pilot study. All patients had clinical Stage M0 disease at initial presentation, which was documented by bone scan (T1c-4,NX). Their corresponding biopsy specimens were stained immunohistochemically for Tbeta15, which was then correlated with the clinical outcome in a blinded manner. The median follow-up was 6 years (range 1 to 19) for all of the patients.

RESULTS

The outcomes of the 32 patients can be grouped into three categories: patients with no evidence of disease (n = 11), patients with PSA failure without documented bone failure (n = 11), and patients with PSA failure and documented bone failure (n = 10). Tbeta15 staining intensity strongly correlated with clinical outcome. Of those patients whose specimens stained 3+ (strongest staining), 62% developed bone failure compared with 13% of those patients whose specimens stained 1+ (weakest staining) (P = 0.01). The 5-year freedom from PSA failure was only 25% for those patients with 3+ staining compared with 83% for those with 1+ staining (P = 0.02).

CONCLUSIONS

The results of this pilot study have demonstrated that Tbeta15 staining intensity may be a potentially important marker to identify high-risk patients with moderately differentiated, clinically localized prostate cancer.

Survival results from a phase I study of etanidazole (SR2508) and radiotherapy in patients with malignant glioma

PURPOSE

To report the survival results from a previous Phase I study of etanidazole (ETA) and radiotherapy in patients with glioblastoma multiforme (GBM n = 50) or anaplastic astrocytoma (AA n = 19) and examine survival according to age, Karnofsky performance status (KPS), and implant status.

PATIENTS AND METHODS

In a previous Phase I study, 70 previously untreated patients (median age 49) with malignant gliomas were accrued. One patient was excluded from analysis because pathology was unverifiable. All had KPS > or = 70. Prior to initiation of treatment, patients were stratified according to whether they were candidates for interstitial implantation. The implant patients (IMP n = 14) received accelerated fractionation radiotherapy (XRT) 2 Gy BID (6 hours apart) to 40 Gy in 2 weeks with ETA 2 gm/m2 x 6 doses, a 2 week break, and then interstitial implant for an additional 50 Gy (4-7 days) with a continuous infusion of ETA over 90-96 hours. There were 55 patients treated on two sequentially conducted non-implant arms. These patients started with accelerated fractionation XRT 2 Gy BID (6 hours apart) to 40 Gy in 2 weeks with ETA 2 gm/m2 x 4-5 doses/week. Non-IMP1 arm (n = 41) received a 2-week break before standard fractionated boost XRT of 2 Gy/day for 2 weeks to a total dose of 60 Gy with ETA. Non-IMP2 arm (n = 14) did not have the 2-week break. All patients had plasma pharmacokinetic monitoring of ETA. Subsequent follow-up study provided information regarding long-term survival status of this group of patients. The Phase I toxicity evaluation was conducted according to the RTOG toxicity scale and was found well tolerated in both groups. Overall actuarial survival was plotted for all patients, by histologic group, and by implant status. Subset analyses of GBM patients by age (< or = 49 or > 49 years), KPS (< or = 80 or > 80) and implant versus non-implant were also performed.

RESULTS

Median survival of GBM patients was 1.1 years and that of anaplastic astrocytoma patients was 3.1 years (p = 0.0001). In GBM patients, KPS > 80, implanted patients, and age < or = 49 were factors found not to be associated with a statistically improved survival.

CONCLUSION

The results of survival in this Phase I etanidazole study of patients with anaplastic astrocytoma are comparable to the results from other studies using bromodeoxyuridine, iododeoxyuridine, or procarbazine, lomustine (CCNU), and vincristine. The use of etanidazole with accelerated radiotherapy does not appear to improve survival in patients with glioblastoma multiforme compared to those treated with conventional therapies.

Particle size and drug interactions of injectable corticosteroids used in ophthalmic practice

PURPOSE

The aim of this study is to compare the particle sizes of commercially available corticosteroids for intralesional injection to manufacturers' specifications and to evaluate changes in size when mixed with other steroids and other commonly used solutions.

METHODS

The particle sizes of dexamethasone sodium phosphate, methylprednisolone acetate, triamcinolone acetonide, and betamethasone sodium phosphate and beta-methasone acetate were measured with the Coulter counter. Each steroid was mixed with each of the others, lidocaine, and lidocaine with epinephrine, then measured immediately and after 1 hour to determine the effect on particle size.

RESULTS

All steroids showed accurate manufacturer specifications. Dexamethasone showed an increase in particle size when mixed with lidocaine alone, immediately and after 1 hour. Triamcinolone showed an increase in particle size only after 1 hour after mixture with lidocaine alone. Triamcinolone, dexamethasone, and methylprednisolone particles increased in size when mixed with lidocaine and epinephrine. Dexamethasone and triamcinolone showed an additional increase in size when allowed to sit for 1 hour after mixture with lidocaine and epinephrine. Mixing steroids caused no increase in particle size.

CONCLUSION

Because an increase in the number of particles greater than 20 microns in a solution also increases the likelihood of vascular occlusion, the authors urge care in the mixing of these drugs, especially with lidocaine and epinephrine. If mixture is necessary, the authors recommend that injection take place immediately subsequent.

Cloning and expression of an antigenic domain of glycoprotein gE of pseudorabies virus in Escherichia coli and its use as antigen in diagnostic assays

Use of a combination of an effective gE gene-deleted pseudorabies virus (PRV) vaccine with a companion diagnostic kit for PRV glycoprotein gE has proven successful in several pseudorabies-eradication programs. To produce a large quantity of functional gE protein for development of a PRV-gE diagnostic kit, an Escherichia coli expression system containing the distal region of the PRV-gE gene of a PRV strain CF was constructed. The expressed protein contained 134 amino acids of gE protein (amino acids 77-210) fused to a 19-amino acids tag containing 6 histidine residues. After induction, a truncated PRV-gE polypeptide of 18-kd was expressed to about 20% of the total E coli proteins. Results of immunoblot analysis indicated that this E coli-produced PRV-gE protein reacted specifically with serum from PRV-hyperimmunized pigs and from field PRV-infected pigs, but not with serum samples from specific-pathogen-free pigs or pigs inoculated with gE-deleted PRV vaccine. These data indicate that, although the recombinant gE protein is produced in E coli, it still retains the antigenicity of the viral gE glycoprotein. Comparison between the recombinant gE protein, using immunoblot analysis with a commercial gE ELISA containing natural PRV-gE protein, revealed comparable test performance. This finding indicated that recombinant gE protein produced by E coli can be used for development of a companion serologic assay for a PRV-gE gene-deleted vaccine.

Formation and properties of a network gel formed from mixtures of diacetylenic and short-chain phosphocholine lipids

A polymerizable gel superaggregate has been formed from low concentrations (6 mM) of phospholipid mixtures of polymerizable 1,2-bis(tricosa-10,12-diynoyl)-sn-glycero-3-phosphocholine and 1,2-bis(dinonoyl)-sn-glycero-3-phosphocholine. Transmission electron microscopy (TEM) revealed that the superaggregate structure consisted of a network of twisted, braided fibers and that the pore size of the gel ranged from 0.1 to 1.0 micron. TEM of gel plated with Ni revealed that the width of the fibers was 280 A. Optical microscopy demonstrated that the onset of the gel phase occurred at mole fraction 0.43 DNPC in the absence of salt and 0.36 in the presence of 0.25 M NaCl. Polymerization did not affect the morphology of the gel but did increase its temperature stability.

Unusual thermal stability of liposomes made from bipolar tetraether lipids

The thermal stability of liposomes made from polar lipids of Sulfolobus acidocaldarius, a thermoacidophilic archaebacterium, was studied. While two analogous nonarchaebacterial liposomes examined were unstable above 50 degrees C, liposomes made of the native tetraether lipids showed stability up to at least 80 degrees C. Incubation of the archaebacterial liposomes at 100 degrees C, under slight pressure, caused an approximate 15% leakage after 60 minutes. Boiling, however, destroys the integrity of the lipid membranes. The tetraether lipid vesicles are less permeable to solute molecules, such as carboxyfluorescein, than the other lipid vesicles at any temperature. The permeability is also less temperature-sensitive than that for other lipids.

Unusual pressure dependence of the lateral motion of pyrene-labeled phosphatidylcholine in bipolar lipid vesicles

The lateral mobility of a pyrene-labeled phosphatidylcholine probe in liposomes containing archaebacterial bipolar lipids has been studied isothermally as a function of pressure. The pressure-dependence of the probe mobility, R, is found to be slightly positive or zero in the temperature range of 17 - 48 degrees C. At temperatures > 48 degrees C, R becomes negative and decreases with temperature. The data indicate that lateral mobility only becomes appreciable at high temperatures. In addition, the R values obtained with other lipid membranes are much lower than that obtained with bipolar liposomes, implying that the membranes of archaebacterial liposomes are laterally immobile, as compared to other lipid membranes.

Purification and characterization of a liposomal-forming tetraether lipid fraction

Polar lipid E, PLE, a native tetraether lipid mixture from Sulfolobus acidocaldarius is shown to spontaneously form multilamellar liposomes in aqueous media. PLE lipids were isolated as a single fraction from the crude lipid extract of S. acidocaldarius on a reverse-phase column followed by TLC and methanol precipitation. The methanol-precipitated mixture was able to form liposomes, whereas the non-precipitated material did not. It has thus been demonstrated, for the first time, that tetraether lipids from S. acidocaldarius can form liposomes, per se, in aqueous media.

Purification of glycerol dialkyl nonitol tetraether from Sulfolobus acidocaldarius

A modified procedure for extraction and purification of hydrolyzed archaebacterial lipids is described. Lipids were extracted from Sulfolobus acidocaldarius using a Soxhlet extraction procedure followed by trichloroacetic acid solvent-extraction of the residue. The yield of total extractable material by this protocol was 14% which, after a two-phase wash, yielded 10% lipid. Modifications to the published steps for purifying the subsequently hydrolyzed lipids were developed to purify glycerol dialkyl nonitol tetraether (GDNT). The nearly colorless final macrocyclic product was characterized by TLC, IR, NMR, and mass spectrometry.

Antibody multivalency effects in the direct binding model for vesicle immunolysis assays

An extension of a previous model of liposome-based immunoassays is presented which incorporates the effects of antibody multivalency in the binding process. Equations based on the distribution of vesicles having both mono- and divalently bound species show the quantitative relationships of the experimental parameters, including vesicle concentration, antigen density on vesicle surfaces, antibody concentration, and antibody affinity (both for the initial binding step and for the subsequent cross-linking step). It is found that in the case of low antibody concentration, the multivalent model can be cast in the form of the previously described monovalent model, replacing the association equilibrium constant with an effective equilibrium constant which is found to depend linearly on the lateral antigen density and on the valency of the binding antibody. Comparisons to certain experiments are made using this more realistic model of complement-mediated vesicle immunoassay. For the case of IgM binding, it is estimated that as few as 1000 antibody molecules can be detected in a typical lytic assay, representing a significant increase in sensitivity over previous predictions.

Analysis of vesicle immunolysis assays. The direct binding model

Assays based on lysis of lipid vesicles have shown high sensitivity. However, little as yet is known about the quantitative relationships among the various assay parameters, due in part to the lack of a predictive theoretical model. This paper presents the derivation of the equations that describe a simple model assay system in terms of the total fraction of vesicles with bound antibodies and the distribution of vesicles with one, two, or more antibodies bound. The equations show how the binding of antibodies to vesicles is affected by such variables as: vesicle concentration, antigen density on vesicle surfaces, antibody concentration, and antibody affinity. With the distribution functions, experiments can be designed to determine the minimum number of antibodies needed to lyse a vesicle. In addition, it is shown how estimations of the ultimate sensitivity of lipid vesicle lytic assays can be made. The model can be used to optimize vesicle lysis assay systems.

Effect of covalent attachment of immunoglobulin fragments on liposomal integrity

Liposome stability during and after covalent coupling of Fab' antibody fragments was investigated. Large unilamellar vesicles containing entrapped 5(6)-carboxyfluorescein (CF) as a marker for liposomal integrity were prepared by extrusion through polycarbonate membranes. N-[4-(p-Maleimidophenyl)-butyryl]phosphatidylethanolamine (MPB-PE) was employed as a liposomal anchor for the covalent coupling of Fab' fragments. We observed that coupling of Fab' fragments to liposomes containing 5 mol % MPB-PE caused a concentration-dependent increase in size and polydispersity of the liposomes. Dependent on the concentration of the MPB-PE anchor in the membrane and the concentration of Fab' added, coupling was associated with the release of up to 95% of the entrapped CF. Rupture of the liposomes was identified as the primary mechanism of CF release during Fab' coupling. Reduction of the MPB-PE concentration to 1 mol % resulted in liposomes that were stable during and after Fab' coupling. The increased stability of these liposomes was due to the lower MPB-PE concentration and not to the lower number of attached Fab' fragments. By proper adjustment of the experimental conditions for coupling, the number of Fab' fragments attached to the 1 mol % MPB-PE liposomes could be increased without affecting the stability of the resulting liposomes. These stable liposomes, made by an extrusion method that avoids the use of organic solvents, detergents, or sonication, are therefore suitable for entrapment of labile compounds and can be used for immunotargeting or immunoassays.

Encapsulation of hemoglobin in phospholipid vesicles

Hemoglobin has been encapsulated in phospholipid vesicles by extrusion of hemoglobin/lipid mixtures through polycarbonate membranes. This technique avoids the use of organic solvents, sonication, and detergents which have proven deleterious to hemoglobin. The vesicles are homogeneous, with a mean size of 2400 A as determined by photon correlation spectroscopy. The encapsulated hemoglobin binds oxygen reversibly and the vesicles are impermeable to ionic compounds. Hemoglobin encapsulated in egg phosphatidylcholine vesicles converts to methemoglobin within 2 days at 4 degrees C. By contrast, when a mixture of dimyristoyl phosphatidylcholine, cholesterol and dicetyl phosphate is used there is no acceleration in methemoglobin formation, and the preparation is stable for at least 14 days at 4 degrees C.

Photon correlation spectroscopy study on the stability of small unilamellar DPPC vesicles

The growth in size of dipalmitoylphosphatidylcholine small unilamellar vesicles (SUV) below Tm has been studied by photon correlation spectroscopy and differential scanning calorimetry. We see an initial fast rise of the hydrodynamic diameter of the vesicles followed by a slower increase. We assign the slow component of the size change to fusion of SUV. The order of the kinetics appears to be higher than first order. The estimated half lifetime of the fusion is approximately 67 h. The diameters for the fast and slow processes at t = O are 756 and 256 A, respectively, while as t leads to infinity the diameters increase to 1,570 and 733 A, respectively.

Self-association of lyophilized horse liver alcohol dehydrogenase

The molecular weights of lyophilized and non-lyophilized horse liver alcohol dehydrogenase have been compared by quasi-elastic light scattering, and ultracentrifugation. Whereas the non-lyophilized enzyme has the expected molecular weight of 78 000, the lyophilized enz)me has an initial molecular weight of about 10(6) which increases with time by an endothermic process. This result shows that any physical measurement using lyophilized liver alcohol dehydrogenase to investigate the enzyme mechanism, which relies upon the molecular size, will be invalid.