Danish heritable retinoblastoma survivors' perspectives on reproductive choices: "It's important for me, not to pass on this condition"

Despite reporting an overall normal life, survivors of heritable retinoblastoma face numerous physical and psychosocial issues. In particular, reproductive decision-making is often complex and difficult. This study aims to examine survivors' reflections on passing on heritable retinoblastoma to their children, how survivors approach their reproductive choices, and how the healthcare system can optimize counseling and support. Semi-structured interviews with Danish adult survivors of heritable retinoblastoma were qualitatively analyzed to explore their experiences. Participants were recruited from the Retinoblastoma Survivorship Clinic, Aarhus University Hospital, Denmark. Thematic data analysis was conducted followed by a condensing process specifically for the subthemes relating to reproductive choices. A common subtheme for all participants was a strong wish to avoid passing on retinoblastoma to their children. The participants emphasized the various medical, practical, emotional, and moral issues impacting their final reproductive choice in the process of family planning to conceive a child unaffected by retinoblastoma. Some had no option other than to conceive naturally and hope for an unaffected baby; while others weighed the pros and cons of choosing natural conception with prenatal testing and then considering termination of pregnancy (in case of an affected fetus) versus choosing fertility treatment with preimplantation genetic testing to achieve an unaffected pregnancy. Several participants underlined the complexity of their decisions, and also expressed feelings of guilt, both toward their affected child, and guilt for putting their partner through many difficult decisions and obstacles due to their genetic condition. Our findings demonstrate how one family-planning decision is not unequivocally "better" or easier than another. Healthcare professionals must provide the necessary information and tools to support the individual's unique decision-making process. Survivors' autonomy and individual needs, as well as the numerous and diverse aspects of heritable retinoblastoma, should be carefully considered.

The Global Retinoblastoma Outcome Study: a prospective, cluster-based analysis of 4064 patients from 149 countries

Background

Retinoblastoma is the most common intraocular cancer worldwide. There is some evidence to suggest that major differences exist in treatment outcomes for children with retinoblastoma from different regions, but these differences have not been assessed on a global scale. We aimed to report 3-year outcomes for children with retinoblastoma globally and to investigate factors associated with survival.

Methods

We did a prospective cluster-based analysis of treatment-naive patients with retinoblastoma who were diagnosed between Jan 1, 2017, and Dec 31, 2017, then treated and followed up for 3 years. Patients were recruited from 260 specialised treatment centres worldwide. Data were obtained from participating centres on primary and additional treatments, duration of follow-up, metastasis, eye globe salvage, and survival outcome. We analysed time to death and time to enucleation with Cox regression models.

Findings

The cohort included 4064 children from 149 countries. The median age at diagnosis was 23·2 months (IQR 11·0–36·5). Extraocular tumour spread (cT4 of the cTNMH classification) at diagnosis was reported in five (0·8%) of 636 children from high-income countries, 55 (5·4%) of 1027 children from upper-middle-income countries, 342 (19·7%) of 1738 children from lower-middle-income countries, and 196 (42·9%) of 457 children from low-income countries. Enucleation surgery was available for all children and intravenous chemotherapy was available for 4014 (98·8%) of 4064 children. The 3-year survival rate was 99·5% (95% CI 98·8–100·0) for children from high-income countries, 91·2% (89·5–93·0) for children from upper-middle-income countries, 80·3% (78·3–82·3) for children from lower-middle-income countries, and 57·3% (52·1-63·0) for children from low-income countries. On analysis, independent factors for worse survival were residence in low-income countries compared to high-income countries (hazard ratio 16·67; 95% CI 4·76–50·00), cT4 advanced tumour compared to cT1 (8·98; 4·44–18·18), and older age at diagnosis in children up to 3 years (1·38 per year; 1·23–1·56). For children aged 3–7 years, the mortality risk decreased slightly (p=0·0104 for the change in slope).

Interpretation

This study, estimated to include approximately half of all new retinoblastoma cases worldwide in 2017, shows profound inequity in survival of children depending on the national income level of their country of residence. In high-income countries, death from retinoblastoma is rare, whereas in low-income countries estimated 3-year survival is just over 50%. Although essential treatments are available in nearly all countries, early diagnosis and treatment in low-income countries are key to improving survival outcomes.

Funding

Queen Elizabeth Diamond Jubilee Trust.

Genetic testing in adult survivors of retinoblastoma in Denmark: A study of the experience and impact of genetic testing many years after initial diagnosis

BACKGROUND

Survivors with heritable retinoblastoma (RB) face a high risk for second primary cancer and RB in their children. Knowledge of heredity can support second cancer surveillance, convey reproductive options or early diagnosis of RB in their offspring. Currently, all newly diagnosed Danish patients with RB are offered genetic testing, as opposed to a minority of survivors diagnosed before available DNA testing.

OBJECTIVE

To examine RB survivors' response to unsolicited contact, uptake of genetic testing, and RB1 variant detection rate, and to qualitatively evaluate the experience and overall impact of genetic testing for heritable RB.

METHODS

Genetically untested adult RB survivors were invited to receive genetic counseling, undergo genetic testing for heritable RB and complete an eye examination. The number of responses, uptake of genetic testing and genetic results are descriptively reported. Additionally, responding survivors participated in a qualitative interview study of the perceived impact of genetic testing. Interviews were audio-recorded, transcribed verbatim and thematically analyzed.

RESULTS

Among invited RB survivors, 58% responded. Of these, 88% opted for genetic counseling and genetic testing. A diagnosis of heritable RB was established in 23% of RB survivors. Interestingly, all of these survivors were unilaterally affected. Analysis of data from the interviews revealed three recurring themes regarding the impact of genetic counseling and testing several years after initial diagnosis: 'Risk of what?', 'Knowledge is important' and 'Impact of the result'. The possible risk ofsecond cancer and RB in their children was new knowledge for several participants; however, in general, the participants appreciated receiving genetic information and certainty about heredity. Accordingly, the impact of genetic counseling and testing was perceived in a positive way.

CONCLUSION

Overall, RB survivors valued the opportunity to receive genetic counseling and undergo genetic testing many years after diagnosis. Responding RB survivors appreciated the invitation to test, felt well-informed and described little decisional conflict regarding their decision-making, valuing the genetic information and certainty. Heritable RB was confirmed in 23% of the previously untested RB survivors. These individuals emphasized the value of knowing and being proactive regarding both reproduction and cancer risk.

Living with heritable retinoblastoma and the perceived role of regular follow-up at a retinoblastoma survivorship clinic: 'That is exactly what I have been missing'

Objective

To explore living with heritable retinoblastoma, specifically survivors’ perceived role of regular follow-up at a retinoblastoma survivorship clinic.

Methods and analysis

Adult survivors of heritable retinoblastoma were recruited from the Retinoblastoma Survivorship Clinic, Aarhus University Hospital. Ten survivors participated in individual explorative, semistructured interviews. Thematic data analysis was conducted.

Results

Five key themes relating to vision, social life, family, second cancer risk and the healthcare system were identified. Subthemes relating to the Retinoblastoma Survivorship Clinic included the retinoblastoma coordinator, cancer risk, psychosocial support and genetic knowledge. The retinoblastoma-related physical and psychosocial issues influenced survivors’ everyday living; however, the opportunity to live a normal life varied considerably, with the majority experiencing no major limitations. The need for specialised management and a coordinator was emphasised to be the main value of the Retinoblastoma Survivorship Clinic.

Conclusion

Despite reporting an overall normal life and no major limitations in daily living activities, our data confirm that heritable retinoblastoma impacts several aspects of daily living. Uniquely, this study demonstrates that the main value of the Retinoblastoma Survivorship Clinic was a specialised contact person and coordinator in the healthcare system, providing continuous and necessary management and guidance after retinoblastoma treatment, and for all aspects of health related to heritable retinoblastoma. The needs of heritable retinoblastoma survivors are complex and extensive, and the specific role of the healthcare system to support survivorship should be prioritised, specialised and multidisciplinary.

Incidence and Mortality of Second Primary Cancers in Danish Patients With Retinoblastoma, 1943-2013

IMPORTANCE

In heritable retinoblastoma, there is a significantly increased risk of second primary cancers (SPCs). Improved knowledge about the incidence and influence of heritability and treatment is important during therapy for patients with retinoblastoma.

OBJECTIVE

To assess the incidence of SPC in patients diagnosed with retinoblastoma in Denmark from 1943 to 2013 with a focus on heritability and the association of external radiotherapy with mortality.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, data were extracted from the Danish Ocular Oncology Group Database containing complete data on all patients diagnosed with retinoblastoma , and obtained from the Danish Cancer Registry, which includes information on all patients with cancer from 1943 to December 31, 2013. Data analysis was conducted from December 1, 2017, to October 1, 2019. Data on 323 patients were included.

EXPOSURES

Heritability and retinoblastoma treatment.

MAIN OUTCOMES AND MEASURES

Standardized incidence rate, excess absolute risk, cumulative incidence of SPC, and mortality from SPC. Association of heritability and treatment with outcomes was estimated.

RESULTS

Of the 323 patients included in the analysis, 181 were men (56%), 133 had heritable retinoblastoma (41%), and 190 had nonheritable retinoblastoma (59%). The median age at diagnosis of SPC was 32.4 (interquartile range, 15.4-43.9) years in patients with heritable retinoblastoma and 38.6 (interquartile range, 20.5-49.4) years in those with nonheritable retinoblastoma. Twenty-five SPCs were identified in patients with heritable retinoblastoma vs 14 in patients with nonheritable retinoblastoma. Standardized incidence rate (SIR) of SPC in patients with heritable retinoblastoma was 11.39 (95% CI, 7.37-16.81) with an excess absolute risk of 70 cases per 10 000 person-years; the highest SIRs were for sarcoma (181.13; 95% CI, 98.94-303.92) and malignant melanoma (26.78; 95% CI, 9.78-58.30). The SIR for SPC in patients with nonheritable retinoblastoma was 1.52 (95% CI, 0.81-2.60). The cumulative incidence of SPCs at age 60 years was significantly higher in patients with heritable retinoblastoma (51%) compared with those with nonheritable retinoblastoma (13%) (P < .001) (hazard ratio, 5.0; 95% CI, 2.5-10.3). No significant differences were identified in overall risk of SPC in patients with heritable retinoblastoma treated with 3 different modalities: external radiotherapy, plaque (but no external) radiotherapy, and enucleation only, but an increased proportion of sarcomas was noted in the irradiated field. Mortality due to SPC was also higher in survivors of heritable retinoblastoma compared with those with nonheritable retinoblastoma (cumulative mortality, 34% vs 12% at age 60 years; P = .03).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the incidence and mortality associated with SPC were significantly higher in patients with heritable retinoblastoma vs patients with nonheritable retinoblastoma. The largest increases in risk were noted for sarcoma and malignant melanoma. External radiotherapy did not appear to increase the risk. These findings are relevant when treating patients with retinoblastoma to manage the risk for SPC.

Travel burden and clinical presentation of retinoblastoma: analysis of 1024 patients from 43 African countries and 518 patients from 40 European countries

BACKGROUND

The travel distance from home to a treatment centre, which may impact the stage at diagnosis, has not been investigated for retinoblastoma, the most common childhood eye cancer. We aimed to investigate the travel burden and its impact on clinical presentation in a large sample of patients with retinoblastoma from Africa and Europe.

METHODS

A cross-sectional analysis including 518 treatment-naïve patients with retinoblastoma residing in 40 European countries and 1024 treatment-naïve patients with retinoblastoma residing in 43 African countries.

RESULTS

Capture rate was 42.2% of expected patients from Africa and 108.8% from Europe. African patients were older (95% CI -12.4 to -5.4, p<0.001), had fewer cases of familial retinoblastoma (95% CI 2.0 to 5.3, p<0.001) and presented with more advanced disease (95% CI 6.0 to 9.8, p<0.001); 43.4% and 15.4% of Africans had extraocular retinoblastoma and distant metastasis at the time of diagnosis, respectively, compared to 2.9% and 1.0% of the Europeans. To reach a retinoblastoma centre, European patients travelled 421.8 km compared to Africans who travelled 185.7 km (p<0.001). On regression analysis, lower-national income level, African residence and older age (p<0.001), but not travel distance (p=0.19), were risk factors for advanced disease.

CONCLUSIONS

Fewer than half the expected number of patients with retinoblastoma presented to African referral centres in 2017, suggesting poor awareness or other barriers to access. Despite the relatively shorter distance travelled by African patients, they presented with later-stage disease. Health education about retinoblastoma is needed for carers and health workers in Africa in order to increase capture rate and promote early referral.

Global Retinoblastoma Presentation and Analysis by National Income Level

Importance

Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale.

Objectives

To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis.

Design, Setting, and Participants

A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017.

Main Outcomes and Measures

Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis.

Results

The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]).

Conclusions and Relevance

This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.

Danish retinoblastoma patients 1943-2013 - genetic testing and clinical implications

BACKGROUND

In heritable retinoblastoma there is a 50% risk of transmitting the RB1 mutation, and offspring carriers have more than 90% risk of developing retinoblastoma. Today, all newly diagnosed retinoblastoma patients in Denmark are screened for mutations in RB1, as opposed to only a minority of patients diagnosed before DNA testing was offered. Knowledge of heredity increases the chance of early diagnosis in offspring, leading to improved prognosis. We present data from the Danish retinoblastoma patients that emphasize the need for genetic counseling and RB1 screening in all untested retinoblastoma survivors.

MATERIAL AND METHODS

Data are extracted from The Danish Ocular Oncology Group Database, a national population database containing data on all Danish retinoblastoma patients since 1943.

RESULTS

In total 323 retinoblastoma patients have been diagnosed between 1943 and 2013. Since 1963, the rate has been stable around 1 per 14 000 live births with 95% of the patients surviving their retinoblastoma. Stratifying data on the time of diagnosis and status of genetic testing, the number of screened patients gradually increased from 5% in the beginning of the period to 96% in the last five-year period. A cohort of 181 retinoblastoma survivors with sporadic disease (15% heritable) did not receive genetic testing. Since the introduction of routine testing, one of 14 sporadic unilateral patients tested (7%) has been identified with a germline mutation. Before routine testing, five additional sporadic unilateral patients have been identified as heritable.

CONCLUSION

Only a minority of Danish retinoblastoma patients diagnosed before routine genetic testing was offered have been RB1 screened. To counsel the remaining untested patients and their families sufficiently regarding the risk to offspring and elevated risk of second primary cancers, we recommend information and access to genetic counseling and RB1 screening. This has ethical, psychological and possible economic consequences, and should be handled with caution.

Interactive 3D computer model of the human corneolimbal region: crypts, projections and stem cells

PURPOSE

This study aims to clarify the existence of and to map the localization of different proposed stem cell niches in the corneal limbal region.

MATERIALS AND METHODS

One human eye was cut into 2200 consecutive sections. Every other section was stained with haematoxylin and eosin, digitized at low and high magnification, aligned, 3D reconstructed and visualized using interactive 3D visualization software. The visualization software has interactive tools that make free rotations in all directions possible and makes it possible to create virtual sections independent of the original cutting plan. In all, one low-magnification and 24 high-magnification interactive 3D models were created. Immunohistochemistry against stem cell markers p63 and ΔNp63α was performed as a supplement to the 3D models.

RESULTS

Using the interactive 3D models, we identified three types of stem cell niches in the limbal region: limbal epithelial crypts (LECs), limbal crypts (LCs) and focal stromal projections (FSPs). In all, eight LECs, 25 LCs and 105 FSPs were identified in the limbal region. The LECs, LCs and FSPs were predominantly located in the superior limbal region with seven LECs, 19 LCs and 93 FSPs in the superior limbal region and one LEC, six LCs and 12 FSPs in the inferior limbal region. Only few LECs, LCs and FSPs were localized nasally and temporally.

CONCLUSION

Interactive 3D models are a powerful tool that may help to shed more light on the existence and spatial localization of the different stem cell niches (LECs, LCs and FSPs) in the corneal limbal region.

Visual outcome, local tumour control, and eye preservation after 106Ru/Rh brachytherapy for choroidal melanoma

To study the visual outcome, local tumour control, and eye preservation 5 years after ruthenium/rhodium 106 brachytherapy for choroidal melanoma. The study included 55 consecutive patients treated by 106Ru/Rh brachytherapy for a choroidal melanoma during the period 1988-2000 and followed through 2004. The 5-year probability for not losing at least 5 Snellen lines was 59% (n = 45), for retaining a visual acuity of 0.33 or better was 28% (n = 34), and for retaining better than 0.1 was 40% (n = 45). The 5-year probability for no local recurrence was 73% and for eye preservation 72% (n = 55). 106Ru/Rh brachytherapy for choroidal melanoma resulted in a clinically significant vision loss, no local recurrence, and eye preservation in most patients after 5 years. 106Ru/Rh brachytherapy can be regarded as a good treatment option for small and medium-sized tumours but not for large tumours.

Clinical phenotype of juvenile open-angle glaucoma linked to chromosome 1q in a Danish family

PURPOSE

To describe in a Danish family the phenotype of members with autosomal dominant juvenile open-angle glaucoma linked to chromosome 1q, GLCA1, and to assess possible biometric differences between the eyes of affected and unaffected subjects.

METHODS

Thirty-five subjects in a six generation family were examined. The records of five additional affected family members were available. Records from former examinations and treatments were also obtained. In 18 affected subjects and 13 unaffected subjects above 24 years biometric parameters were assessed and compared between the groups.

RESULTS

The age at diagnosis of glaucoma was on average 18 years (range 8 to 33 years). Bilateral intraocular pressure was high at the time of diagnosis (mean 37 mmHg, range 28-69 mmHg). All subjects except two needed filtering surgery shortly after diagnosis (mean 1 year, range 0-8 years). Gonioscopy displayed open chamber angle and goniodysgenesis in all affected subjects, but no dysgenesis in unaffected subjects. A comparison of biometric parameters of affected and unaffected subjects showed a deeper anterior chamber, but no other differences were found.

CONCLUSION

The phenotype of the affected family members is characterized by juvenile onset of glaucoma, open chamber angle with goniodysgenesis, high initial intraocular pressure, and the need for filtering surgery to control pressure. The deeper anterior chamber in affected subjects could indicate more extensive maldevelopment in affected subjects.

Ultrasound biomicroscopy. III. Accuracy and agreement of measurements

PURPOSE

To estimate the accuracy of measurements by the 50 MHz Humphrey Ultrasound Biomicroscope and evaluate the agreement of measurements by ultrasound biomicroscopy and optical pachometry.

METHODS

The accuracy was estimated by comparing measurements by ultrasound biomicroscopy with more exact mechanical methods. Forty-seven PMMA intraocular lenses and 52 distances between horizontal separated sutures were measured. The agreement between ultrasound biomicroscopy and optical pachometry was evaluated by comparing measurements of central cornea thickness and anterior chamber depth of 46 eyes.

RESULTS

The axial measurements by ultrasound biomicroscopy was on average 10 microm higher than the reference method (SEM 3 microm). The lateral measurements was without systematic difference from the reference method (SEM 5 microm). The mean central corneal thickness was considerably higher by optical pachometry, 557+/-5 microm (SEM), than by ultrasound biomicroscopy, 533+/-5 microm. Similarly for anterior chamber depth where mean measurements were 2955+/-66 microm and 2897+/-63 microm, respectively.

CONCLUSIONS

The axial and lateral accuracy of ultrasound biomicroscopic measurements was good. The agreement between measurements obtained by ultrasound biomicroscopy and optical pachometry was poor in this investigation. Several circumstances could be accountable for this.

Ultrasound biomicroscopical study of the irido-corneal angle in dominant juvenile open-angle glaucoma, in POAG, and in normal eyes

PURPOSE

To compare various parameters of the chamber angle in a pedigree with dominant goniodysgenesis and juvenile open-angle glaucoma linked to chromosome 1q, GLC1A, with those in patients with adult-onset primary open-angle glaucoma, and in normal eyes.

METHODS

Ultrasound biomicroscopy was performed on 10 eyes with dominant goniodysgenesis and juvenile open-angle glaucoma, on 12 eyes with adult-onset primary open-angle glaucoma, and 24 normal eyes. Eight parameters were measured.

RESULTS

The anterior chamber angle, angle opening distance 500 microm from the scleral spur, trabecular meshwork--iris distance, and trabecular meshwork--iris pigment epithelium distance were statistically significantly higher in the group with juvenile glaucoma.

CONCLUSION

The wider chamber angle in dominant juvenile open-angle glaucoma could suggest a more complex anomaly with involvement of cornea and iris in addition to goniodysgenesis. The presence of goniodysgenesis in the dominant juvenile open-angle glaucoma patients could not be detected by ultrasound biomicroscopy, however.

Ultrasound biomicroscopy. II. Intraobserver and interobserver reproducibility of measurements

PURPOSE

To evaluate intraobserver and interobserver reproducibility of measurements in images obtained by the 50 MHz Humphrey Ultrasound Biomicroscope.

METHODS

The first stored image of central cornea, central anterior chamber, and angle structures obtained at 50 examinations were measured twice by three observers. Nine different parameters were measured in angle images and two in images of central cornea and anterior chamber. Intraobserver reproducibility was assessed by calculating the coefficient of variation and interobserver reproducibility by a two-ways ANOVA.

RESULTS

Intraobserver reproducibility was high for all measurements of central cornea thickness and anterior chamber depth with a coefficient of variation (%) < or = 3.8%. In angle images the intraobserver reproducibility of measurements was often lower (coefficient of variation (%) 1.3-52.6%). The lower reproducibility was most noticeable in measurements involving the less defined structures. Interobserver reproducibility was poor.

CONCLUSIONS

Comparison of measurements are best done of well defined structures and by only one observer.

Ultrasound biomicroscopy. I. Precision of measurements

PURPOSE

To evaluate the precision of anterior chamber dimensions measured by the 50 MHz Humphrey Ultrasound Biomicroscope, the influence of various subprocedures, and the importance of clear definition of structures.

METHODS

Fourty-eight right eyes of 26 normal subjects and 22 glaucoma patients were scanned centrally and at the chamber angle at three positions under standardized conditions. Eight different parameters were measured in angle images and two in images of central cornea and anterior chamber. Four variance components were calculated.

RESULTS

Measurement of the clearest defined structures had the highest precision. In angle images the precision expressed as the coefficient of variation was <21%, except for measurement of iris-ciliary process (range: 3-59%). All subprocedures contributed to the overall variance, image to image variation the most.

CONCLUSIONS

The precision of most measured parameters seems reasonable for clinical use. All subprocedures contributed significantly to the overall variance. The parameters that were related to clearly defined structures had the highest precision.

Indications for cataract surgery in a Danish county 1980 and 1990

From 1980 to 1990 the number of cataract extractions in our department increased from 268 to 827, i.e. 209% within the same referral area. A review was made to see if the indications for cataract extraction had changed in that period. The increase in frequency of cataract extractions was statistically significant in all age groups except males aged 60-69. The increase was most noticeable in the older age groups. Preoperative visual activities were moderately higher in 1990 compared with 1980. The frequency of second eye surgery did not change in the period. Females had in 1980 as in 1990 a higher frequency of cataract extractions than males in all age groups > 60 years.

Confirmation of linkage to 1q21-31 in a Danish autosomal dominant juvenile-onset glaucoma family and evidence of genetic heterogeneity

Autosomal dominant juvenile-onset open-angle glaucoma has been mapped to 1q21-31 in a number of American families. Our study confirms linkage in a Danish five-generation dominant juvenile-onset glaucoma family with a maximum two-point lod score of 6.67 at the D1S210 locus. Multipoint linkage analysis in a nine-generation Swedish family with dominant juvenile-onset glaucoma and iris hypoplasia excludes linkage to the region of approximately 18 cM between loci D1S104 and D1S218, shown to contain the previously mapped glaucoma gene. This study thus provides support for genetic heterogeneity with respect to dominant juvenile-onset glaucoma.

[Monosymptomatic pupillary dilatation caused by scopolamine patch]

A case of monosymptomatic unilateral mydriasis caused by scopolamine patches is presented. The same symptom caused by pressure from an aneurysm on the oculomotor nerve is exceptionally rare.

[Retinal detachment after intracapsular and extracapsular cataract extraction]

In a retrospective study we reviewed the postoperative incidence of retinal detachment in a consecutive series of 762 eyes operated on with intracapsular cataract extraction and a consecutive series of 1351 eyes operated on with extracapsular cataract extraction. Follow-up time was 2 1/2-4 1/2 years in both series. The incidence of retinal detachment was 0.79% after intracapsular cataract extraction and 0.44% after extracapsular cataract extraction. The difference was not statistically significant. Age below 70 years was not statistically significantly correlated to retinal detachment.

Fluconazole in the management of fungal ocular infections

The number of fungal infections has increased dramatically, and those involving the eye pose a serious problem and treatment challenge to practicing physicians. Despite the overall effectiveness of conventional treatment with amphotericin B, there are several well-recognized disadvantages associated with this drug. The topical agent natamycin, although effective against the filamentous fungi, is less effective against Candida species. Ketoconazole, an effective broad-spectrum, oral antifungal, possesses a better safety profile than amphotericin B, but is also associated with potential toxicity and drug interactions. The ongoing search for improved antifungal compounds led to the development of fluconazole. This review article focuses on fluconazole in the treatment of patients with fungal infections of the eye. In addition to its proven effectiveness and safety in patients with various mycoses, the pharmacokinetic profile of fluconazole confers many advantages including diffusion into ocular tissue. A number of reported cases document the effectiveness of this triazole in human ocularmycoses without the occurrence of significant side effects.

Retinal detachment following intracapsular and extracapsular cataract extraction. A comparative, retrospective follow-up study

In a retrospective study we reviewed the post-operative incidence of retinal detachment in a consecutive series of 762 eyes operated on with intracapsular cataract extraction and a consecutive series of 1351 eyes operated on with extracapsular cataract extraction. Follow-up time was 2 1/2-4 1/2 years in both series. The incidence of retinal detachment was 0.79% after intracapsular cataract extraction and 0.44% after extracapsular cataract extraction. The difference was not statistically significant. Age below 70 years was not statistically significantly correlated to retinal detachment.

Infectious mononucleosis presenting as a unilateral conjunctival tumour

A case of a unilateral conjunctival tumour as the initial manifestation in the course of acute infectious mononucleosis is reported. The tumour was observed two weeks before occurrence of fever, general malaise, and sore throat.

Fluconazole in the treatment of candida albicans endophthalmitis

A 29-year-old former drug addict with candida albicans endophthalmitis determined by cultivation was treated with vitrectomy and systemic fluconazole. The infection resolved completely and the patient recovered a visual acuity of 6/6. Fluconazole was well tolerated and a high concentration was found in the vitreous cavity.