Ideal Implant Structured Breast Implants: Core Study Results through 10 Years

BACKGROUND

The Ideal Implant structured breast implant uses different technology than unstructured saline or silicone gel implants, making it a third type of implant. U.S. Food and Drug Administration (FDA) and Health Canada granted approval in November of 2014. This saline-filled implant has an internal structure consisting of a series of nested shells that support the upper pole when upright and control movement of the saline to provide a natural feel. Because women can look in the mirror to know their implants are intact, they have peace of mind. In contrast, most women are concerned about silicone gel implant ruptures, which are silent and require FDA-recommended magnetic resonance imaging or ultrasound scans for detection.

METHODS

This U.S. trial enrolled 502 women: 399 for primary and 103 for revision augmentation. Investigators were 45 American Board of Plastic Surgery-certified plastic surgeons at 35 sites. Of the 502 women enrolled, 426 (84.9%) completed 10-year follow-up visits, a higher percentage than all other FDA breast implant trials.

RESULTS

Through 10 years of follow-up, surgeon satisfaction was 94.8% for primary and 87.4% for revision augmentation; and patient satisfaction was 92.7% for primary and 82.3% for revision augmentation. Cumulative Kaplan-Meier risk rates for two major adverse events were lower than in the silicone gel implant trials: Baker class III and IV capsular contracture was 6.6% for primary and 11.5% for revision augmentation; and rupture/deflation was 3.7% for primary and 4.7% for revision augmentation.

CONCLUSION

Ten-year results from 426 women show the Ideal Implant has high patient and surgeon satisfaction, a low rate of capsular contracture, and a low rate of rupture/deflation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Anterior uveitis associated with latanoprost

PURPOSE

To report the association of anterior uveitis with the use of latanoprost.

METHODS

We studied four patients with complicated open-angle glaucoma who had anterior uveitis associated with the use of latanoprost. The uveitis was unilateral and occurred only in the eye receiving latanoprost in three patients. In one patient, latanoprost was used in both eyes, and the uveitis was bilateral. Four of five eyes had a history of prior inflammation and/or prior incisional surgery. All patients were rechallenged with the drug.

RESULTS

The uveitis improved after cessation of latanoprost with or without topical corticosteroids. It recurred after rechallenging with latanoprost in all eyes.

CONCLUSION

There is a possible association between latanoprost and anterior uveitis. Topical prostaglandin analogs may be relatively contraindicated in patients with a history of uveitis or prior ocular surgery. This association may also be possible in eyes that have not had previous uveitis or incisional surgery.

Binocular function in early glaucoma

PURPOSE

This study investigated whether certain binocular mechanisms are disrupted in early glaucoma.

METHODS

Glaucoma patients, suspects, and normals were tested on a battery of psychophysical tests consisting of flicker sensitivity (5 and 34 Hz), temporal cut-off frequency (CFF), contrast sensitivity (Pelli-Robson chart), and stereoacuity. Monocular channels were evaluated with tests of monocular flicker performance and spatial contrast sensitivity. Binocular summation on spatial and temporal tests was used to reflect integrity of binocular neural interactions. Stereoacuity was taken as a measure of performance of disparity processing mechanisms.

RESULTS

The groups differed in terms of binocular flicker sensitivity at both temporal rates, binocular and monocular peak contrast sensitivity, and stereoacuity. Binocular summation of both spatial and temporal sensitivity was normal. The glaucoma suspect group was distinguishable from the age-matched normal group on binocular contrast sensitivity and stereoacuity.

CONCLUSIONS

The binocular mechanisms that mediate stereoacuity appear to be heavily disrupted, whereas the binocular mechanisms that mediate central neural interaction of monocular inputs are normal. Although monocular spatiotemporal abilities are disrupted, the binocular processes combine the monocular input normally. In addition, our results suggest a benefit of binocular testing for routine assessment of glaucoma patients. The profound disruption of stereoacuity appears to result from disorder in the spatial sampling array at the ganglion-cell level similar to the disorder reported in the normal periphery and the central retina of strabismic amblyopes. These and previous findings were reviewed to evaluate the supposition of preferential M-pathway disruption in early glaucoma. Such a model can not be reconciled with the present findings. We conclude that measurements of temporal modulation sensitivity fit well with such a model, but that the current evidence of spatiotemporal contrast sensitivity disruption is less supportive of such a model.

Timolol hemihydrate vs timolol maleate to treat ocular hypertension and open-angle glaucoma

PURPOSE

We compared the therapeutic efficacy and safety of timolol hemihydrate to timolol maleate in patients with ocular hypertension and chronic open-angle glaucoma.

METHODS

We conducted this three-month study as a multicentered, masked, parallel group comparison. Both the 0.25% and 0.5% concentrations were evaluated against similar concentrations of timolol maleate. Dosing was twice daily. An open-label, nine-month study followed the masked portion of the protocol, in which all patients received either 0.25% or 0.5% timolol hemihydrate. A total of 371 patients were included in both the 0.25% and 0.5% studies.

RESULTS

We found statistically similar intraocular pressures with both the 0.25% (18.3 and 18.6 mm Hg for the hemihydrate and maleate groups, respectively) and 0.5% (19.9 and 19.5 mm Hg for the hemihydrate and maleate groups, respectively) concentrations of timolol hemihydrate and timolol maleate after three months of masked treatment. Likewise, peak intraocular effect at two hours after taking the medication was statistically similar between medicines at both concentrations. Likewise, both ocular and systemic safety were similar between the maleate and hemihydrate preparations at both concentrations. In the nine-month open-label protocol, therapeutic efficacy (19.9 and 19.1 mm Hg for the 0.25% and 0.5% concentrations, respectively) and safety of timolol hemihydrate were similar to effect and safety of the three-month protocol.

CONCLUSIONS

This study suggests that timolol hemihydrate had an ocular hypotensive efficacy and safety profile statistically equivalent to that of timolol maleate for up to three months of therapy. Timolol hemihydrate showed efficacy and safety similar to that observed within the first three months, for up to one year of therapy.

Prevent Blindness America visual field screening study. The Prevent Blindness America Glaucoma Advisory Committee

PURPOSE

To assess the screening efficacy and practical use of two portable devices to detect moderate to severe visual field loss rapidly in population screening.

METHODS

Henson visual field analysis and Damato campimetry for glaucoma were performed in a healthy adult population, to determine false-positive rates; in established glaucoma patients and suspects, to determine false-negative rates; and in a general adult population, to assess practical use in actual screenings.

RESULTS

There were no false-positive test failures among the 82 normal subjects who completed the Henson two-step screening. Eighty of 83 normal subjects passed Damato campimetry, resulting in a false-positive rate of 3.6%. Among 83 glaucoma suspects and patients, the Henson test identified 49 (84%) of 58 subjects whose full-threshold fields from Humphrey perimetry were abnormal, 38 (97%) of 39 of whom had moderate to severe visual field loss. The Damato campimeter detected 55 (81%) of 68 subjects with any pathologic loss on full-threshold visual fields, 44 (92%) of 48 of whom had moderate to severe visual field loss. Among 1,278 subjects tested in general population screenings, 55 subjects (4.3%) failed either or both tests.

CONCLUSIONS

The Henson visual field analyzer can discriminate moderately to severely diseased from normal visual fields with high sensitivity and specificity. The Damato campimeter can reliably detect moderate to severe visual field loss with a tolerably low false-positive rate. To overcome the weakness of glaucoma screening by tonometry alone, some forms of visual field testing may be acceptably brief (cost effective) and accurate (sensitive and specific).

Pharmacokinetics, acid-base balance and intraocular pressure effects of ethyloxaloylazolamide--a novel topically active carbonic anhydrase inhibitor

Studies evaluated a novel series of biscarbonylamides of 2-amino-1,3,4-thiadiazole-5-sulfonamide (2-ATS) for topical use as ocular hypotensive carbonic anhydrase inhibitors (CAI). Transcorneal accession rate constants (k(in)) for ethyloxaloylazolamide (EtOxAz), ethylsuccinylazolamide (EtSuxAz) and ethyladipoylazolamide (EtAdipAz), and activity against carbonic anhydrase (CA) were determined in vitro by an enzymatic assay and High Performance Liquid Chromatography (HPLC). The ocular hypotensive effect was measured by pneumatonometry on conscious normotensive New Zealand White (NZW) rabbits, using masked, randomly assigned paired-eye design for treatment vs. control. At various time points following treatment, aqueous humor, ciliary processes and corneal buttons were collected and assayed for drug concentrations using enzymatic assay and HPLC. Transcorneal accession rates for the novel compounds were 1.5 to 18 times that of the parent compound, acetazolamide (Actz). The activity factor for EtOxAz was 72.8 x 10(3) hr-1 of 23 times that of Actz. The activity factors for EtSuxAz and EtAdipAz were 6.8 and 1.1 x 10(3) hr-1, respectively. Subcutaneous administration of EtOxAz. EtSuxAz, and EtAdipAz, in 225 mumol kg-1 concentrations, induced a significant decrease in the intraocular pressure (IOP) at 1 hr post injection of 4, 5.8 and 6 mmHg for EtOxAz, EtSuxAz and EtAdipAz, respectively (P < 0.05 for each). Topical application of 75 mM EtOxAz lowered the IOP by 3.0 mmHg (P < 0.05). This effect was maximal after 60 min and persisted for at least 5 hr. EtSuxAz and EtAdipAz did not alter the IOP significantly when given topically. Subcutaneous administration of the three compounds was associated with acidosis (pH as low as 7.21). Topical application did not cause any changes in the acid-base balance. There was a direct correlation between the amount of drug delivered to the ciliary process and the magnitude of ocular hypotensive effect. Following topical application EtOxAz reached the ciliary epithelium in concentrations sufficient to inhibit more than 99.95% of the ciliary carbonic anhydrase (> 8 microM), while plasma drug concentrations were below the limit of detection by the assay (< 0.2 microM). Within the first hour after topical application, half of the EtOxAz was eliminated from the anterior uvea. In summary, EtOxAz is a topically effective CAI. Structural modifications of thiadiazole sulfonamides, with the increase of both water and lipid solubilities, improved the transcorneal accession while preserving sufficient CA inhibitory activity, resulting in a significant IOP decrease following topical application of EtOxAz.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of the efficacy of various metipranolol-pilocarpine combinations in patients with ocular hypertension and primary open-angle glaucoma

We compared the ocular hypotensive effects of four fixed-dose metipranolol-pilocarpine combinations in nineteen ocular hypertensive subjects and glaucoma patients. Each patient was tested with all of the study medications: vehicle alone, 0.1% metipranolol HCl + 2% pilocarpine HCl, 0.1% metipranolol HCl + 4% pilocarpine HCl, 0.3% metipranolol HCl + 2% pilocarpine HCl, and 0.3% metipranolol HCl + 4% pilocarpine HCl, in a single dose, randomized, double-masked, cross-over placebo-controlled trial. In addition, another eight age and baseline intraocular pressure (IOP)-matched subjects received 0.1% or 0.3% metipranolol HCl, while a similar group of 14 volunteers received 2% or 4% pilocarpine HCl. A two week washout period was instituted between the various groups of treatments. All four metipranolol-pilocarpine combinations were more effective than placebo or either medication alone in reducing the average IOP for up to 8 hours (p < 0.05 for each treatment group). Metipranolol HCl 0.3%, regardless of the pilocarpine concentration, demonstrated the most significant IOP lowering effect, reducing the IOP by 4.9 mm Hg or about 20% from baseline. However, 0.1% metipranolol HCl in combination with 4% pilocarpine HCl was found almost as effective with a 18.5% reduction in IOP from baseline, but a shorter duration of action. In conclusion, all metipranolol-pilocarpine combinations were more efficacious than either medication alone in a single-dose trial. Additional multiple-dose studies are needed to determine the long-term effectiveness and tolerance of combining 0.3% metipranolol HCl with either 2% or 4% pilocarpine HCl.

The efficacy of brimonidine in decreasing elevations in intraocular pressure after laser trabeculoplasty

PURPOSE

The authors explored the empirical dosing requirement for administration of an alpha 2-adrenoceptor agonist, brimonidine, and determined its efficacy in decreasing elevations in intraocular pressure (IOP) after 360 degrees argon laser trabeculoplasty (ALT).

METHODS

This vehicle-controlled, double-masked, multicenter trial evaluated three dosing regimens of brimonidine. Two hundred thirty-two patients for whom 360 degrees ALT was indicated were randomized into one of four treatment groups: 0.5% brimonidine both before and after ALT; brimonidine before but vehicle after ALT; vehicle before but brimonidine after ALT; or vehicle at both times.

RESULTS

During the first 3 hours after 360 degrees ALT, the overall incidence of IOP elevations of 5 mmHg or greater was 38% (23 of 60 eyes) in the group receiving vehicle only, and it ranged from 3% to 9% (2 of 62 to 5 of 53 eyes) in the groups receiving any brimonidine treatment. There was little difference in efficacy between the three dosing regimens of brimonidine. Brimonidine was well tolerated by the patients.

CONCLUSION

Based on this large, controlled, multicenter study, 0.5% brimonidine was an effective agent for reducing elevations in IOP after 360 degrees ALT. Only one dose, administered either before or after 360 degrees ALT, was required.

In vitro inhibition of collagen formation by 2,4-pyridine dicarboxylate and minoxidil in rabbit corneal fibroblasts

Two anti-fibrotic agents were evaluated in vitro for potential application in trabeculectomy. The rate of collagen formation by cultured rabbit corneal fibroblasts was determined by [3H]proline uptake and hydroxylation assay. Incubation of fibroblasts, for 96 hours, with 16 mM 2,4-pyridine dicarboxylic acid (2,4-PDCA), a competitive inhibitor of prolyl 4-hydroxylase, decreased [3H]OH-proline formation from control by 28.2 +/- 3.9%; (average +/- S.E.M), whereas 10 mM minoxidil, an antihypertensive pyrimidine oxide and a lysyl hydroxylase inhibitor, induced a decrease of 17.3 +/- 4.5%. Incubating fibroblasts with a mixture of the two inhibitors, 16 mM 2,4-PDCA and 10 mM minoxidil, resulted in a further decrease in [3H]proline incorporation of 40.7 +/- 5.1%. After 96 hours of incubation with the inhibitors, rabbit corneal fibroblast growth was decreased from control by 17.2 +/- 4.2% and 10.5 +/- 4.5% for 16 mM 2,4-PDCA and 10 mM minoxidil, respectively. These effects were dose dependent. The results suggest that both 2,4-PDCA and minoxidil have an inhibitory effect on collagen formation and may be useful in delaying surgical wound healing.

A comparison of the ocular tolerability of a single dose of timolol and levobunolol in healthy normotensive volunteers

Subject acceptance of a single dose of timolol and levobunolol was compared in a three-center, double-masked, randomized, crossover study in healthy normal subjects. We tested 115 subjects who received the medications OU, in a random order, separated by a washout period of three to seven days. At the end of the administration, the subjects were asked to report any symptoms and were monitored by ophthalmologic examination. Those receiving levobunolol reported a two- to threefold higher frequency of symptoms than did those receiving timolol (P = .0002, by Mainland-Gart chi-square test). Thirty-five subjects (30.4%) treated with levobunolol complained of burning versus 14 (12.2%) receiving timolol (P = .0021). Similar results were obtained in regard to stinging (31 versus 10 subjects; P = .0011). The duration of these symptoms did not differ between the two groups (P > .05). Timolol induced considerably less burning and stinging on day 1 compared with levobunolol, using a visual analog scale over time (P = .0004). Seventy-nine percent of those stating a preference chose timolol (P < 3 x 10(-9).

Initial treatment of glaucoma: surgery or medications

Should surgery or medications be the initial therapy for primary open angle glaucoma? In this set of articles, Drs. Sherwood, Migdal, and Hitchings present evidence suggesting that filtration surgery provides better intraocular pressure control than does medical treatment, good (or better) visual field preservation, and visual acuity as good as that in medically treated fellow eyes. They also cite cost effectiveness, quality of life, and possible adverse effects of medical treatment on future surgery. Drs. Sharir and Zimmerman, on the other hand, favor initial medical therapy, questioning the validity of some reports on surgical results, citing the risks of complications, and noting recent and current progress in the development of antiglaucoma medications. Dr. Schultz' editorial evaluates both points of view, concluding that additional prospective randomized tests may be useful and that either approach may be a viable option, as long as it is individualized to each particular patient.

Topical ophthalmic beta blockers: a comparative review

Topically administered beta blockers are the preferred medical therapy for glaucoma. These agents reduce intraocular pressure (IOP), thereby preventing damage to the optic nerve and the subsequent loss of vision. Timolol, betaxolol, levobunolol, metipranolol, and carteolol are the topical beta blockers available in the U.S. They have similar IOP-lowering efficacy, but differ in other pharmacological properties. Topically administered beta blockers are generally well tolerated. They undergo systemic absorption, however, and can adversely affect cardiovascular and bronchopulmonary function in patients with existing diseases such as heart failure, sinus bradycardia, chronic obstructive airways disease, or asthma. Betaxolol, which is beta 1-selective, and carteolol, which has intrinsic sympathomimetic activity (ISA), may have systemic tolerability profiles superior to the traditional nonselective, non-ISA beta blockers. These hypotheses require confirmation in controlled clinical trials. Local adverse effects associated with beta blockers include stinging, burning, red eye, itching, tearing and loss of corneal sensitivity. Stinging upon instillation is a particularly frequent finding with betaxolol (up to 30% to 40% of patients). Preliminary evidence suggests that carteolol has the best local tolerability profile of these drugs.

A double-masked, placebo-controlled evaluation of timolol in a gel vehicle

We evaluated a topical formulation of timolol in an anionic heteropolysaccharide gellan gum (Gelrite). Fifty-five white patients with ocular hypertension entered a double-masked, placebo-controlled, four-period, incomplete block crossover study. After washout of any ocular hypotensive medications, the intraocular pressure of both eyes of all patients was measured at 0 (09:00 h), 2, 4, 6, 8, 12, and 24 h (diurnal baseline). Patients were then randomized to receive, at 2-week intervals, one drop of each of four of the six treatments in one eye (0.008% timolol gel, 0.1% timolol gel, placebo gel, 0.008% timolol solution, 0.1% timolol solution, and placebo solution). Fellow eyes received the appropriate placebo. As measured by least-squares means, adjusted for the unmedicated baseline diurnal values, there was a clear dose-response, with the 0.1% treatments being more effective ocular hypotensive agents than the 0.008% treatments, which in turn were more effective than the placebo treatments. Within each concentration at several observation points, the gel formulation elicited a 1-2-mm Hg greater efficacy than the solution. Gel-treated subjects had a greater incidence of blurred vision. We conclude that formulation of timolol with a gel may increase efficacy, and thus duration of action. This may possibly allow use of a lower concentration of timolol or a reduced frequency of instillation. Further evaluation in chronic dosing studies is justified.

Therapeutic index of epinephrine and dipivefrin with nasolacrimal occlusion

We assessed the effect of nasolacrimal occlusion on the therapeutic index of the adrenoreceptor agonists in healthy volunteers and patients with glaucoma. Nasolacrimal occlusion did not significantly alter the response to 2% epinephrine or to 0.1% dipivefrin in healthy subjects, suggesting that both 2% epinephrine and 0.1% dipivefrin are at the top of the dose-response curve. When 0.5% epinephrine with nasolacrimal occlusion was tested in patients with glaucoma, effects were noticeable at four and eight hours (P less than .05), but not at 12 hours. For 2% epinephrine, there was no significant difference at any measurement time. Epinephrine (1%) with and without nasolacrimal occlusion gave results similar to those of 2% epinephrine, suggesting that 1% epinephrine is also at the top of the dose-response curve. Nasolacrimal occlusion did not increase the ocular hypotensive effect of either of these concentrations. Because dipivefrin, the most widely used formulation in this class, is a prodrug of epinephrine that has a corneal penetration approximately 17 times that of epinephrine, 0.05% dipivefrin, every 12 hours, might be an adequate dosage for maximal effect. Although nasolacrimal occlusion did not alter the drug effect of 0.1% dipivefrin, preventing as much drug as possible from reaching the systemic circulation is desirable.

Therapeutic index of pilocarpine, carbachol, and timolol with nasolacrimal occlusion

We assessed the effect of nasolacrimal occlusion on the therapeutic index of various antiglaucoma medications in healthy volunteers and patients with glaucoma. Nasolacrimal occlusion used with pilocarpine 2% every 12 hours gave the maximal ocular hypotensive response. Carbachol 1.5% every 12 hours with nasolacrimal occlusion gave the maximal response for this drug. For timolol, nasolacrimal occlusion collapsed the dose-response curve and extended the duration of action. A final trial of carbachol added to timolol with nasolacrimal occlusion showed that timolol 0.25% and carbachol 1.5% every 12 hours gave the maximal response for this combination. Our findings suggest that most of the commercially used ocular hypotensive agents can achieve the same maximal effect with lower concentrations and less frequent administration (never exceeding every 12 hours) than are currently recommended should nasolacrimal occlusion be performed. Furthermore, nasolacrimal occlusion should markedly decrease the systemic absorption of topical ocular drugs and lessen the chance of systemic side effects.

Sneezing as a cause of acute angle-closure glaucoma

We report the case of a patient who had an attack of acute angle-closure glaucoma precipitated by sneezing, probably as a result of a sudden increase in venous back pressure. This young woman had a history of allergic sinusitis.

Tonometry comparison: Goldmann versus Tono-Pen

Tono-Pen and Goldmann tonometers were compared in 152 eyes of healthy subjects (Group A) and 69 eyes of patients after intraocular procedures (Group B). In Group A, the readings from both the tonometers showed no statistically significant difference in the 0 to 15mmHg range. However, the Tono-Pen values were lower in eyes with intraocular pressures between 16 and 30mmHg (P less than .0001). This questions the reliability of Tono-Pen as an adequate screening instrument. The correlation between the two instruments was acceptable in Group B (r = .89), indicating that the Tono-Pen may be used cautiously to determine intraocular pressure in postoperative patients.

The effect of a glaucoma medication reminder cap on patient compliance and intraocular pressure

A multi-site, open-labeled clinical trial was conducted to evaluate the ease of use and acceptance of a newly developed medication cap with a memory aid (C Cap Compliance Cap, Allergan, Inc.) and its effect on patient compliance and intraocular pressure. One-hundred-twenty-two patients with glaucoma or ocular hypertension received their prescribed eye drops in bottles with the compliance cap. Overall, 83% of the patients found the compliance cap very easy to use. By the end of the study, significantly more patients (67%) claimed 100% compliance than prior to using the compliance cap (41%). An overall drop in intraocular pressure of 0.8 mm Hg was seen. However, in a subset of patients who reported an increase in compliance, mean intraocular pressure decreased from baseline by 1.7 mm Hg. The results of this study suggest that the compliance cap helps patients with glaucoma or ocular hypertension remember to take their medication as prescribed.

Automated perimetry, tonometry, and questionnaire in glaucoma screening

To evaluate the sensitivity and specificity of various portions of the glaucoma screening process, 145 participants underwent complete ophthalmic examinations. A weighted questionnaire was 20% (2 patients) and 36% (5 suspects) sensitive for the glaucoma patients and glaucoma suspects, respectively. Tonometry alone was 20% (2 patients) and 7% (1 suspect) sensitive for glaucoma patients and glaucoma suspects, respectively. Automated perimetry of the central 30 degrees and nasal periphery identified nine (90%) of the glaucoma patients and five (36%) of the glaucoma suspects. The presence of increased intraocular pressure was not by itself very useful, but when perimetry or tonometry was used, 10 (100%) of the glaucoma group was identified. We recommend that automated suprathreshold perimetry and tonometry be performed in glaucoma screening.

Effect of intracameral carbachol on intraocular pressure after cataract extraction

Thirty-two patients were randomly assigned to a treatment or a control group to determine the dose-response and duration of action of intracameral carbachol on immediate postoperative intraocular pressure after extracapsular cataract extraction using a viscoelastic substance. Patients in the treatment group received 0.5, 0.25, or 0.1 ml of 0.01% intracameral carbachol. Patients in the control group received 0.1 or 0.5 ml of balanced salt solution. Intraocular pressures of all patients were measured preoperatively and at three, six, 12, 24, and 48 hours postoperatively. The control group as a whole showed a 9.5-mm Hg intraocular pressure rise at three hours, a 10.0-mm Hg rise at six hours, a 9.0-mm Hg rise at 12 hours, and a 7.2-mm Hg rise at 24 hours postoperatively. The group treated with 0.5 ml of carbachol maintained stable intraocular pressures through the 48-hour measurement period. The groups treated with 0.25 and 0.1 ml of carbachol maintained stable intraocular pressures through 24 hours postoperatively. The differences in intraocular pressure were statistically significant for all treated groups through the 24-hour measurement.

Management of upper gastrointestinal hemorrhage in patients with pseudoxanthoma elasticum

Pseudoxanthoma elasticum is a rare inherited connective tissue disorder, which exhibits genetic heterogeneity. It is characterized by elastic tissue degeneration involving many organ systems, with typical cutaneous, ocular, arterial, and gastrointestinal manifestations. Upper gastrointestinal tract hemorrhage occurs in 13% of patients with pseudoxanthoma elasticum and is often resistant to conventional methods of treatment. A case report involving gastric hemorrhage in a patient with pseudoxanthoma elasticum is presented. The characteristics of pseudoxanthoma elasticum are reviewed, and the management of upper gastrointestinal tract hemorrhage in these patients is discussed.

Magnesium and methionine deprivation affect the response of rats to boron deprivation

A series of nine experiments were done to obtain further evidence that boron might be involved in major mineral metabolism (Ca, P, and Mg), thus indicating that boron is an essential nutrient for animals. Eight factorially arranged experiments of 6-10 wk durations were done with weanling Sprague-Dawley male rats. One factorially arranged experiment was done with weanling spontaneously hypertensive rats. The variables in each experiment were dietary boron supplements of 0 and 3 micrograms g, and dietary magnesium supplements of either 200 (Experiments 1-3) or 100 (Experiments 4-9) and 400 micrograms/g. In Experiments 7 and 9, a third variable was dietary manganese supplements of 25 and 50 micrograms/g. Methionine status was varied throughout the series of experiments by supplementing the casein-based diet with methionine and arginine. Findings were obtained indicating that the severity of magnesium deprivation and the methionine status of the rat strongly influence the extent and nature of the interaction between magnesium and boron, and the response to boron deprivation. When magnesium deprivation was severe enough to cause typical signs of deficiency, a significant interaction between boron and magnesium was found. Generally, the interaction was characterized by the deprivation of one of the elements making the deficiency signs of the other more marked. The interaction was most evident when the diet was not supplemented with methionine and especially when the diet contained luxuriant arginine. Signs of boron deprivation were also more marked and consistent when the diet contained marginal methionine and luxuriant arginine. Among the signs of boron deprivation exhibited by rats fed marginal methionine were depressed growth and bone magnesium concentration, and elevated spleen wt/body wt and kidney wt/body wt ratios. Because the boron supplement of 3 micrograms/g did not make the dietary intake of this element unusual, it seems likely that the response of the rats to dietary boron in the present study were manifestations of physiological, not pharmacological, actions, and support the hypothesis that boron is an essential nutrient for the rat.

Intraocular pressure following ECCE and IOL implantation in patients with glaucoma

Patients with glaucoma may suffer optic nerve head damage due to elevated intraocular pressure (IOP) after any intraocular procedure. We retrospectively reviewed the IOP data in 82 consecutive patients (103 eyes) with glaucoma after extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PC-IOL) implantation. Nine eyes had previous trabeculectomy and three eyes required combined trabeculectomy with ECCE and PC-IOL. The average follow-up period is 1.5 years (range 0.5 to 6 years). The postoperative IOP rise of 8 mm Hg over baseline or above 23 mm Hg was observed in 45 eyes (49.5%). Two eyes needed argon laser trabeculoplasty and one required trabeculectomy to control postoperative IOP elevation. Most of the patients required the same or lesser number of medications for IOP control after surgery. Results suggest that ECCE with PC-IOL may be a relatively safe procedure in cataract patients with preexisting glaucoma.

Intraocular pressure following secondary anterior chamber lens implantation

Secondary anterior chamber implantation has become relatively simple since the advent of viscoelastic materials. Still, glaucoma, cystoid macular edema, endophthalmitis, and astigmatism remain vision-threatening complications. We studied intraocular pressures (IOPs) following this surgery in 102 patients (124 eyes) over 6 years. Elevated IOP was noted in 32 eyes (25.8%), but only 14 (11.3%) needed long-term medical treatment. None, however, required laser iridectomy, trabeculoplasty, or trabeculectomy. Patients should be selected for secondary anterior chamber implantation only after more conservative measures have been exhausted.

Evaluation of the Krupin-Denver valve implant in normotensive and glaucomatous beagles

The Krupin-Denver valve was implanted unilaterally in 2 normotensive and in 6 glaucomatous Beagles. The fellow eye of each dog had an external trabeculectomy. Before and after surgery, all dogs were evaluated serially by gonioscopy, biomicroscopy, tonometry, and tonography. The valve implant remained patent in 2 normotensive and in 2 glaucomatous Beagles throughout the 12 months of observation. Valve function was lost in 4 glaucomatous Beagles 4 to 6 weeks (3 dogs) and 6 months (1 dog) after implantation. Light microscopic and scanning electron microscopic evaluations of early loss of implant function revealed occlusion of the lumen and/or valve mechanism by inflammatory debris and cells. The late loss of valve function was related to chronic inflammatory response and fibrosis about the valve mechanism and tubing within the sclera.

Improved ischemic island skin flap survival with continuous intraarterial infusion of adenosine triphosphate--magnesium chloride and superoxide dismutase: a rat model

Neurovascular island skin flaps are still hampered by occasional necrosis of their most distal aspect. Cells subjected to prolonged hypoxic conditions become intracellularly depleted of needed metabolic substrates and eventually die. Once hypoxic conditions are improved, ischemic tissue suffers further injury from the rapid accumulation of oxygen free radicals. This study showed 53% survival of a standard random flap constructed on the inferior epigastric neurovascular bundle of a rat. Random flap survival increased to 65% after intraarterial infusion of adenosine triphosphate--magnesium chloride (ATP-MgCl2); to 75% after superoxide dismutase infusion; and to 98% after combined ATP-MgCl2 and superoxide dismutase infusion. Neither substrate appeared to act by increasing blood flow to the ischemic tissue.