Comparison of postcataract surgery anti-inflammatory regimens on the incidence of cystoid macular edema, iritis, pain, and photophobia

PURPOSE

To compare postcataract surgery anti-inflammatory regimens of intracanalicular dexamethasone insert and topical bromfenac on the incidence of cystoid macular edema (CME), iritis, pain, and photophobia.

SETTING

Eyes of York Cataract & Laser Center, York, Pennsylvania.

DESIGN

Retrospective chart review.

METHODS

Case records of 647 consecutive patients (1001 eyes) who underwent cataract surgery and received dexamethasone intracanalicular insert 0.4 mg (Group 1; 482 eyes) or topical nonsteroidal anti-inflammatory drug (NSAID) (bromfenac 0.075% 2 times a day) for 4 weeks postoperatively (Group 2; 519 eyes) were included. Both groups received intracameral moxifloxacin and phenylephrine/ketorolac. Patients with prior CME, vitreomacular traction, combined cataract/glaucoma surgery, and medication protocols different from those examined in this study were excluded.

RESULTS

Compared with the dexamethasone insert group, the topical NSAID group had a significantly lower incidence of CME (0.4% [2/519] vs 3.9% [19/482], P < .001) and photophobia (1.9% [10/519] vs 4.8% [23/482], P = .012). The incidence of breakthrough iritis (3.5% [18/519] vs 5.6% [27/482], P = .104) and pain also trended lower (4.0% [21/519] vs 5.4% [26/482], P = .314) in the topical NSAID group.

CONCLUSIONS

Topical NSAIDs were found to be more effective in controlling CME, pain, iritis, and photophobia after cataract surgery compared with the intracanalicular dexamethasone insert in the presence of intracameral phenylephrine/ketorolac.

Uveitic secondary glaucoma: influence in James Joyce's (1882-1941) last works

James Joyce, considered one of the pre-eminent novelists of the 20th century, attained international renown with his work Ulysses. Its lack of standard punctuation makes it difficult to read. An example would be the famous non-punctuated 'Molly Bloom soliloquy' in the last chapter of Ulysses. Why is Joyce considered so difficult to read? He wrote and proofread Ulysses and Finnegans wake, his last works, during his battle against glaucoma, when his vision was seriously blurred. The distracting and confusing diacritical marks might be explained by Joyce's reduced visual acuity. Could Ulysses and Finnegans wake have been different if Joyce's visual problems had begun in the second rather than the first half of 20th century?

Longterm visual prognosis of patients with ocular Adamantiades-Behçet's disease treated with interferon-alpha-2a

OBJECTIVE

Relapsing ocular involvement is one of the major manifestations in Adamantiades-Behçet's disease (ABD). Combining systemic corticosteroids with cyclosporin A is currently the treatment of choice. Interferon-alpha (IFN-alpha) has proven to be effective in mucocutaneous ABD and has been reported to improve ocular lesions. We examined the longterm effects of IFN-alpha-2a in a case series of 45 patients with ocular involvement.

METHODS

Since 1988, 45 patients (79 eyes of 90 eyes) with ocular involvement in ABD have been treated with IFN-alpha (3 x 6-9 Mio IU per wk). In the initial acute phase of the disease, patients additionally received short-term corticosteroids (oral prednisolone 100 mg/day), tapered to a maintenance dose of 10 mg/day within 2 weeks. IFN-alpha-2a was administered as longterm therapy with a mean duration of 30 months (range 1.1-101 mo).

RESULTS

IFN-alpha-2a/prednisolone treatment was effective against vasculitis, optic nerve neuropathy, and iritis. Sixty-four eyes had no recurrence under therapy. To date, recurrences have been seen in 26 eyes under IFN-alpha treatment. Flu-like symptoms were recorded in nearly all patients (n = 43). Further side effects were dose-dependent reversible thrombocytopenia (n = 1), psychosis (n = 3), depression (n = 13), thyroiditis (n = 1), and reversible diffuse alopecia (n = 7). In our series, 92% of all eyes showed stable or improved visual acuity in longterm followup.

CONCLUSION

Longterm remission of ocular inflammation can be achieved with the combination of IFN-alpha and low-dose corticosteroids.

Tubulointerstitial nephritis and uveitis syndrome associated with hyperthyroidism

We report a 17-year-old male patient with tubulointerstitial nephritis and uveitis (TINU) associated with hyperthyroidism. He presented with a 2-month history of fatigue, loss of appetite, low-grade fever, and a 12-kg weight loss when he was admitted to our hospital. He had iritis, which was complicated by fibrin in the anterior chamber, diagnosed by slit-lamp examination. On laboratory examinations, deteriorated renal function (blood urea nitrogen level was 25.9 mg/dl and creatinine level was 2.82 mg/dl) and elevated urinary levels of N-acetyl-beta-D-glucosaminidase (33.1 U/l) and beta2-microglobulin (78,600 microg/l) were observed. Serum thyroid-stimulating hormone (TSH) was undetectable, at less than 0.01 microIU/ml, and free triiodothyronine and free thyroxine were elevated, up to 5.23 pg/ml and 2.85 ng/dl, respectively. The titers of antithyroglobulin and antithyroid microsomal and TSH-receptor antibodies were not elevated. Abdominal and thyroidal ultrasonography showed evident bilateral enlargement of the kidneys and diffuse enlargement of the thyroid gland. Iodine-123 scintigraphy showed low uptake in the thyroid gland. The biopsied renal specimen showed mild edema and severe diffuse infiltration of mononuclear cells and few eosinophils in the interstitium, without any glomerular or vascular abnormalities. Based on the clinical features and pathological findings, a diagnosis of TINU syndrome with associated hyperthyroidism was made. Treatment was started with 30 mg/day of prednisolone. The iritis disappeared, and the patient's clinical status improved remarkably. This case suggests the possibility of thyroid dysfunction in some patients with TINU syndrome, and we believe thyroid function should be measured in all TINU patients. Moreover, histopathological diagnosis of the thyroid glands before treatment is necessary for TINU patients with thyroid dysfunction.

Disease and psychological status in ankylosing spondylitis

OBJECTIVES

Psychological factors may be important in the assessment and management of ankylosing spondylitis (AS). Our primary objective was to describe associations between disease and psychological status in AS, using AS-specific assessment tools and questionnaires. Our secondary objectives were to identify patient subgroups based on such associations and to determine the stability of the measures over time.

METHODS

A total of 110 patients were assessed at 6-monthly intervals up to four times using tools to measure disease [Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI) and the Bath Ankylosing Spondylitis Metrology Index (BASMI)], psychological [Hospital Anxiety and Depression Questionnaire (HADS), Health Locus of Control-Form C Questionnaire (HLC-C)] and generic health [Short form (SF)-36] status.

RESULTS

Eighty-nine participants completed all four assessments. Throughout the study, BASDAI, BASFI and BASMI scores correlated significantly with anxiety, depression, internality and health status, but not with levels of belief in chance or powerful others. Clinically anxious or depressed subgroups had significantly worse BASDAI and BASFI, but not BASMI, scores. BASMI scores were the least closely linked to psychological status. Mean scores for disease, psychological and health status were clinically stable over the 18 months period.

CONCLUSIONS

Disease status scores in AS correlated significantly with anxiety, depression, internality and health status. Interpretation of AS disease scores should take an account of psychological status and the choice of measures used. These findings have important potential applications in AS management and monitoring, including the identification of patients for biological therapies.

Collamer intraocular lens implantation with active uveitis

Two patients with active iritis developed cataracts and had successful cataract surgery with implantation of a Collamer (Staar Surgical, AG) intraocular lens (IOL). Both patients developed severe bilateral uveitis, which in 1 patient was refractory to control. Different IOL materials have been used in iritis patients with varying degrees of success. The IOLs used in these patients remained free of cellular and noncellular deposits, such as those that frequently develop on the anterior surface of IOLs in uveitis patients. Two of the 3 eyes developed a secondary membrane that was successfully treated by a neodymium:YAG laser posterior capsulotomy.

Inflammatory eye, skin, and bowel disease in spondyloarthritis: genetic, phenotypic, and environmental factors

OBJECTIVE

To explore the nature of the interrelationship between inflammatory disease of the spine/joints, skin, eye, and bowel [i.e., ankylosing spondylitis (AS), psoriasis, iritis, inflammatory bowel disease (IBD)].

METHODS

The study used 4 approaches: (1) analysis of the prevalence of secondary disorders within the AS individual (chi-square and matched pair analysis); (2) study of the temporal relationship between the onset of the different conditions; (3) evaluation of the prevalence of disease among first degree relatives; and (4) influence of secondary disorders on outcome of AS.

RESULTS

1. Among 3287 patients with AS, more than expected had either spondylitis associated with multiple co-disorders or pure AS (with no co-diseases); fewer than expected had AS plus a single co-disease (chi-square = 32.2, p < 0.001). In a matched pair analysis, patients with AS and a secondary disorder were more likely to have an additional concomitant disease, e.g., IBD-AS (n = 335) patients had a higher prevalence of iritis [45.4% vs 36.7%; OR 1.4 (1.1-2.0)] or psoriasis [23.9% vs 14.3%; OR 1.9 (1.3-2.8)] than controls. 2. Among our database subjects, the symptomatic onset of the spinal disease precedes or is contemporaneous with gut, skin, and eye involvement (matched pair t test, p < 0.001). 3. Patients with multiple disorders predict the highest prevalence of co-diseases (i.e., psoriasis, IBD, iritis, or AS) within family members, followed by those AS patients with only IBD, psoriasis, or iritis in descending order. 4. Both psoriasis and IBD increase severity in terrms of function and disease activity of AS in the patient. Radiological change is greatest for those AS subjects with iritis.

CONCLUSION

There is a striking overlap within patients and family members of rheumatological, dermatological, and gastroenterological diseases. The susceptibility genes of these co-disorders appear to overlap with each other and with AS: 1. A patient with 2 inflammatory conditions is at an increased risk of developing an additional related inflammatory disorder. 2. Those with enteropathic spondylarthritis would appear to carry the greatest genetic load in terms of first degree relatives developing inflammatory conditions (including psoriasis and iritis that are not seen in the index IBD-AS patient). 3. The secondary disorders do not precede AS (arguing against psoriasis and IBD allowing for an environmental conduit to pathogenic triggers in AS). The susceptibility factors for these inflammatory conditions may be additive or have a synergistic effect on each other. There is evidence for a shared gene hypothesis.

Is Posner Schlossman syndrome benign?

PURPOSE

To determine the clinical course of patients with Posner Schlossman syndrome (PSS).

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Fifty-three eyes of 50 patients.

METHODS

The case notes of all patients with PSS seen at the Uveitis Clinic of Singapore National Eye Centre were reviewed for evidence of glaucoma damage and risk factors.

MAIN OUTCOME MEASURES

Visual field and optic disc changes consistent with glaucoma.

RESULTS

There were 28 men and 22 women, and their mean age at onset was 35 years. Fourteen eyes (26.4%) were diagnosed to have developed glaucoma as a result of repeated attacks of PSS. Patients with 10 years or more of PSS have a 2.8 times higher risk (95% confidence interval 1.19-6.52) of developing glaucoma compared with patients with less than 10 years duration of the disease. Nine eyes (17%) underwent glaucoma filtering surgery with antimetabolites. Their postoperative follow-up ranged from 15 to 50 months (mean, 37 months). Four eyes continued to have episodes of iritis after surgery, and one of these eyes had elevated intraocular pressure during the event.

CONCLUSIONS

A significant number of patients with PSS have glaucoma develop over time, and they need to have their optic disc appearance and visual fields carefully monitored.

[A case of seronegative spondylarthropathy with iritis and retroperitoneal fibrosis]

In 1985 a 41-year old male visited a local hospital because of congestion in the bulbar conjunctiva, which was diagnosed as iritis. In August 1990, right coxalgia and arthralgia of metatarsophalangeal joints appeared, with recurrence of iritis. In October, stiffness in the hands and arthralgia of proximal interphalangeal joints also started. In July 1991, the right coxalgia worsened, resulting in walking difficulty. He was admitted to the Kitasato University Hospital. He presented with bilateral iritis, polyarthritis with limited ranges of motion and sacroilitis. The Schober's test was positive at 3 cm. Serological tests for rheumatoid factor and HLA-B 27 were negative. Abdominal computer tomographic scan revealed low density lesion around the aorta. PSL 10 mg was initiated, and iritis and arthritis remitted. Progression of the periaortic lesion was not observed during the subsequent 5 years. In this case, iritis preceded limited ranges of motion in the vertebrae and sacroilitis. From these findings, seronegative spondylarthropathy with peripheral arthritis was diagnosed. The periaortic lesion seen in this case probably corresponds to chronic periaortitis recently reported as a subset of idiopathic retroperitoneal fibrosis. The two lesions observed in the present case may be interpreted as caused by inflammation of the connective tissue initially either at the vertebrae or around the aorta, which had advanced to involve the other lesion.

Retinal vasculitis revealed by fluorescein angiography in patients with inflammatory bowel disease

Fluorescein angiography was performed to examine retinal vascular abnormalities in five consecutive patients with inflammatory bowel disease seen during the 2 years from April 1995 to March 1997, in a university hospital. All patients showed dye leakage from retinal capillaries in the peripheral fundi of both eyes. Other ocular findings included iritis in both eyes of two patients and clinically significant macular edema in the unilateral eye of one patient. This study indicates that subclinical retinal vasculitis, revealed only by fluorescein angiography, is present in patients with inflammatory bowel disease.

Cataract surgery in a patient with severe chronic iritis and corneal endothelial damage

We report a patient with broad anterior synechias and corneal endothelial damage. The patient had chronic iritis and cataracts secondary to chronic iritis in both eyes. Because the right eye had broad anterior synechias and severe corneal endothelial damage, extracapsular cataract extraction and intraocular lens implantation were performed through the basal iris. Good postoperative visual acuity was obtained. The cornea showed little trauma from the surgery and remained clear 36 months postoperatively.

Serous detachment of the ciliary body in Harada disease

PURPOSE

To evaluate the involvement of the anterior ocular segment in Harada disease.

METHODS

In a prospective study, ultrasound biomicroscopy was performed in 18 consecutive eyes of nine patients with Harada disease in its acute phase before and after onset of systemic corticosteroid therapy. Examination was repeated every 3 days until the resolution of serous retinal detachment.

RESULTS

Serous detachment of the ciliary body was present in 11 (61%) of 18 eyes before treatment. The circumference of the ciliary body was detached in 10 of the 11 eyes. The height of ciliary detachment ranged from 20% to 250% of the scleral thickness. Ciliary detachment was more prominent in eyes with more extensive retinal detachment. There was no relation between the frequency of ciliary detachment and the severity of iritis. On day 3 of treatment, ciliary detachment had disappeared in seven eyes. In the other four eyes, it diminished in height to less than 10% of scleral thickness. Retinal detachment disappeared on days 6 through 17 (mean, day 11) of treatment. Two eyes of one patient showed very shallow anterior chambers. These eyes showed high ciliary detachment at 250% of scleral thickness. In another patient, both eyes developed -5.0 diopters of transient myopia.

CONCLUSION

Ciliary detachment was a frequent finding in the acute stage of Harada disease. Its resolution was more prompt than that of serous retinal detachment after treatment. Ciliary detachment may be related to the development of a shallow anterior chamber.

Idiopathic perniosis and its mimics: a clinical and histological study of 38 cases

Perniosis is a term applied to cold-induced painful or pruritic erythematous or violaceous acral papular or nodular lesions. We examined 39 skin biopsies from 38 patients who presented with acral purpuric lesions, suggesting a diagnosis of perniosis clinically or pathologically. The presence of a systemic or extracutaneous disease was established in 17 patients, including 5 with systemic lupus erythematosus (SLE), 3 with antiphospholipid antibodies, in 1 in whom there was underlying HIV disease, 2 with viral hepatitis, 2 with rheumatoid arthritis (RA), 2 with cryofibrinogenemia, 1 with hypergammaglobulinemia, 1 with iritis, and 1 with Crohn's disease. In the other 21 patients, the clinical presentations prompted further studies in 12, which showed a positive antinuclear antibody (ANA) in 10. A diagnosis of idiopathic perniosis (IP) was rendered in all 21 of these patients including those in whom a positive ANA was discovered, based on the absence of any other serological markers, signs, or symptoms indicative of a specific systemic disease complex; many had Raynaud's phenomenon, small joint arthralgias, atopy, or a family history of either connective tissue disease or Raynaud's disease. The histopathology of IP comprised a superficial and deep angiocentric lymphocytic infiltrate with papillary dermal edema and lymphocytic exocytosis directed to retia and acrosyringia. A few cases showed a mild vacuolopathic or lichenoid interface dermatitis, adventitial dermal mucinosis, lymphocytic eccrine hidradenitis, vascular ectasia, and thrombosis confined to dermal papillae capillaries. The biopsies from patients with iritis, RA, and Crohn's disease showed a granulomatous vasculitis and a granuloma annulare-like tissue reaction. The biopsies from the patients with SLE, cryofibrinogenemia, primary antiphospholipid antibody syndrome, and hypergammaglobulinemia shared a similar histopathology comprising an interface dermatitis, superficial and deep angiocentric and eccrinotropic lymphocytic infiltrates, vascular ectasia, and dermal mucinosis with prominent involvement of the eccrine coil. Many cases did not show features of IP, namely papillary dermal edema, thrombosis of dermal papillary capillaries, and lymphocytic exocytosis into the retia and acrosyringia. There was frequent vascular fibrin deposition involving reticular dermal vessels. The latter two variables were statistically significant discriminators between IP and in perniotic lesions observed in the setting of underlying systemic disease. With respect to the latter, some cases occurred in the setting of cold exposure and were designated by us as "secondary perniosis" (SP), whereas others showed no specific association with cold exposure and were designated as perniotic mimics (PMs) based exclusively on the gross and microscopic morphology of the lesions.

Red eye unresponsive to treatment

Red eyes that fail to respond quickly and completely to topical antibiotic treatment require more extensive evaluation to relieve the symptoms and avert possible sight-threatening complications. The initial differential diagnosis of red eye, which includes iritis, acute glaucoma, keratitis and corneal ulcer, and rarer disorders, must be reexamined. A commonly misdiagnosed cause of red eye is the dry eye syndrome. As a primary or secondary problem, the dry eye syndrome must be treated appropriately to avert sight-threatening complications and to alleviate substantial discomfort. The dry eye syndrome may represent the presenting sign of Sjögren's syndrome or it may be due to medication use, with important systemic and ocular implications.

The red eye

The red eye is a clinical problem encountered on a daily basis in most emergency departments. A careful history and focused ophthalmologic examination will lead to a correct diagnosis and proper therapy. The red eye without photophobia, pain, or visual disturbance is most commonly a result of conjunctivitis. The presence of any of these symptoms indicates a need to investigate for a more serious cause. Infectious causes of conjunctivitis should always be investigated, but allergies and hypersensitivity also should be considered if the history is appropriate. Emergency department treatment of the red eye should only include corticosteroids when the diagnosis is certain and ophthalmologic consultation is obtained.

Antibodies to Klebsiella pneumoniae, Escherichia coli and Proteus mirabilis in the sera of ankylosing spondylitis patients with/without iritis and enthesitis

IgM, IgG and IgA class serum antibodies against the whole Klebsiella pneumoniae, Escherichia coli and Proteus mirabilis bacteria, as well as against K. pneumoniae and E. coli lipopolysaccharides (LPSs) were studied earlier in the sera of 98 patients with ankylosing spondylitis (AS) and in 102 healthy blood donors by enzyme immunoassay. In this study the patients were divided into groups according to the clinical picture, i.e. presence or absence of iritis and enthesitis. The previous major finding of increased IgA class antibody levels against the whole K. pneumoniae bacteria in AS patients when compared to the healthy controls was not specifically associated with any single patient group in the present study. However, the patients with iritis had higher levels of IgA class antibodies to LPS of K. pneumoniae and E. coli when compared to the patients without iritis. In addition, the patients without enthesitis had higher level of IgG class antibodies against whole K. pneumoniae bacteria compared to the patients with enthesitis. The increased IgA class antibody levels against K. pneumoniae and E. coli LPS in AS patients with iritis may reflect an inflammatory process in the gut area. Furthermore, there were certain other differences in the immunological parameters between the AS patients with and without iritis or enthesitis and the possibility that they reflect different mechanisms involved in the disease processes cannot be excluded.

Ulcerative colitis associated with Takayasu's disease

A 25-year-old Japanese woman had both ulcerative colitis and Takayasu's disease and was positive for HLA-A24, BW52, and DR2. She was found to have thickening of the wall of the carotid artery on contrast-enhanced computerized tomography of the neck and chest. Prednisolone, beraprost, and sulfapyridine achieved rapid remission of both diseases.

Acute iritis associated with primary Sjögren's syndrome and high-titer anti-SS-A/Ro and anti-SS-B/La antibodies. Treatment with combination immunosuppressive therapy

OBJECTIVE

We describe a patient with primary Sjögren's syndrome who developed severe, acute, anterior uveitis (iritis), an uncommon complication in this setting.

METHODS

We present the case report of the clinical findings, course, treatment, and resolution of the acute uveitis. Titers of anti-SS-A/Ro and anti-SS-B/La antibodies were assessed (by immunodiffusion), as were fluorescent antinuclear antibodies (on HEp-2 cells) and cryoglobulins.

RESULTS

Initial treatment with topical steroids, oral prednisone (20 mg/day), and oral methotrexate was unsuccessful. The iritis resolved after combined treatment with intravenous cyclophosphamide (1,500 mg/month), high-dose prednisone (60 mg/day), and cyclosporine (5 mg/kg/day).

CONCLUSION

An uncommon, severe complication of primary Sjögren's syndrome is acute uveitis. Combination immunosuppressive therapy may be needed to control this condition.

Causes of blindness and visual handicap in the Central African Republic

The causes of bilateral blindness (best visual acuity less than 3/60) in 1371 people in the Central African Republic seen between 1985 and 1989 who attended eye clinics in 10 out of the 16 prefectures across the country are given. The main causes of bilateral blindness were cataract (51%), glaucoma (12.7%), and onchocerciasis (8.1%). In 710 patients with unilateral blindness the main causes were cataract (38%), glaucoma (10%), iritis (7.5%), and trauma (6.3%). Bilateral blindness in children was rarely seen. The causes of visual impairment (vision between 6/18 and 3/60) in 424 patients were cataract, including aphakia (38%), maculopathy (14%), and onchocerciasis (7%).

Iritis in children with varicella

A prospective study that included 82 consecutive children seen over 2 years by five pediatricians was undertaken to determine the incidence of iritis in children with chickenpox. Twenty-one (25%) children without pox on their lids were found to have iritis. Follow-up of children with objective evidence of iritis revealed no long-term sequelae.

[Clinical analysis of recurrences of herpes simplex keratitis]

The rates of recurrence in 180 cases of herpes simplex keratitis in 1, 2 and 3 years after the primary attack were found to be 20%, 31.5% and 34.5% respectively, irrespective of sex and types of the lesions. The recurrence rate was significantly higher in cases complicated with corneal neovascularization or iritis and slightly higher in children and older patients. The factors involved and possible measures for reducing the recurrence rate were discussed.

Acute iritis. How to preserve good vision

Acute iritis, which is often seen in young adults, may cause red eye, photophobia, and aching discomfort. Many times, the condition can be ameliorated or completely reversed by cautious use of cycloplegic agents and corticosteroids. However, undiagnosed or improperly treated iritis can lead to glaucoma and loss of vision.

Ocular manifestations of syphilis

Since the mid-1970s, the number of new cases of infectious syphilis has begun to increase. Ocular manifestations of secondary and late syphilis occur. The optometric role in the management of infectious syphilis is one of detection, consultation with internists and neurologists for systemic treatment, topical treatment of anterior uveitis, and monitoring for recurrence of disease. This report describes an elderly patient presenting with recurrent, bilateral iritis and optic atrophy as initial clinical manifestations of syphilitic infection.

Characterization of uveitis associated with spondyloarthritis

At a university based referral clinic, 236 consecutive patients with uveitis were evaluated by a rheumatologist; 13% of these patients had spondyloarthritis including 17 patients with Reiter's syndrome and 13 patients with ankylosing spondylitis (AS). The uveitis associated with AS or Reiter's syndrome had distinctive characteristics; it was acute in onset, unilateral, frequently recurrent, and spared the choroid and retina. Two thirds of the patients with spondyloarthritis were not suspected or known to have Reiter's syndrome or AS before referral. Since many diseases of the joints also affect the uveal tract, the recognition of the specific pattern of uveal involvement can greatly facilitate the differential diagnosis.

Neodymium:YAG laser zonulysis for treatment of lens subluxation

Nine eyes with lens subluxation in seven patients (6 patients with Marfan's syndrome, 1 with idiopathic lens subluxation) were treated by neodymium:YAG (Nd:YAG) laser zonulysis. The procedure uses an Nd:YAG laser to lyse the zonules to obtain a clear aphakic visual axis. Pretreatment best-corrected visual acuity was 20/60 or worse in eight eyes (6 eyes less than or equal to 20/200). Movement of the crystalline lens was achieved after zonulysis in all cases (100%), and a clear aphakic visual axis, sufficient to maintain aphakic correction without diplopia or glare, was obtained in eight eyes (88.9%). The procedure was combined with optical iridotomy in three cases (33.3%). Five cases (55.6%) required more than one zonulysis treatment. Visual acuity improved two or more Snellen lines in all but one eye (7 eyes greater than or equal to 20/60). Four cases had complications which included: increased intraocular pressure (IOP), mild iritis, recurrent migration of the lens into the visual axis, and crystalline lens damage. The final two complications necessitated eventual surgical removal of the lens. These results suggest that Nd:YAG laser zonulysis may be of benefit as an alternative treatment modality for selected patients with lens subluxation.

Longitudinal study of serum antibody response to bovine corneal protein (BCP 54) in Behçet's disease

Serum samples from a patient diagnosed as having active Behçet's syndrome with iritis were evaluated by the enzyme-linked immunosorbent assay for antibodies against a purified bovine corneal protein, molecular weight 54,000 daltons (BCP 54). Significantly elevated antibody levels to BCP 54 were found in all serum samples collected over a 2-year period. Anti-BCP 54 antibody levels remained within a very narrow range, at least twofold higher than those of controls. In contrast, no antibody to retinal S antigen was detected. These results indicate the presence of specific anti-BCP 54 autoantibodies in sera from a Behçet's patient and suggest that autoantibodies may play a role in the etiopathogenesis of uveitis.

The acute painful eye

A number of ocular and nonocular conditions may produce an acutely painful eye or orbit. A careful history and physical examination with special attention to the cornea, sclera, fundus, and cranial nerves will usually delineate the etiology of the pain. In particular, certain life- or vision-threatening conditions such as leaking internal carotid aneurysm, cavernous sinus thrombosis, orbital cellulitis, acute narrow-angle glaucoma, and temporal arteritis must be kept in mind.

Intraocular pentastomiasis causing unilateral glaucoma

We present a case of intraocular pentastomiasis in a 12-year-old Israel Arab boy. A single secondary pentastomid larva, most likely of Linguatula serrata, was found in the anterior chamber of the right eye, attached loosely to the pupil's border by a fibrinous mass. Associated conditions were iritis, subluxation of the lens, and secondary glaucoma. This is the first documentation of human pentastomiasis in Israel.

Pseudomelanoma of the iris in herpes simplex keratoiritis

A 37-year-old white man with a long history of recurrent herpetic keratitis presented with a rapidly enlarging pigmented iris lesion. The primary diagnostic concern was that the lesion might be a malignant melanoma. A biopsy of the mass was done and proved it to be a granuloma with granulomatous arteritis and infarction of the iris. In a patient with a history of recurrent ocular inflammation, such a hypersensitivity granuloma should be considered in the differential diagnosis of iris melanoma.

[Secondary forms of glaucoma]

The various forms of secondary glaucoma are discussed on the basis of their different pathogenesis. Elevation of IOP is most frequently associated with inflammation of the uveal tract. Vascular changes in the uvea, in particular rubeosis iridis but also angiomatoses of the retina, can cause secondary glaucoma. Tumors of the uvea and retina often lead to increased intraocular pressure; and lastly, blunt and perforating injuries are frequently followed by glaucoma. Treatment of all these different forms of secondary glaucoma is discussed.

Diseases associated with psoriasis in a general population of 159,200 middle-aged, urban, native Swedes

A defined general population of 159,200 male and female native Swedes born in the period of 1911-1940, from an urban catchment area of the then only general hospital, was followed over a decade (1970-1979) with regard to inpatient hospitalization for all kinds of diagnoses. Psoriasis cases (n = 372) are significantly (p less than 0.001) associated with a spectrum of diseases: male as well as female psoriatics seem to show excess rates of viral infections, alcoholism, hypertension, pneumonia, liver cirrhosis, urticaria, and rheumatoid arthritis. Psoriasis in males only seem to be associated with iritis and ankylosing spondylitis, whereas psoriasis in females only is associated with lung cancer, diabetes, obesity, myocardial infarction and asthma.

Extracapsular lens extraction and posterior chamber intraocular lens insertion combined with trabeculectomy

Trabeculectomy for primary glaucoma was successfully combined with extracapsular lens extraction and insertion of a Pearce tripod posterior chamber lens in seven eyes of five patients. The results were similar to those expected from each component of the operation when performed alone, and all eyes achieved visual acuity of 6/9 or better with control of intraocular pressure below 22 mmHg without supplementary medical treatment. The incidence of mild anterior uveitis (three out of seven eyes) and hyphaema (two out of seven eyes) was greater than usual with this type of cataract extraction but no more than expected after trabeculectomy. Mydriatic drops may be used to treat postoperative iritis without danger to the stability of this pattern of implant. In addition the anterior chamber cannot become shallow, as the rigid legs of this lens extend behind the iris beyond the periphery of the cornea and prevent forward movement of the implant even if there is excessively free drainage of aqueous after the operation.