_________________________________________ SCIENTIFICPOSTERS Retina and Vitreous-Invited via Retina Society Symposium All presenters will attend their posters on Sunday from 1:15 to 2:45 PM, and at various times throughout the Annual Meeting. Individual attendance hours will be indicated on a mock clock at each poster board. Scientific Poster 1 Management of Moderately Severe (Grades C-2 and C-3) PVR Ronald G Michels, MD, Balt'imore, MD One hundred ten consecutive cases of proliferative vitreo· retinopathy (PVR) were operated on at the Wilmer Institute be- tween 1983-1986. The patients ranged in age from 21 to 79 years and had previous retinal reattachment surgery in 90% of cases. An anatomic successful result was obtained in 79% of cases using vitreous surgery with or without revision of the scleral buckle. A median of two further retinal reattachment procedures were per- formed. The median final visual acuity was 20/400. Features of the vitreoretinal anatomy, choice of surgical methods, and other aspects of technique will be presented. Scientific Poster 3 Extracellular Modulating Factors in the Development of Proliferative Vitreoretinopathy Bert M Glaser, MD, Baltimore, MD The events leading to the formation of traction retinal detach- ments in proliferative vitreoretinopathy (PVR) occur in response to alterations in the balance among a number of biochemical fac- tors within the eye. These "extracellular modulating factors (EMFs)" include collagens, fibronectin, glycosaminoglycans, platelet-derived growth factor (PDGF), and transforming growth factor beta (TGF-beta) among others. Furthermore, it is the spe- cific combination of EMFs that determine the nature of the biological response. For example, TGF-beta can either stimulate or inhibit depending upon the presence of PDGF. Further studies to elucidate the exact combination of extracellular modulating fac- tors that either promote or prevent the cellular events leading to PVR are needed. Scientific Poster 4 Treatment of Traumatic Traction Detachment with PVR Combined with Severe Damage of the Anterior Segment R Ziv()jrwvic, MD; W H Beekhuis, MD; G pan Rij, MD; JGC Renardel de Lavalette, MD, Rotterdam, Ti'te Netnerlands The majority of patients having this most severe form of traction detachment sustained it as a result of a traffic accident. Most cases were monocular. Reconstruction of the anterior segment, open-sky and pars plana vitrectomy, retinal surgery, silicone oil injection and corneal graft, were used in 30 patients during the past seven years. Although most cases were operated on long after the trauma (from six months to two years), functional suc- cess has been achieved in a small number of cases. The results suggest that similar surgery immediately after the trauma would produce better results. Pathologic findings, surgical techniques and results will be discussed. Scientific Poster 5 Evidence for an Adhesion Between the Neurosensory Retina and the Retinal Pigment Epithelium 24 Hours Following Laser Photocoagulation James C Fo1lc, MD; Patrick Coonan, MD; Robert Folberg, MD, Iowa City, IA The formation of a rctinal-to-pigment epithelium adhesion is im- portant in the management of retinal detachments. In severe de- tachments complicated by proliferative vitreoretinopathy, photo- coagulation is often used intraoperatively to counteract residual traction and to prevent the passage of fluid, gas or silicone through open retinal breaks. We have histopathologic evidence in primate and human eyes that there is an established adhesion be- tween the retina and the RPE 24 hours the application of argon and krypton photocoagulation. This findmg supports the use of intraoperative endophotocoagulation to enhance the retinal-RPE adhesion during the early postoperative period. Scientific Poster 6 Spontaneous Retinal Detachment and Proliferative Vitreoretinopathy in Labrador Retrievers Norman P Blair, MD, Chicano, IL Animal models ofjroliferative vitreoretinopathy (PVR) may help us understand an treat the human disease. Labrador retrievers develop a familial condition with myopia, cataract, vitreous degen- eration and detachment, and skeletal dysplasia. Retinal breaks, usually giant tears, lead to retinal detachment and PVR. Cellular membranes with collagenous material grow on both surfaces of the retina and formed vitreous. By electron microscopy the prolif- erating cellular elements include retinal pigment epithelial cells, glial cells, macrophages and ciliary epithelial cells. This PVR has the advantage over other models of occurring spontaneously. It may prove useful in studies of the pathogenesis and pharmacolog- ic therapy of PVR. 108
Retina and Vitreous-Invited via Retina Society Symposium All presenters will attend their posters on Sunday from 1:15 to 2:45 PM, and at various times throughout the Annual Meeting. Individual attendance hours will be indicated on a mock clock at each poster board.
Scientific Poster 1 Management of Moderately Severe (Grades C-2 and C-3) PVR Ronald G Michels, MD, Balt'imore, MD
One hundred ten consecutive cases of proliferative vitreo· retinopathy (PVR) were operated on at the Wilmer Institute between 1983-1986. The patients ranged in age from 21 to 79 years and had previous retinal reattachment surgery in 90% of cases. An anatomic successful result was obtained in 79% of cases using vitreous surgery with or without revision of the scleral buckle. A median of two further retinal reattachment procedures were performed. The median final visual acuity was 20/400. Features of the vitreoretinal anatomy, choice of surgical methods, and other aspects of technique will be presented.
Scientific Poster 3
Extracellular Modulating Factors in the Development of Proliferative Vitreoretinopathy Bert M Glaser, MD, Baltimore, MD
The events leading to the formation of traction retinal detachments in proliferative vitreoretinopathy (PVR) occur in response to alterations in the balance among a number of biochemical factors within the eye. These "extracellular modulating factors (EMFs)" include collagens, fibronectin, glycosaminoglycans, platelet-derived growth factor (PDGF), and transforming growth factor beta (TGF-beta) among others. Furthermore, it is the specific combination of EMFs that determine the nature of the biological response. For example, TGF-beta can either stimulate or inhibit depending upon the presence of PDGF. Further studies to elucidate the exact combination of extracellular modulating factors that either promote or prevent the cellular events leading to PVR are needed.
Scientific Poster 4 Treatment of Traumatic Traction Detachment with PVR Combined with Severe Damage of the Anterior Segment R Ziv()jrwvic, MD; W H Beekhuis, MD; G pan Rij, MD; JGC Renardel de Lavalette, MD, Rotterdam, Ti'te Netnerlands The majority of patients having this most severe form of traction detachment sustained it as a result of a traffic accident. Most cases were monocular. Reconstruction of the anterior segment, open-sky and pars plana vitrectomy, retinal surgery, silicone oil injection and corneal graft, were used in 30 patients during the past seven years. Although most cases were operated on long after the trauma (from six months to two years), functional success has been achieved in a small number of cases. The results suggest that similar surgery immediately after the trauma would produce better results. Pathologic findings, surgical techniques and results will be discussed.
Scientific Poster 5
Evidence for an Adhesion Between the Neurosensory Retina and the Retinal Pigment Epithelium 24 Hours Following Laser Photocoagulation James C Fo1lc, MD; Patrick Coonan, MD; Robert Folberg, MD, Iowa City, IA The formation of a rctinal-to-pigment epithelium adhesion is important in the management of retinal detachments. In severe detachments complicated by proliferative vitreoretinopathy, photocoagulation is often used intraoperatively to counteract residual traction and to prevent the passage of fluid, gas or silicone through open retinal breaks. We have histopathologic evidence in primate and human eyes that there is an established adhesion between the retina and the RPE 24 hours followin~ the application of argon and krypton photocoagulation. This findmg supports the use of intraoperative endophotocoagulation to enhance the retinal-RPE adhesion during the early postoperative period.
Scientific Poster 6 Spontaneous Retinal Detachment and Proliferative Vitreoretinopathy in Labrador Retrievers Norman P Blair, MD, Chicano, IL Animal models ofjroliferative vitreoretinopathy (PVR) may help us understand an treat the human disease. Labrador retrievers develop a familial condition with myopia, cataract, vitreous degeneration and detachment, and skeletal dysplasia. Retinal breaks, usually giant tears, lead to retinal detachment and PVR. Cellular membranes with collagenous material grow on both surfaces of the retina and formed vitreous. By electron microscopy the proliferating cellular elements include retinal pigment epithelial cells, glial cells, macrophages and ciliary epithelial cells. This PVR has the advantage over other models of occurring spontaneously. It may prove useful in studies of the pathogenesis and pharmacologic therapy of PVR.
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Scientific Poster 7 High-Density Fluorosilicone Oil in Vitreous Surgery HU1n Chung, MD; Felipe I Tolentino, MD; Mi{;uel F Refoio, DSc; Jaime Acosta, MD; H MacKenzie Freeman, MD, Boston, MA
Fluorosilicone oil, a high-density oil, is tolerated in the vitreous cavity. We studied its intraoperative usefulness in surgery to reattach retina that detached after a spontaneous giant break or large retinotomies for refractory anterior loop retraction. We created retinal detachment in rabbit by performing giant retinotomies, and then compared the effect of f1uorosilicone oil and sodium hyaluronate. Fluorosilicone oil flattened the retina in all (16) eyes, but sodium hyaluronate flattened it in only half the eyes. Fluorosilicone oil could be removed completely after surgery, suggesting that it can be used effectively and safely.
Scientific Poster 8
Silicone Oil and Complicated Retinal Detachment in Acute Retinal Necrosis Syndrome DavidH Fischer, MD; RojivAnand, MD, Philadelphia, PA
Retinal detachment is the most feared complication of acute retinal necrosis syndrome (ARNS). Results of conventional surgery are disappointing, related to multiple posterior breaks and proliferative vitreoretinopathy (PVR). Phthisis bulbi is common in failed cases. Four patients with failed vitreoretinal surgery and PVR (C3-D3), underwent silicone oil injection. Anatomic and visual results showed improvement in all cases. Two patients with primary scleral buckling, vitrectomy and silicone oil injection had successful re-attachments and improved vision. Silicone oil injection has improved visual and anatomic results of complicated rGtinal detachments in ARNS.
Scientific Poster 9 Ablation of Retinal Pigment Epithelium by Laser in Giant Retinal Tears Tatsuo Hirose, MD, Boston, MA
Retinal pigment epithelium (RPE) plays a vital role in pathogeneiiis of PVR. Mechanical ablation of RPE exposed to vitreous during surgery helps in permanent retinal reattachment in giant tears (AAO 1986). The author reportii laser ablation of RPE exposed to the vitreous after successful reattachment of retina by conventional operation in 30 eyes with giant tears. The laser was not applied to the retinal flap that covered RPE. The treated area eventually developed extensive chorioretinal scar. The retina has stayed reattached in all but two, in which the retina redetached. Follow-up period is from 1 to 10 years. Early RPE ablation by laser appears helpful in cases where a large area of bare RPE is exposed to the vitreous in danger of developing PVR.
Scientific Poster 10 Tolerance of Perfiuorocarbon, Fluorosilicone, and Silicone Liquids in the Vitreous Cavity Mark E Hammer, MD, Tampa, FL; Deborah F Rinder, Birmingham, AL; E Lynn Hicks, Columbia, SC; Chang-Hsu Yang, MD, ColumlYia, SC; Carlton A Hornung, PhD, Columbia, SC; W Sanderson Grizzard, MD, Tampa, FL; Sandra Myers, Tampa,FL We compared the clinical and histopathological tolerance of liquid perfluorocarbons, f1uorosilicone oils, and silicone oils (polydimethylsiloxanes) in the vitreous cavity in a rabbit moder Silicone was well tolerated. Fluorosilicone oils developed very slight emulsification and mild foam cell response. Perfluorocarbon liquids exacerbated cataract formation and developed total emulsification and a severe foam cell response. A highly purified 5000 centistoke silicone oil was found to be particularly well tolerated and is being used in a clinical trial for the treatment of retinal detachment due to a proliferative vitreoretinopathy.
Scientific Poster 11 Silicone Oil for Management of Proliferative Vitreoretinopathy-A Comparison of Six-Month and Two-Year Results William L Hutton, MD; Dwain G Fuller, MD; William B Snytkr, MD; Albert Vaiser, MD; Rand Spencer, MD; Bradley F Jost, MD, Dallas, TX We followed 29 eyes with C3-D3 proliferative vitreoretinopathy treated with silicone oil and compared the status of the eye and visual results at the six month and two year follow-up. Seventy-two percent were reattached and attained a vision of 5/200 or better at six months. Forty-eight percent had 51200 or better visiOn at two years. Attrition in visual acuities was related to recurrent retinal detachment or corneal decompensation. These complications occurred more commonly in eyes which retained silicone. This study reinforces the concept that significant long-term complications often develop in eyes initially treated successfully with silicone oil and that timely removal of the silicone oil may mitigate these complications.
Scientific Poster 12 Silicone Implant with Vitrectomy in Proliferative Vitreoretinopathy Hidenao Ideta, MD; Michiko Ishikawa, MD; Shunsuke Inoue, MD; Yukio Yoshino, MD, Kumamoto City, Japan In treating proliferative vitreoretinopathy (PVR), we found that in addition to vitrectomy, a 360 degree silicone implant was more effective than an explant in counteracting the anterior circumferential vitreous contraction. In the last 5 years we treated 89 eyes of severe PVR (69 PVR-D and 20 PVR-C) with both the 360 degree silicone implant and vitrectomy. Among the 89 eyes, 71 obtained reattachment of the retina after the first surgery. 18 eyes required second surgery, and 4 required third surgery. The overall success rate was 83.2%, suggesting the usefulness of the implant.
Scientific Poster 13 Liposome-Encapsulated 5-Fluorouracil in the Treatment of Proliferative Vitreoretinopathy Brian C JoonderJh, MD; Gholam A Peyman, MD; Peggy H Fishman, MD; 13Mram Khoobehi, MD; Beatrice Y Yue, PhD, ChicO!Jo, IL Liposomes are small bilayer vesicles composed of phospholipids that can entrap drugs for slow release. We investigated the use of liposome-encapsulated 5-fluorouracil(5-FU), an antiproliferative agent, in the treatment of proliferative vitreoretinopathy (PVR) in an animal model. Doses of up to 1.6 mg administered intravitreally in rabbits demonstrated no retinal toxicity. Liposome-encapsulated 5-FU was also found to have an increased intravitreal half-life compared to the same dose of free 5-FU. Finally, in an experimeqtal animal model of PVE, we found a trend toward a reduced rate of tractional retinal detachments using liposome-encapsulated 5-FU versus that with free 5-U and controls. Thus, intravitreal liposome-encapsulated 5-FU may be of value in treating PVR in humans.
Scientific Poster 14 Long-Term Results of Perfluorocarbon Gases and Vitrectomy in Proliferative Vitreoretinopathy Robert Lopez, MD, New York, NY; Alan Wauner, MD, New York, NY; Stanley Chang, MD, New York, NY; Harvey A LincofJ, MD, New York, NY; Robert A Braunstein, MD, Morristown, NJ; M H Heinemann, MD, New York, NY; D Jackson Colmnan, MD, New York,NY Ninety patients with retinal detachment and proliferative vitreoretinopathy treated with vitrectomy and the perfluorocarbon gases were analyzed for results and complications. Retina Society classification grades C2 through D3 were treated with an overall anatomic reattachment in 72% at six months postoperatively. Over 86% of the cases were Grade D. The frequency of reoperation was 34%, and supplemental gas injection 23%. Sixty-seven percent of phakic patients underwent lensectomy. Long-term stability of visual function was observed in patients with anatomic reattachment.
Scientific Poster 15 Postvitrectomy Redetachment in Proliferative Vitreoretinopathy Due to Pars Plana Hole at Inferotemporal Sclerotomy Site Ian L McAllister, MD; SanjordM Meyers, MD, Cleveland, OH To identify factors that may improve the treatment of proliferative vitreoretinopathy (PVR), we reviewed 20 consecutive nondiabetic PVR cases undergoing vitrectomy from January 1984 through June 1986. Of the eight failed cases, two cases initially redetached inferiorly as the gas bubble decreased postoperatively. In both cases it appeared that the pars rhlna hole at the inferotemporal sclerotomy site and the residua inferior PVR led to the redetachment. We will present schematic diagrams to illustrate these cases. Since PVR is frequently more severe inferiorly (peripheral PVR, anterior loop traction), we consider making all the sclerotomy sites in the superior 180 degrees in PVR cases undergoing vitrectomy.
Scientific Poster 16 Enzyme-Assisted Vitrectomy Norman D Radtke, MD; K N Liu, MD; Michael T Tseng, PhD, Louisville, KY
Purified bacterial collagenase (Nucleolysin, Advance Bidfactures) has been used experimentally in the surgical management of proliferative vitreoretinopathy. The optimal concentration and duration of exposure during its use. have yet to be fully evaluated. Data obtained from in vitro study demonstrates that collagenase solubilizes human epiretinal membranes in a dose- and time-dependent fashion and does not alter the ultrastructural integrity of the cellular components. This investigation points out further need to refine the range of clinical efficacy of purified bacterial collagenase in proliferative vitreoretinopathy, proliferative diabetic retinopathy, and retinopathy of prematurity.
Scientific Poster 17 Retinol and Cholesterol in Intraocular Silicone Oil Miguel F Re/ojo, DSc; Hum Chung, MD; Felipe I Tolentino, MD; H MacKenzie Freeman, MD, Boston, MA
We tested lipid extraction by intravitreous silicone an<~ fluorosilicone oils used for repairing some retinal detachments. In oil (1000 cs) removed from rabbit eyes 1-10 weeks postoperatively, retinol found was 1.0-4.5 ~g/ml in silicone oil and 0.75-9.4 ~g/ml in fluorosilicone oil. Silicone and fluorosilicone oils (1000 cs) removed from two patients (102 & 7.5 weeks postoperatively) gave reaction for retinol (2 .9 & 5.4 ~g/ml.) Silicone oil (1000 and 12,500 cs) from two patients (52 and 96 weeks postoperatively) gave reaction for cholesterol (239 and 99 ~g/ml). Silicone oils may interfere with retinal physiology by extraction of its lipids.
Scientific Poster 18 C3F8 Gas, Panretinal Photocoagulation, and Vitrectomy in the Treatment of Severe Proliferative Vitreoretinopathy Jason S Slakter, MD, Great Neck, NY; Yale L Fisher, MD, New York, NY; Jeffrey L Shakin, MD, New York, NY; John A Sorenson, MD, New York, NY; DonaldM Shafer, MD, New York, NY
Seventy-five consecutive patients with total retina] detachments and severe PVR underwent pars plana vitrectdmy, lenseetomy, pan retinal lhotocoagulation, perfluorocarbon (C3F8)lfIuid ex~ change, an scleral buckling. 78% of the patients had sustained posterior retinal reattachment with a minimum of 12 months follow-up. In 26% of these cases, partial, peripheral retinal detachments associated with periretinal membrane growth developed postoperatively. These detachments remained entirely within the boundaries of the previously placed laser burns, and did not progress to involve the posterior retina. Visual acuity of 20/400 or better was obtained by 58% of the patients. This technique should provide a more consistent and successful result in the treatment of severe PVR.
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Scientific Poster 19 Low Dose Radiation Inhibits Retinal Pigment Epithelial Cell Proliferation Paul Sternberg Jr, MD; Trams A Meredith, MD; Janet Hart7nann, BS; Ian Crocker, MD, Atlanta, GA Recently, we found that low dose radiation therapy reduces the incidence of experimental traction retinal detachment (TRD) in a rabbit model. To study the mechanism of low dose radiation's effect, we placed 50,00~ cultured human retinal pigment epithelial (RPE) cells in 9.5 cm multiwell dishes, allowed the cells to attach, and radiated the cells with 0, 100, 200 and 500 rads. Cells were trypsinized from the wells at days 1,4,7, and 14 and counted. Counts were 86,700 ± 1200 for the control dishes and 40,800 ± 1500 for dishes receiving 500 rads at day 1; they were 328,000 ± 3600 for control and 111,000 ± 2600 for 500 rads at day
· 7. A dose dependent response was seen. Low dose radiation may reduce the incidence of TRD by inhibiting RPE cell proliferation.
Scientific Poster 20 5-Fluorouracil Buckles and RPE Proliferation in Situ Lory C Snady-!.fcCoy, MD, Boston, MA; Salim A Bis~ara, MD, Boston, MA; Sileldon M Buzney, MD, Boston, MA; Mtcilael W Gaynon, MD, Stanford, CA Vinyl acetate impregnated with 5FU (5FUB) for use as a scleral buckle has been shown to suppre!\s growth of injected fibroblasts in the vitreous of animals. To further test this model, experimental holes were created in 12 rabbits after which a 5FUB containing 20% 5FU by weight was positioned on diathermy-treated sclera for at least 1 month. Contralateral control eyes received no 5FU. 5FUB prevented RPE proliferation and membrane formation in only 3 of 12 eyes as demonstrated by fundus photography and scanning electron microscopy. 50% of eyes showed significant toxicity to 5FU at this dose. 5FU proved ineffective in preventing RPE proliferation in situ, perhaps the earliest stage of proliferative vitreoretinopathy.
Scientific Poster 21 Proliferative Vitreoretinopathy: An Analysis of Factors in Retinal Detachmellts Using the PVR Classification R Sloan Wilson, MD, Little Rock, AR; David V. Poer, MD, Indianapolis, IN; James H. Landers, MD, Little Rock, AR One hundred twenty-one consecutive cases of rhegmatogenous retinal detachment were studied using the Proliferative Vitreoretinopathy (PVR) classification. Twelve preoperative, surgical, and postoperative variables which might have predictive value for retinal reattachment and visual prognosis were analyzed by computer. The results are displayed on eight graphs.
Scientific Poster 22 Cyanoacrylate Retinopexy in the Management of Complicated Retinal Detachment Brooks W McCuen II, MD, Durham, NC; Tetsuo HUla, MD, Tokyo, Japan; Sherif M Shllta, MD, Cairo, Egypt
Failures in vitreous surgery for complex vitreoretinal disorders are frequently due to an inability to keep preexisting or iatrogenic retinal breaks permanently closed. We have used transvitreal delivel~ed cyanoacrylate tissue adhesive to seal retinal breaks in 25 patients undel·going vitreous surgery for complicated retinal detachment. With a minimum follow-up period of 6 moriths, all but one retinal hole has remained closed and complete retinal reattachment posterior to the encircling buckle was achieved in 18 of 25 eyes (72%). In 10 of the 25 eyes (40%), the final visual acuity was 5/200 or better.
Scientific Poster 23 Pharmacologic Therapy of Proliferative Vitreoretinopathy Mark S Blumenkranz, MD, Royal Oak, MI; Michael Hartzer, PhD, Rochester, MI
Contractile membl·anes on both retinal surfaces and within the vitreous gel are the fundamental lesions in proliferative vitreoretinopathy (PVR). Recent advances in the understanding and pharmacologic treatment of PVR have centered around both inhibition of cellular proliferation and contraction. Antimetaholites, including the f1uoropyrimidines, taxol, daunomycin and colchicine inhibit both proliferation and contraction by interfering with intracellular DN A and RNA reprocessing, althou~h with concomitant potential toxicity. Newer classes of agents mcluding heparin and tetrapeptide inhibi~ contraction by interfering with cell-substrate, and cell-cell adheSIOn.
Scientific Poster 24 Silicone Oil Combined Vitrectomy in 120 PVR Cases Followed up to 5 Years Jay L Federman, MD; Hermann b Schubert, MD; L()V K Sarin, PhilCJklphia, PA We report 120 PVR cases, C-g or worse, with silicone oil used dUring retina-vitreous SU1·gery. All cases had between 1 and 4 previous vitrectomies. Anatomic reattachment of the macula was seen in greater than 80% of the cases. Of these, a peripheral detachment was found in approximately gO% of the cases. Greater than 50% of the cases showed an improvement in visual acuity, the best of which was 20/50. Complications included emulsification, silicone oil keratopathy, cataract formation, glaucoma, inflammation, pain and continued cellular proliferation. The results and complications of the entire group of patients is presented.
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Scientific Poster 25
Stimulation of RP~ Proliferation and Migration by Macrophages .. . SneldlJn M BuzTteJj, MD, Boston, MA; Saltm A Btsilara, MD, Jerusalem, Israel; Rollin L Thayer, Boston, MA Macrophages have .been n?ted ip clini~1 an~ experimf!ntal. retinal tears associated wlth prollferatmg retmal pIgment epIthelIal cells (RPE) which may contribute to proliferative vitreoretinopathy (PVR). In an effort to assess the interactive effect of macroph~ges upon RPE, peritoneal macrophages were harves.t~d from mICe and maintained in tissue culture. M~rophage-conditlOn~ culture medium (MCCM) was assayed agamst cultured bovme RPE. MCCM stimulated the proliferation of RPE 2.5 times more. than cells grown in basal medium with serum (p<O.OOl). RPE mIgrated faster in MCCM than in control medium (p< .01), "healing" a mechanically induced ~ef;ct in ~ cultured mon?layer .. Because macrQphages appear to stimulate RPE, modula~mg theIr s;creted factors or eliminating their presence could be Important m the treatment of PVR.
Scientific Poster 26 BCNU in Silicone Oil Prevents Proliferation of RPE Cells Felipe I Tolentino, MD; Hum Chung, MD; Miguel F. Rejaio, MD; Norio Ueno, PhD, Boston, MA
Silicone oil has no antiproliferative properties, but dissolves and can serve as a vehicle in the vitreous cavity for BCNU (1-3 bis [2-chlorethyl]-1 ~itrosour~e), ~ poten~ antiprolifera~ive .~ug. ~e performed in vItro and m VIVO studIes of BCNU m SIlIcone 011.
The BCNU dosages that inhibited 50% of growth (ID50) of cultured bovine RPE cells were 13 ~ glml of water and 36 ~ glml of silicone oil. Experimental observations suggest that BCNU dissolved in silicone oil may be useful in preventing reproliferation of vitreous membranes in proliferative vitreoretinopathy.
Retina and Vitreous All presenters will attend their posters on Sunday from to 1:15 to 2:45 PM, and at various times throughout the Annual Meeting. Individual attendance hours will be indicated on a mock clock at each poster board.
Scientific Poster 27 A Comparison of the Risk Factors Associated with Hemi (HRVO), Central (CRVO), and Branch (BRVO) Retinal Occlusion Aaron P Appiah, MD; Clement L Tr(fff/,pe, MD, Boston, MA
Hemiretinal vein occlusion (HRVO) has been reported as an anatomical variant of CRVO and different from BRVO, suggesting that risk factors for HRVO and CRVO would be similar. To test this hypothesis, a retrospective study of 117 CRVO, 214 BRVO and 28 HRVO patients with the CRVO and BRVO groups. Elevated erythrocyte sedimentation rate (P = .018) and chronic obstructive pulmonary disease (p= .04) were more prevalent in the HRVO than the BRVO group, whereas hypertension and hyperopia were clinically more prevalent in the BRVO group. There were no significantly different risk factors between the CRVO and HRVO groups, thus supporting the test hypothesis.
Scientific Poster 28 Effect of Rhegmatogenous Retinal Detachment on Vitreous Fluorophotometry William E J a.ckson, MD; Robert K Snyder, MD; Sieglinde Freed, Denver, CO Forty eyes with rhegmatogenous retinal detachment (RRD) and ten normal eyes were studied to investigate the influence of RRD on vitreous fluorophotometry (VFL) readings. Four groups were studied: 1. normals; 2. shallow RRD; 3. moderately elevated RRD; 4. highly bullous RRD. Directional scans were done and sampling volumes showed that, at 3 mm from the retina, VFL concentrations were higher for group 3 than for groups 1 and 2. At mid-vitreous, significantly higher VFL values were found for groups 2 and 3 than for group 1. Very high and uniformly distributed VFL values were found for eyes in group 4. Findings show that even very limited changes in retinal position can affect VFL measurements. Results provide further information for the assessment of the blood/retinal barrier.
Scientific Poster 29 Visual Manifestations of the Lupus Anticoagulant John W Crofts, MD, Detroit, MI; G Robert Lesser, MD, Detroit, MI; Steven R Levine, MD, Detroit, MI; John Floberg, MD, Ann Arbor, MI; K M A Welch, MD, Detroit, MI
The lupus anticoagulant (LA) is an acquired serum immunoglobulin whIch alters pTatelet aggregation and coagulation ~ameters resulting in prolonged Partial Thromboplastin Time (PTI') and serologic changes. Most commonly, this condition is found with systemic lupus erythematosus (SLE) but has also been associated with other collagen vascular diseases and in otherwise healthy individuals. Despite the elevated PTT suggesting impaired coagulation, the LA causes thrombotic events clinically. We present five patients with LA having branch retinal artery occlusion, vertebrabasilar insufficiency, transient visual loss, or intermittent diplopia. Screening tests for the LA and its relationship to retinopathy in SLE are discussed.
Scientific Poster 30 Pathology of Proliferative Vitreoretinopathy Andrew WEller, MD; Thomas R Friberg, MD; Bruce Johnson, MD, Pittsburgh, PA
Proliferative vitreoretinopathy (PVR) is the most common cause of failure in retinal detachment surgery. We examined 10 surgical enucleation specimens with PVR to better define the morphological characteristics of the process. Other investigators have studied the fine structure of PVR membranes using vitrectomy specimens obtained at the time of retinal detachment repair. Our whole globe material demonstrates the relationship of the membranes to the retina and vitreous base, and the cellular characteristics of the proliferative membranes. Of clinical interest, we describe the histopathology of anterior loop traction and subretinal proliferation. Immunohistochemical studies aid in further characterization of the cellular components of PVR.
Scientific Poster 31 Clinical Use of Digitized Fundus and Fluorescein Images ill Laser Photocoagulation of the Macula Thomas R friberf!: M.D;.Andrew.W Elle~, MD; Paul G RehkClPJ. MD; JosejJn, W H arnukt, MD, P~ttsburgn, PA
We have used an image acquisition system (PAR IS2000) to acquire digital color and fluorescein images in over 50 patients with macular disease. Images are written directly onto optical laser discs and then reassembled for display on a high resolution video monitor, completely avoiding the need to expose and process photographic film. Using registration and simultaneous outline routines, fluorescein images of neovascular membranes can be enhanced and the extent of the membrane can be outlined electronically onto color images. We have found digital imagery particularly useful in determining whether laser photocoagulation completely covers the area initially targeted for treatment, and to follow macular pathology sequentially.
Scientific Poster 32 Secondary Epiretinal Membrane Release and Posterior Vitreous Detachment Craig M Greven, MD; M Madison Slusher, MD; Richard G Weaver, MD, Winston-Salem, NC The spontaneous release of both primary and secondary epiretinal macular membranes is a rare and infrequently documented clinical phenomenon whose mechanism is poorly understood. We examined four patients with secondary macular membranes who, while being followed, demonstrated spontaneous release of the membrane. Each patient subsequently exhibited decreased retinal striae and improved visual function. In all four cases we observed that a posterior vitreous separation occurred concomitantly with release of the membrane. In each case the membrane remained adherent to the posterior vitreous face. We postulate that posterior vitreous separation is the mechanism by which secondary epiretinal membranes release form the macula.
Scientific Poster 33 Schiotz Tonometry Underestimates Intraocular Pressure after Pars Plana Vitrectomy with and without Fluid-gas Exchange Lucian V Del Priore, MD, PhD; Ronald G Michels, MD; MirtaA Nunez, COT; Bert M Glaser, MD; Serge de Bustros, MD, Baltimore, MD Schiotz tonometry is a portable and convenient method to measure lOP after pars plana vitrectomy (PPV). The accuracy of Schiotz (TS), Goldmann applanation (TA) and pneumatic (Tp) tonometry after PPV was determined by measuring TS, T A and Tp before and after surgery in 45 patients. There was no Cfifference between Tp and T A after PPV with or without fluid-gas exchange. TS is lower than T A and Tp' by 2 + 2 mmHg before surgery, by 5±5 mmHg one (fay after PPV, and by 8p3 mmHg one day after PPV with fluid-gas exchange. TS agreed with T A and Tp within one month after surgery. Schiotz tonometry shoufd not be used to measure lOP immediately after PPV.
Scientific Poster 34 Macular Retinal Capillary Hemodynamics in Diabetes Mellitus Stephen H Sinclair, MD, Philadelphia, P A
Using the blue field entoptic simulation technique we have evaluated macular retinal capillary blood speed in 40 insulin-dependent, non-hypertensive diabetics, and 24 age-matched normal controls. Retinal lesions were graded by masked evaluation of fluorescein angiograms and fundus photographs. Mean capillary retinal blood speed was elevated 25% in the diabetics (p<.OI) compared with the normals, and was elevated 31% (p= .02) in 16 diabetics with no microangiopathy compared with 16 age- and sex- matched normals. The leukocyte density, however, was not increased in the diabetics along with the speed, but was slightly reduced (p= n.s.) suggesting microvascular physiologic obstruction and shunting, even when no microangiopathic lesions were observed.
Scientific Poster 35 Evolution of Angioid Streaks AhmadM Mansour, MD, ChicO!Jo, IL
Angioid streaks of the fundus are not apparent at birth. In order to study their evolution, we examined the fundus pictures of 137 subjects with angioid streaks. The earliest form of angioid streaks became apparent at age 8 with the finding of narrow short radial discontinuous hypopigmented streaks. Thereafter angioid streaks enlarged in length and width. The end stage was a disciform scarring, helicoid peripapillary atrophy, or diffuse choroidal sclerosis with obscuration of the angioid streaks. We conclude that angioid streaks represent a dynamic manifestation of an underlying retinochoroidal degenerative process.
Scientific Poster 36 Contact Transscleral Photocoagulation with Nd:YAG Laser Pulsed and CW Rosario Brancato; Ugo Mench'ini, MD; Giuseppe Trabucchi, MD; Giovanni Leoni, MD, Milano, Italy
Contact transscleral laser treatment is a new approach to chorioretinal photocoagulation. A specially adapted probe at the end of a fiber optic system is used to deliver laser, bringing it into contact with the sclera corresponding to the chorioretinal area to be photocoagulated. Nd:YAG laser emission (1064 nm) is well transmitted through the sclera while it is principally absorbed by the choroidal pigment and the retinal pigment epithelium. We studied the ophthalmoscopic and histological effects of transscleral chorioretinal photocoagulation on 6 rabbit eyes with continuous (cw) and pulsed Nd:YAG laser. We also studied the histological and ultrastructural changes produced on the chorioretina of 2 human eyes enucleated because of a choroidal melanoma which had previously been treated with contact transscleral cw Nd:YAG laser.
Scientific Poster 37 The Bent Endoillumination Probe Fadi Z El Baha, MD; Hichard G Chenoweth, MD; Jeffrey K Luttrull, MD; Richard F Dreyer, MD, Portland, OR
We devised a bent-tipped endoillumination probe that offers many advantages over the commonly used straight probe. The new instrument is similar to the straight fiberoptic probe except for the final 2 mm of its tip that is bent at a 90° angle. Its applications include: a) direct visualization of the anteroperipheral vitreous; b) avoidance of lens damage during excision of anteroperipheral vitreous on opposite side of the eye; c) visualization of the posterior lens capsule by tangential illumination during excision of retrolental central vitreous opacities; d) visualization by tangential illumination of shallowly detached posterior vitreous or elevated epiretinal membranes; e) easy visualization of iatrogenically indented retina for exploration or endolaser photocoagulation.
Scientific Poster 38 Effects of Varying Vitreous Infusate Temperature on Intraocular Hemostasis and Retinal Metabolism RichardF Dreyer, MD; FadiZElBaba, MD; Alvin Eisner, PhD, Portland, OR The present study- investigated whether changing the temperature of vitreous mfusion solutions affected intraocular bleeding and whether retinal function might be reduced by such changes. Intraocular bleeding time was measured during infusion of room temperature, cooled, and warmed infusion solutions in 42 rabbit eyes. Adult cynomolgus monkeys were studied by electroretinography after infusion of room temperature and cooled infusion solutions. Intraocular bleeding times were increased when cooled infusion solutions were used (p<0.05). Intraocular hemostasis was not improved when infusion solutions were warmed (p <0.05). Intraocular cooling extinguished the electroretinographic B-wave; recovery did occur. Recovery time was dependent on duration and degree of cooling.
Scientific Poster 39 Sequential Retinal Tears Following Intraocular Gas Injection Richard F Dreyer, MD; Fadi Z El Baba, MD ; Jeffrey K Luttrull, MD, Portland, OR Two pseudophakic patients underwent uneventful scleral buckling for rhegmatogenous retinal detachment involving the superior retina. On the first postoperative day, 100% sulfurhexafluoride gas was injected intravitreally to flatten stiff folds which elevated the retinal tears, allowing subretinal fluid to persist posterior to the buckle. Twenty-four hours after gas injection, both retinas were flat superiorly but detached inferiorly with new vitreous base flap tears in previously attached retina. These cases illustrate a complication of intraocular gas injection. Although sequential tears occur in 7-10% of eyes after scleral buckling, they are usually near pre-existing retinal breaks and occur 3 days to 22 months after surgery. These patients experienced breaks 180 0
from the original tears, 48 hours after sur~ery. The tears were probably created by upward traction on the mferior vitreous base by the superior gas bubble. Postoperative gas injection may cause sequential vitreous base tears. A prolonged waiting period for spontaneous retinal settling is probably safer than early gas injection.
Scientific Poster 40 Calcium Oxalate Retinopathy Associated With Methoxyflurane Abuse Allen S Roth, MD, Shaker Heights, OH; MichaelA Novak, MD, Cleveland, OH; Mark R Levine, MD, Cleveland, OH A 34-year-old woman developed methoxyflurane retinopathy after two years of inhalational abuse of methoxyflurane. X-rays of the hands revealed periosteal new bone formation in the phalanges. After she developed renal failure, a renal biopsy demonstrated calcium oxalate crystals in the renal tubules. Crystalline deposits Were noted, on clinical examination, along the retinal arteriolar walls and in the deep retina or retinal pigment epithelium. This is the first reported case of methoxyflurane abuse in which periosteal new bone formation, nephropathy, and retinopathy all developed.
Scientific Poster 42 Toxic Maculopathy Secondary to Ethylene Dibromide Exposure SamuelN Garrett, MD; William Waterhouse, MD, San Francisco, CA
Ethylene dibromide (EDB) is restricted from residential usage as a fumigant because of severe multi-system toxicity. Previous ophthalmic findings have been limited to external irritation secondary to its vesicant activity. A 29-year-old man and his family received accidental toxic exposure to EDB in 1982. The patient had normal previous ophthalmic examination and negative family history. He developed an immediate decrease in central vision which progressed to 20/400 central acuity in both eyes with the fundoscopic appearance of "bull's eye" maculopathy and macular RPE window defects on fluorescein angiography. Electrophysiologic testing was normal. His wife was also found to have focal macular RPE defects and granular appearance in both eyes.
Scientific Poster 43 Vitreous Cells and Retinal Tears in Asymptomatic Eyes Edwin E Boldrey, MD, Palo Alto, CA
The asymptomatic fellow eyes of 589 consecutive patients with photopsias and/or floaters were ;;tudied prospectively. In each case, 25 factors possible associated with retinal tears were recorded prior to peripheral retinal exam, and the presence of those factors was correlated with the 15 eyes (2.5% of cases) which were found to have retinal tears. Of all factors studied, only multiple vitreous cells showed a useful correlation with retinal tears, 31.6% (6/19) of eyes with 2+ or more vitreous cells having a retinal tear vs. 1.60/0 (9/570) of those with 1 + or less cells (p< .0001). Asymptomatic eyes with unexplained vitreous cells deserve careful peripheral retinal examination.
Scientific Poster 44 A Modified Contact Lens for Far Peripheral Retinal Examination in Pseudophakes Edwin E Boldrey, MD, Palo Alto, CA
Clarity of visualization of the far peripheral retina as seen with a standard 8 mirror contact lens can be compromised severely in pseudophakic patients by marginal astigmatism. This astigmatism is induced by the sharp angle of view through the lens implant. Most of this blur can be eliminated by attaching a minus cylinder astigmatic lens of appropriate power and orientation to the front surface of a modified 3 mirror contact lens, with this astigmatic lens overlying the contact lens' far peripheral mirror. This new contact lens can be used for both examination and laser treatment.
Scientific Poster 45 Anatomic Relationship of the Ora Serrata to the Spiral of Tilleaux Marylin H Wnite, MD, San Antonio, TX; H Michael Lambert, MD, LacklandAFB, TX When placing a prophylactic scleral buckle, if media is opaque, conventional teaching states the spiral of Tilleaux marks the location of the ora serrata_ On literature review, no source for this was found; our study explores this anatomic relationship_ In twenty cadaver eyes, narrow--gauge needles were placed penetrating the center of each rectus muscle insertion, and aistance to the ora was measured. Insertions ranged from 1.75 mm posterior to 2.25 mm anterior to the ora, with 68% within 1 mm of it. In ten eyes, distance from the edge of insertion was also measured. Results indicate the centers of rectus insertions, especially lateral rectus, are approximately over ora, with edges of insertion more posterior and variable.
Scientific Poster 46 Ultrasonography of Stage IV and V Retinopathy of Prematurity Steven R Shields, MD; Eugene de Juan, MD; Robert Machemer, MD, Durham, NC In the surgical treatment of cicatricial retinopathy of prematurity (ROP), the preoperative retinal configuration and the postoperative anatomic success correlate strongly. We reviewed ultrasonograms of 48 eyes in 26 patients with grade 4 and 5 ROP and compared these with intraoperative findings. Ultrasonography reliably demonstrates the detachment's configuration, the location and extent of peripheral troughs, the presence of subretinal blood and fibrovascular proliferations. This is possible even in uncooperative infants. We conclude that ultrasound in cicatricial ROP is a sensitive indicator for the configuration of retinal detachments and thus is an objective means of preoperatively establishing the prognosis for these very difficult cases.
Stargardt's Disease is characterized by progressive and bilateral degeneration of the macula with an autosomal recessive inheritance pattern. We report three generations of a family with macular atrophy; associated findings include choroidal silence and retinal flecks on fluorescein angiography . Abnormal electrophysiologic changes were consistent with observed clinical findings. Involvement of an adolescent female, her mother and her maternal grandfather imply autosomal dominant inheritance. We believe that this is the first reported case of autosomal dominant Stargardt's Disease.
Scientific Poster 48 Acute Posterior Vitreous Detachment and Its Consequences Norman E Byer, MD, Torrance, CA
The rationale for prophylactic treatment of peripheral retinal lesions rests upon the assumed risks that occur at the time of acute posterior vitreous detachment. A group of 350 non-referred consecutive patients with a diagnosis of acute posterior vitreous detachment was prospectively studied for the presence of pre-existing vitreoretinal pathology. Of the total group, 45 (12%) had acute tractional retinal tears. Lattice degeneration was present in 48 eyes, 11 (23%) of which had acute tears. However, in 36% of these the tears occurred in "normal" retinal areas. Cystic retinal tufts were seen in 27 eyes, and 8 (29%) had new tractional tears. Pre-existing retinal breaks and senile retinoschisis showed no relation to new traction retinal breaks.
Scientific Poster 49 Late Onset Retinitis Pigmentosa: Diagnostic Dilemma CynthiaJ MacKay, MD; Peter Gouras, MD, New York, NY
In a retrospective study of 197 consecutive RP patients, 16 (9%) were late onset. Average age at diagnosis was 63. All had vessel narrowing (18% mild, 64% moderate, 18% severe) but 41% lacked bone spicules. Unlike earlier onset RP, nyctalopia was frequently mild and of recent onset; 3 (18%) denied it. All had visual field loss, and glaucoma was falsely suspected in some. 82% had extinguished ERGs to single flash, but only 6% with computer averaging. Deterioration could be rapid. An ERG is essential if vessel narrowing and unexplained field loss are present, even if an elderly patient lacks bone spicules or nyctalopia.
Scientific Poster 50 Simultaneous ERG-VER Recording Cynth1:a J MacKay, MD; Mariel Brittis, MD; Peter Gouras, MD, New York,NY
A new technique of recording the ERG and VER simultaneously from both eyes using skin electrodes is described. It is quick to perform, highly informative, and easily tolerated. Advantages over conventional techniques include: 1. simultaneous evaluation of the entire visual pathway, including peripheral retina, posterior pole, optic nerve and visual cortex, of both eyes independently; 2. evaluation of children and infants (no contact lens); 3. insight into previously unexplored early retrochiasmal responses preceding the VER.
Scientific Poster 51 Treatment of Peripapillary Choroidal Neovascular Membranes Stewart A Daniels, MD;Lawrence S Morse, MD, PhD; Marc 0 Yoshizumi, MD; Yossi Sidikaro, MD, Los Angeles, CA Peripapillary choroidal neovascular membranes (PPCNVM) in age-related macular degeneration can result in loss of central vision. We retrospectively studied 25 cases of PPCNVM, which were treated with laser photocoagulation. Treatment criteria included serous detachment of the fovea, progression of PPCNVM or exudate, or loss of acuity in the fellow eye f~'om a disciform scar. Avera~e follow-up was 32 months. Visual outcome was correlated to dIstance from the PPCNVM to the fovea (p< .001). All eyes (&/5) treated with Argon blue-green laser lost acuity. Of the eyes treated with Krypton red (KRL) or Argon green lasers (AGL), 19 of 20 improved or remained the same. KRL or AGL photocoagulation is effective in treating PPCNBM in selected patients.
Scientific Poster 52 Tolerance of Titanium Retinal Tacks by the Human Eye Ramesh C Tripathi, MD, PhD, Chicago, IL; Robert A Levine, MD, Chicao?,,IL; BrendaJ Tripathj, PhD, G,hicago, IL; David Pon, MD, Cnu;ago, IL; R C F Falckn, MD, Tnun.der Bay, ON, Canoila; Ken P Moffat, MD, Toronto, ON, Canoila The use of titanium tacks is a recent innovative approach in retinal detachment surgery. Three tacks were implanted into the posterior retina of a human eye for a traumatic giant retinal detachment and, some five months later, the blind painful eye was enucleated. We report the first histopathologic case in whIch one tack had floated into the anterior chamber; the other two anchored the retina in situ. Removal of the latter tacks from the aldehyde-fixed globe revealed a full-thickness perforating wound in the retina, pigment epithelium, Bruch's membrane, ch. Ol'oid, and sclera. The chorioretinal scar and only a mild inflammatory reaction in the sclera indicate that titanium retinal tacks in situ may be tolerated well by the posterior coats of the human eye.
Scientific Poster 53 Pathologic Myopia and Subretinal Hemorrhages Florence A Milch, MD; Lawrence A Yannuzzi, MD; A Josepn Rudick, MD, New York, NY
In the absence of choroidal inflammation or tumors, subretinal hemorrhage (SRH) has ~enerally been associated with the presence of occult or discermble subretinal neovascularization (SRN). This is a report on the nature and prospective course of 25 patients with pathologic myopia and associated SRH, which cleared spontaneously without clinical or fluorescein angiographic signs of active or regressed SRN. Important factors evaluated in the natural course of these patients mcluded axial length, lacquer cracks, posterior staphyloma and visual acuity. A standardizea definition of pathologic myopia, based on associated manifestation in the funaus is presented for future comparative and similar studies.
Scientific Poster 54 Hermansky-Pudlak Syndrome: Ophthalmic Findings C Gail Summers, MD; Richard A King, MD; William H Knobloch, MD; Carl J Witkop, DDS, Minneapolis, MN
Hermansky-Pudlak Syndrome (HPS), a type of tyrosinase positive oculocutaneous albinism associated with hemorrhagic diathesis, has a variable phenotypic expression. Eleven patients with HPS were evaluated prospectively to determine extent of visual impairment and possible relationship to degree of hypopigmentation. Best corrected visual acuity ranged from 20/50 to 201200. Iris transillumination, graded by comparison to standard photos, showed moderate pigmentation to total deficiency of iris pigment, and no obvious relationship to visual acuity. All patients showed hypopigmented fundi, foveal hypoplasia and excessive crossing of the optic fibers by evoked potentials. This study demonstrates the variable expression of ophthalmic findings in HPS and lack of correlation with the amount of ocular pigment detected.
Scientific Poster 55 Outer Retinal Toxoplasmosis John D Matthm4Js, MD, Greensboro, NC; John J Weiter, MD, PhD, Boston, MA
Toxoplasma gondii is a recognized neurotrophic organism which involves the neUrosensory retina. Typical ocular toxoplasmosis is not difficult to recognize. However, there is a subset of this clinical spectrum recently described [JDM Gass: Arch Oph 103, 1332] which is characterized by grey-white lesions at the level of the outer retina or retinal pigment epithelium. There is no vitreous reaction to this retinal lesion. We report four additional cases of Outer Retinal Toxoplasmosis. Recognition of this variation is impOl·tant since prompt treatment in our series, before serologic confirmation, resulted in improved vision in all <:ases.
Scientific Poster 56 The Effect of Modified Grid Laser Photocoagulation on the Central Visual Field in Diabetic Macular Edema Gerald G Striph, MD; William M Hart Jr, MD; R Joseph Olk, MD; Lon S Pol'iner, MD, St. Louis, MO
We studied the effect of either argon or krypton modified grid laser treatments for diabetic macular edema on the foveal sensitivity, color discrimination, and central visual field. To date, data from 25 eyes have been analyzed. Mean change in foveal sensitivity was -0.96±8.9 dB and in the central 5 degrees was -3.6±4.5 dB. Two masked observers were unable to correctly separate preoperative from pos.toperative fields. The study parameters did not differ significantly (p> .05) between the argon and krypton subgroups. Results suggest that single grid treatments do not cause a significant (p> .05) change in these parameters.
Scientific Poster 57 Increased Numbers of Activated T-Cells are Associated with Lack of Progression in Retinitis Pigmentosa Lowell L Williams, MD; Laurence E Leguire, PhD; Barry T Shannon, PhD, Columbus, OH A state of increased immunologic activity, called T-cell activation, can be identified by the lymphocyte surface epitope, Tal, using flow cytometry. It is present during active infection, on continuous cell lines, and prior to disease progression in multiple sclerosis. In 51 Retinitis Pigmentosa (RP) patients we found increased absolute numbers of Tal positive cells in 13 of 22 dominant RP (59%, mean cell count = 712, SD=236 mm3) and in 13 of 29 reces: sive RP (45%, mean=659, SD=233 mm3). Normal controls averaged 335 (SD = 120 mm3). In both dominant and_recessive, increased T-cell activation correlated with a lack of subjective RP disease progression suggesting that heightened immunoregulation may affect the genetic expression of RP pathology.
Scientific Poster 58 Human Cultured RPE: A Decrease in Alpha-Mannosidase Activity with Increased Patient Age Richard E Wyszynski, MD, Cleveland Heights, OH; Carrie David, BS, Cleveland, OH; William E Bruner, MD, Cleveland, OH; Kirk M Morgan, MD, Cleveland, OH; Paul Sternberg, MD, Atlanta, GA; Janet Hartmann, BS, Atlanta, GA Each RPE cell engulfs about 7,500 rod outer segments daily. Unlike other phagocytic cells, the RPE cell has a very long life. It would be expected that small changes in degradative enzyme efficiency or amount may have significant visual co'nsequences over a period of time. We studiedlysosomal enzymes of human cultured RPE cells established from patients of various ages. We found that a-mannosidase velocity significantly dect·eases with increased donor age (r= 0.746, p= 0.006). This is not tme for other glycosidases studied. Since the man nose mOnomer is significant in the oligosaccharide portions of rhodopsin, the findings of our study could explain some of the common clinical RPE and retinal degenerations if the findirigs are duplicated in vivo.
Scientific Poster 59 SEM-Vascular Casts and Clinico-Anatomopathological Correlation on Macular Degeneration Andrzej W Fryczkowski, MD, PhD; Mark S Sherman, MD, Tucson, AZ We examined both eyes (obtained at autopsy) from a 79 year old man with a history of age-related macular degeneration (ARM D) and glaucoma. He was legally blind in both eyes. One eye was studied using routine histopathological techniques and transmission electron microscopy. The vasculature of the companion eye was injected with Batson plastic mixture, forming a vascular cast which was studied using scanning electron microscopy. This is the first demonstration of vascular casts in ARMD. We observed focal vascular abnormalities, including a unique "moth-eaten" appearance of the choriocapillaris at the posterior pole. This data will be presented with histopathological and clinical photographs and integt·ated into our present understanding of ARMD.
Scientific Poster 60 A Comparitive Evaluation of Currently Available Dye Lasers Jason S Slakter, MD, Great Neck, NY; Lawrence A Yannuzzi, MD, New York, NY
The three dye laser systems currently available in the United States (Coherent, Cooper vision, and Meditech) were evaluated with respect to: 1) power output reliability and reproducibility, 2) wavelength range and stability, and 3) technological aspects of the generation, modulation, and delivery of the dye laser energy. Advantages and disadvantages of the overall design and performance characteristics of each of the lasers were examined. Inconsistencies between the indicated and actual power output, limitations in the range of available wavelengths, and instability of the dye systems were discovered. Potential hazards in the clinical application of these lasers were also uncovered. Recommendations and plans for modification of the laser systems are discussed.
Scientific Poster 61 Retinal Phototoxicity from the Operating Microscope: The Effect of Inspired Oxygen Glen J Jaffe, MD; Alexander R Irvine, MD; John W Severinghaus, MD; Irmgard S Wood, MD; Charles M Haugen, AB, BS, San Francisco, CA
Retinal pho~otoxi~ity. cause? by the operating. microscope has been recogmzed With mcreasmg frequency followmg a variety of ophthalmic surgical procedures. Recent evidence suggests that oxygen may potentiate the retinal 'damage. Light from the operating microscope was used to produce retinal lesions in five phakic rhesus monkeys to determine the threshold for retinal aamage, and to see if high concentrations of inspired oxygen increased the phototoxic effect. We found that clinically and histopathologically visible photochemical lesions were produced following 3·10 minutes of light exposure. The size of the lesions near tht·eshold were 50-180% larger under high oxygen conditions. The results of this study have important implications for clinical practice; they indicate that the operating microscope can produce photic maculopathy rapidly, and that oxygen administered durmg ophthalmic procedures may add to the damage if appropriate precautions are not taken.
Scientific Poster 62 Electroretinographic Findings in Iris Neovascularization Due to Acute Central Retinal Vein Occlusion Th01nas J McPhee, MD; Mary A Johnson, PhD; Michael j Elman, MD; Daniel Finkelstein, MD, Baltimore, MD The degree of retinal dysfunction in 14 patients with iris neovasculat·ization secondary to acute central retinal vein occlusion (CRVO) was assessed using electroretinography (ERG). ERG evidence of severe dysfunction was found in every patient. The ERG abnormalities showed the same pattern of dysfunction as is seen in severe proliferative diabetic retinopathy associated with extensive capillary drop-out and presumed widespread retinal ischemia. The ERG was four times more discriminating than fluorescein angiography in the identification of. severe CRVO with iris neovascularization. The ERG can add important information as to the severity of retinal dysfunction in CRVO with rebeosis.
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Scientific Poster 63 Prediction of the Kinetics of Disappearance of SF6and C3F8 Intraocular Gas Bubbles . RaymondF Wong, MD; John T Thompson, MD, New Haven, CT Prediction of intraocular bubble size and rate of disappearance of intraocular gases are important factors in determining the volume and type of gas used to tamponade a retinal break. Estimation of gas bubble volume by memscus height is inaccurate due -to the eye's spherical geometry. A mathematical model converting me· niscus height to volume was found to be accurate when tested in rabbit eye!> after lensectomy and vitrectomy. The disappearance of both gases obeyed first order kinetics with a half life of 19 hours for SF6 and 66 hours for CgFg. The half lives in these aphakic eyes were less than those of phakic rabbit eyes. These results provide a noninvasive method to monitor and predict intraocular kinetics of both gases. (Invited From ARVO Meeting)
Scientific Poster 64 Procoagulant Activity of Retinal Vascular Endothelium is Induced by RPE Cells: Role in Regression of Neovascularization Laurie H Kuwashima, MD; Bert M Glaser, MD, Baltimore, MD An initial event in the regression of new blood vessels is their occlusion by intraluminal fibrin clots. We asked whether an inducer of new blood vessel regression, human RPE-conditioned medium (RPE-CM), induces clot-forming activity (CF A) of cultured endothelium. As expected, human plasma exposed to cultured endothelium had little tendency to clot (clotting time=7 minutes). However, incubation of endothelium with RPE-CM resulted in enhanced endothelial CF A with a shortening of the clotting time to 1-2 minutes. Eridothelial CFA induced by RPE-CM was dose-dependent and maximal within 4 hours. The ability of RPE cells to release a diffusible substance inducing endothelial CF A suggests a method by which cell-cell Interactions may function to control neovascularization.(lnvited From ARVO Meeting)
Scientific Poster 65 Computer Assisted ~ea Analysis of Macular Ischemia in Sickle· Cell Retinopathy Geoffrey R Kaplan, M.D; Peter A Van Houten, MD.; Morton F Goldberg, MD; Maurue F Rohb, MD; Steven B Conon, MD, Chicago,IL The extent of macular disease can be determined by quantification of macular ischemia. The area of the Joveal avascular zone (F AZ) was measured on fluorescein angiograms with a compute2 assisted plotting method on five normal eyes (mean 0.12 mm ±SD 0.08),10 eyes with sickle cell reti~opathy but no clinical evidence of maculopathy (mean 0.20 mm ± SD 0.16), and 11 eyes with sickle cellzetinopathy and clinical evidence of maculopathy (mean 0.78 mm ± SD 0.40). The difference between the areas of the F AZ was statistically significant when eyes with maculopathy were compared to normal eyes (p= .0009) and to sickle retinopathy eyes without maculopathy (p= .002). Octopus visual field perimetry and contrast sensitivity were correlated with macular ischemia. These techniques appear to be both sensitive and quantifiable in detecting early macular disease. (Invited From ARVO Meeting)
Scientific Poster 66 Compensation Filtering Improves Word Recognition ill Observers with Age-related Maculopathies Teri B Lawton, PhD, P01lOJiena, CA
Image enhancement devices are needed for observers with Age-Related Maculopathies (ARM) to read normal text. Contrast sensitivity functions of ARM observers were measured to assess losses in visual function . Disciform ARM patients showed losses i~ co!'!trast sens!tiv.it.y for all spatial frequencies. ~ord recognition Improved slgmflcantly when ARM observers VIewed words filtered by boosting the spatial-frequency amplitudes that are less visible compared to an age-matched normal observer. 27% to 70% more magnification was needed for unfiltered words compared to filtered words. The improvement in word recognition increased as the severity of an observer's Vision loss increased. These individualized compensation filters improve the clarity and Visibility of words to aid reading. (Invited From ARVO Meeting)
Scientific Poster 67 Transscleral Laser Retinopexy and Cyclodestruction Using a Contact Sapphire Crystal Probe HC'rmann D Schubert, MD, Ph'ilOJielphia, PA; Jay L Federman, MD, ?hiladelphia, PA; FU7(1itoka,4ndo, MD, Nagoya, Japan; Ralpil C EagleJr, MD, Piltladelpilta, PA; NokoKatoil, MD, Chicago, IL; Gholam A Peyman, MD, Chicago, IL Laser light (Argon and cw YAG) was delivered ,through a synthetic sapphire crystal which was held in direct conjunctival contact perpendicular to the ciliary body and peripheral retina .of pigmented rabbits. The threshold for retinal whitening was 0.5 Joule (J). Reproducible whitening of the ciliary body occurred at 0.5-1 J. Histologic examination of the acute injury at 2 days, 1, 3, 6 and 12 weeks, showed lesions centered around the pigmented layers. While severe chorioretinal damage and hemorrhage occurred at .2 J, no scleral or conjunctival perforation was noted. These preliminary studies show that transscleral contact .lasers may be safely used in clinical situations where selective damage to pigmented tissues is the primary objective. (Invited From ARVO Meeting)
Scientific Poster 68 Autoimmune Related Retinopathy (ARR Syndrome) John L K eltner, MD, Davis, CA We previously presented four patients with possible immune-mediated retinopathy in cancer patients (CAR syndrome). We have now identified four additional patients who apparently do not have cancer but have retinopathy with ring scotomas or depressed visual fields and abnormal ERGs. These patients had other systemic abnormalities. They demonstrated anti-retina antibodies with a positive ELISA titer greater than 1:200 and a molecular weight different from those antibodies found in the CAR syndrome patients. We suggest that there may be multiple etiologies for the autoimmune related retinopathy. ,This postf!r. is physically l?cated outside .i~s topjc area. See Neuro- Opittitalmowgy· for otlter posters on tit'/,S topic.)
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Cataract All presenters wUl attend their posters on Sunday from 11:30 AM to 1:00 PM, and at various times throughout the Annual Meeting. Individual attendance hours will be indicated on a mock clock at each poster board.
Scientific Poster 69 Visual Results Following Vitreous Loss and Primary Lens Implantation Alan V Spigelman, MD; Bruce D Nichol$, MD; Thomas D Lindqu'ist, MD, PhD; Richard L Lindstrom, MD, PhD, Minneapol'is, MN
The decision to implant an intraocular lens following vitreous loss at cataract surgery is enigmatic. To address this issue we retrospectively identified all cases performed at the University of Minnesota in the last thr6.:! years that had an intraocular lens implanted following anterior vitrectomy. Twenty patients received a posterior chamber lens. All patients achieved 20/40 or better vision,. though one p~tient had a retinal detachment. Six patients receIved an anterIor chamber lens. Four of these patients achieved 20/40 or better vision and two achieved 20/50 vision. One of these patients also had a retinal detachment. Follow-up ranged from three to 18 months. This review demonstrates that with meticulous anterior vitrectomy, good visual results canbe accomplished. However, retinal detachment still appears to occur more frequently in these cases than in uncomplicated ones.
Scientific Poster 70 Enzyme Digestion of the Lens in Small-Incision Cataract Surgery Laura L Paul, MS; Louise C Moorhead, MD; CD Armeniades PhD, Houston, TX "
In this i'f' vitro stud~, we ev~luated four enzymes (pronase, carboxypeptIdase B, sphmgomyelmase, and phospholipase C) with regard to their effectiveness in digesting the lens cortex so that it could be cleanly aspirated through a #20 gauge needle, leaving the capsular bag intact. Using paired human lenses (donated by the Lions Eyebank of Houston), we treated one lens from each pair with a given enzyme and compared the amounts of material aspirated respectively from the untreated and treated lens. Results from 52 pairs show 27% removal in untreated lenses, compared to 62 and 54% for pronase and sphingomyelinase used alone, and 77% removal with the two enzymes used together (p < 0.01). The remaining material consisted of nuclear remnants. These early results show that enzyme lens digestion has considerable promise in small-incision surgery.
Scientific Poster 71 UV,Absorption by Intraocular Lenses Patrick S O'Connor, MD; Thomas J Tredici, MD; Patrick T O'Connor, Brooks AFB, TX There is an ongoing controversy over the role of ultraviolet radia~ion in the causation of cataracts and retinal dysfunction. Followmg cataract surgery, the aphakic eye transmits the more abiotic ultraviolet rays to the retina. Intraocular lens manufacturers are adding UV absorbing materials to their lenses. Thirty-four commercially available. UV ~sorbing and non-absorbing intraocular lenses were exammed WIth a spectrophotometer to determine their UV absorbing characteristics. This data was then compared to the established values of a human middle-age lens (age 54). UV absorbing lenses are not qujte as effective as the human lens, but are far superior to a non-UV absorbing lens in screening out UV light between 300 and 400 nm.
Scientific Poster 72 Respiratory Distress Following Nadbath Block Steven B Koemg, MD; Jonathan Kay, MD; Robert Snyder, MD, Milwaukee, WI Thr~e patie?~s de-.:eloped dysphagia and resp!ratory distress followmg admInIstratIon of a Nadbath block. ThIs complication may have resulted from inadvertent paralysis of the ipsilateral glossopharyngeal and vagus nerves, causing pooling of oropharyngeal secretions and difficulty in handling secretions resulting in ];lryngospasm. Respiratory distress following a Nadbath block may require repositioning the patient and appropriate therapy for laryngospasm. Short hypodermic needles (less than 12mm), small volumes of anesthetic solution (less than 3cc), and omission of hyaluronidase may reduce the incidence of this complication.
Scientific Poster 73 Blue-Dot Cataract John!3 Cotter, MD; Ahmed A Hidayat, MD, Riyadh, Saudi Araina In two family members with blue-dot punctate opacities and concomitant posterior capsular opacity, extracapsular removal of I~nses was perfo~med .. Histopathologically, the blue-dot opacities disclosed focally liquefied cortex that contained abnormal lens fibers in the form of granular, minute globular and elongated structures. The glo~ular structures were smaller than Morgagnian glob,ules. Scannmg electron microscopY revealed a similar appearance. Energy dispersive analysis by X-rays (EDAX) was performed, but showed no evidence of abnormal or increased al!lounts of normally present elements in the lens when compared WIth age matched cataractous lenses. The peculiar structural appearance of blue-dot cataract fibers and normal "EDAX" results support the hypothesis that a "blue-dot" appearance in punctate cataracts is an optical phenomenon resulting from dispersion of light.
Scientific Poster 74 Ophthalmic Surgical Complications in Werner's Syndrome Klaus W Ruprecht, MD; Jost B Jono.s, MD; Gottfried 0 H Naumann, MD; Erich Gebhart, MD; Dieter Platt, MD; Dietrich Schachtschabel, MD, West Germany
In 10 of 18 eyes from 9 patients with cytogenetically (7 pos., 2 not examined) fibroblast culture (5 pos., 4 not examined) and in osmotic red blood cell fragility (4 increased, 5 not examined) proven WERNER's syndrome underwent cataract surgery (10 ICCE, 8 ECCE) at an average age of 35.56 ± 8.3 years. Cataract surgery was complicated by endothelial decompensation (8x), anterior synechiae (4 x), secondary epiretinal gliosis (4 x), cystoid macular edema (3x), unplaned filtering bleb (2x), postoperative anterior ischemic optic neuropathy (Ix). Biochemical and clinical considerations suggest: small surgical incision, tight sutures and no steroids locally.
Scientific Poster 75 A New Method of Predicting Visual Acuity Mter Cataract Surgery Using the Blue Field Entoptoscope and Projected Slides Timothy Lischwe, MD; Carl HIde, MD, Columbia, MO
Using the Blue Field Entoptoscope, 69 patients with clear media were asked to compare the number of corpuscles visualized to a series of projected slides having progressively fewer ill'awn corpuscles. Of the patients who selected~ 120 corpuscles, 89% were 20/40 or better, and those who selected ~ 100 corpuscles, 82% were 20/50 or worse. The percentages were higher for ARMD patients (100% and 85%) than for diabetic patients (33% and 75%). Fifty-six preoperative cataract or YAG-capsulotomy patients were then tested with the same apparatus to predict their potential visual acuity. Of the 23 patients with a preoperative acuity of 20/200 or better, and who selected ~120 corpuscles, 1000/0 were 20/40 or better postoperatively.
Scientific Poster 76 Rapid Determination of IOL Tilt and Decentration Through the Undilated Pupil H Jay Wisnicki, MD, New York, NY; Hiroshi Uozato, PhD, Ko.shihara, Japan; DavidL Guyton, MD, Baltimore, MD
Alignment of the examiner's hand light with the third and fourth easily-observed Purkinje images (from the front and back surfaces of the implanted IOL) identifies the apparent optical axis of the IOL. Tilt of the IOL can be estimated (or measured with an arc perimeter) by the angle between the apparent optical axis and the patient's line of sight (actual tiltRjO.85xapparent tilt). Decentration is noted directly by the distance of the IOL optical axis from the center of the pupil. Using this simple technique, postoperative IOL position can be followed without dilating the pupil.
Scientific Poster 77 Vitreous Loss in Resident Cataract Surgery Wooclford S Van Meter, MD; Thomo.s J Smith, MD; Douglo.s G Owen, MD; Maureen Maliszewski, RN, Lexington, KY Vitreous loss remains a serious complication of cataract surgery. It has been suggested that high rates of vitreous loss (9%, Browning, Ophtttalmology, 1985) may be an inevitable Consequence when residents are learning extracapsular techniques. We retrospectively analyzed all (n = 762) cataract procedures performed by second and third year residents in a single V A hospital over the period 1983-1986. Vitreous loss occurred in 8.9% of all cases in 83-84. In January 1985, a new program of resident training was instituted. In 1985-1986 the rate had reduced to 4.0%. For seven resident surgeons in 1986, the rate was 1.2%. Statistical analysis confirms that these results cannot be attributed to any individual surgeon. We believe that a proper educational program including practice surgery, graded responsibility, and experienced assistance can ill'amatically reduce the rate of this serious complication in resident surgery.
Scientific Poster 78 Increased Mortality Following Cataract Surgery: A Statistical Analysis Matthew E Farber, MD, Morgantown, WV; William H Benson, MD, Morgantown, WV; Richard J Caplan, PhD, Pittsburgh, PA Associations between cataract surgery and increased mortality have been reported. We conducted a retrospective review of the mortality of 193 consecutive patients under~oing elective cataract surgery between 111179 and 12/31180. Statistical analyses including survival curve estimates reflecting direct age adjustment revealed that the cataract group mortality, 31.7%, after five year follow-up was significantly greater than the control group, 11.2% (P = 0.0017). Cox regression with diabetes as an independent variable indicated diabetes (P E .93) did not significantly influence group mortality. These results support the association between cataract surgery and increased mortality.
Scientific Poster 79 Binocular Function in Unilateral Aphakia: Correlation Between Stereoacuity and Aniseikonia Osamu Katsumi, MD, Boston, MA; Tatsuo Hirose, MD, Boston, MA; YoshitakaMiyanoga, MD, Tokyo, Japan; IsamuAsaoka, MD, Tokyo, Japan, Horioko Okuno, MD, Tokyo, Japan In dealing with cases of unilateral cataract, one has to par attention not only to the acuity of the operated eye but also bmocular function in the postoperative period. This need is attributed to disruption of binocular function due to image size difference. We investigated the level of aniseikonia using the New Aniseikonia Test and also stereoacuity in ninety patients with unilateral cataract corrected with intraocular lens and contact lens. In the intraocular lens group, average aniseikonia was 2.8%. Sixty-eight of the group obtained stereoacuity better than 100 sec. In the contact lens group aniseikonia was 4.6%, and 40% achieved the stereoacuity of 100 sec. or better. We concluded that intraocular lens correction is a more effective means of obtaining good binocular function in unilateral cataract.
Scientific Poster 80 Hyaluronidase Reverses Sodium Hyaluronate-Induced Outflow Obstruction Thomas A Deutsch, MD, ChicOfjo, IL; J Terry Ernest, MD, PhD, ChicOfjo, IL; Kimberly Neely, MD, ChicOfjo, IL; Thomas K Goldstick, PhD, Evamton, IL
The use of sodium hyaluronic acid (SH) during anterior segment surgery often results in postoperative elevated intraocular pressure, presumably because of outflow obstruction. We studied the effect of the enzyme hyaluronidase on this outflow obstruction in an eye bank eye model. SH caused a 75 percent reduction in outflow facility which was unaffected by washout with saline (p>0.5). However, hyaluronidase completely reversed the outflow obstruction in doses as low as 38 units. These data suggest that hyaluronidase could be clinically useful in preventing the intraocular pressure elevations associated with the use of viscoelastic sub· stances in anterior segment surgery. (Invited From ARVO Meeting)
Scientific Poster 81 Preclinical Evaluation of Photodynamic Therapy to Retard Lens Epithelial Proliferation Mter Endocapsular Lensectomy Robert W Lingua, MD; Jean·Marie Parel; Steven Fle1J3ler, PhD, Miami,FL Cytotoxic photoactivation of dihematoporphyrin ethers (DHE) has been successfully employed for selective tissue destruction in antineoplastic therapy (PDT). Using a 510 nm light source, PDT of the lens capsule epithelium was performed on rabbits after endo· cajJsular emulsification and cortex aspiration. There was no clini· cally significant retardation of lens epithelium regrowth among controls and in the 100 ug/ml DHE-56J light groups. In the 1.25 mg/ml DHE·Healon and DHE-IgG, 120J PDT regimens, a greater treatment effect was noted histologically, but vitritis was evident in both animals. Effective endocapsular therapy may require a monoclonal IgG-DHE conjugate to improve specificity and capsular inflation to allow uniform irradiance of retained lens epithelial cells. (Invited From ARVO Meeting)
Cornea and External Disease All presenters 'Will attend their posters on Sunday from 3:00 to 4:30 PM, and at various times throughout the Annual Meeting. Individual attendance hours 'Will be indicated on a mock clock at each poster board.
Scientific Poster 82 Toxic Keratoconjunctivitis Secondary to High-Dose Systemic Cytarabine Therapy: A Dose-Related Disorder Andrew W Lawton, MD, San Antonio, TX; James W K aresh, MD, Baltimore, MD; Edward J Goldman, MD, Baltimore, MD; Verinder S Nirankar, MD, Baltimore, MD,' Kim Reck, MS, Baltimore, MD
Four patients receiving high-dose systemic cytarabine for leukemia developed bilateral, diffuse, deep epithelial opacities and a mild punctate epithelial keratopathy. This responded partially to topical hypertonic saline and corticosteroids, but intensified during additional courses of systemic chemotherapy. Epithelial biopsies from two patients taken from the peripheral cornea showed degeneration of basilar epithelial cells on both light and transmission electron microscopy. This is indicative of a direct toxic effect of cytarabine on reproducing corneal epithelial cells. All four cases strongly suggest that the corneal toxicity induced by cytarabine is dose-related and not idiosyncratic.
Scientific Poster 83 Enzyme Immunoassay in the Detection of Chlamydial Antigens in Patients with Trachoma KnalidF Tohbara, MD, Riyadh, SaudiaArabia; AmjadRahi, MD, PhD, Dammam, Saudi Arabia
Conjunctival swabs and scrapings were obtained form thirty-eight eyes with active trachoma and sixteen patients with inactive trachoma. Specimens were subjected to enzyme-linked immunosorbent assay (ELISA), immunofluorescent assay using monoclonal antibodies (IFMA), Giemsa staining and chlamydial cultures. Detection of the chlamydial agent was found to be highest by culture and ELISA and lowest by Giemsa and IFMA. All sixteen patients with inactive trachoma had negative ELISA for chlamydial antigens. Patients with active trachoma showed 20% positive ELISA in the mild group and 57% in patients with moderate-severe trachoma. ELISA appears to be a simple, sensitive and specific assay for the diagnosis of active trachoma in children.
Scientific Poster 84 Acanthamoebal, Bacterial, and Fungal Contamination of Contact Lens Storage Solutions Jay M Lustbader, MD; Walter J Stark, MD; Gregory P Kracher, OD; Patricia Charache, MD; Tracey R Hamburg, MD; Thomas Spahr, Baltimore, MD
Microbial keratitis due to acanthamoebae, bacteria, and fungi in patients wearing contact lenses is a problem of increasing clinical importance. The role of contaminated contact lens storage solutions in contributing to this problem has not yet been fully elucidated. We cultured the lens storage solutions from 100 normal patients. None of the solutions studied was positive for growth of acanthamoebae, but 44% of the cultures were contaminated with bacteria and/or fungi. Patients with positive and negative cultures were compared according to a variety of lens wear and care parameters. Heat disinfection systems and unpreserved storage solutions were more commonly found in the positive group.
Scientific Poster 85 Comparison of Diagnostic Laboratory Techniques in the Various Stages of Trachoma Peter B Taylor, MD, San. Francisco, CA; Eilee!t MBurd, J,fS, San FrancISCo, CA; Knalid F Tohbara, MD, R~yadh, Saud~ Arabia Value of Giemsa staining, fluorescein-tagged monoclonal antibody (MAb) and cell culture in the various stages of trachoma (WHO classification) was assessed. Conjunctival scrapings from 127 eyes with minimal (n=21), mild (n=26), moderate (n=29) and severe (n= 51) trachoma were processed for the detection of Chlamydia. Giemsa equaled MAb in minimal cases and detected more mOderate cases (min = 14%, mild = 11.5%, mod=42%, sev= 13%. MAb was better than Giemsa in mild and severe cases (min = 14%, mild = 19%, mod=29%, sev=26%). Additional data suggest that laboratory evaluation of trachoma in the absence of cell culture requires both Giemsa and MAb analysis for best results.
Scientific Poster 86 Implantation of Posterior Chamber IOLs during Keratoplasty for Pseudophakic and Aphakic Corneal Edema H Kaz Soong, MD; Roger F Meyer, MD; Alan Sugar, MD, Ann Arbor,M! Because of their many advantages, posterior chamber (PC) IOLs were sutured to the posterior iris (in the absence of a lens capsule) in combination with keratoplasty for pseudophakic and aphakic bullous keratopathy (PBK & ABK) in 53 cases. IOL exchanges were performed in PBK (44 cases) and secondary IOL implantations were performed in ABK (9 cases). 96% of the grafts remained clear and 61% of the cases had visual acuities of better than 20/60 with an average follow-up time of 6.4 (range 3-13) months. The most common cause of poor vision was CME present preoperatively in 20 eyes and postoperatively in 22. Other causes of persistent visual impairment included macular degeneration (5 cases), retinal detachment (2 cases), and 1 case each of preoperative glaucoma damage, severe postoperative glaucoma, and endophthalmitis. Short-term results indicate that this procedure may be a viable alternative to the use of secondary anterior chamber IOL implantation during keratoplasty.
Scientific Poster 87 Ocular Presentation of Chronic Lymphocytic Leukemia Thomas M Reynolds, MD; Deborah D Sendele, MD, Chattanooga, TN Leukemia can involve almost any ocular tissue and atypical ocular signs may be the initial manifestation of a leukemic process. A 48-year-old white female presented with a one year history of red eyes treated with tear substitutes by a local physician. Examination revealed multiple bilateral subconjunctival nodules and excisional biopsy of these unusual lesions along with results of CBC and bone marrow biopsy revealed the diagnosis of chronic lymphocytic leukemia (CLL). Only one other documented case of CLL with an ocular presentation has been reported. Survival rates in CLL are significantly improved by earlier diagnosis; therefore, it behooves the ophthalmologist to recognize and identify specific ocular lesions since a delay in diagnosis can contribute to an inauspicious prognosis.
Scientific Poster 88 Increased Mortality Associated with Lymphocytic Infiltration of Choroidal Malignant Melanoma Stephen R Fransen, MD, Oklahoma City, OK; Robert P Shaver, MD, Oklahoma City, OK A consecutive series of 155 patients undergoing enucleation for choroidal melanoma was analyzed to determine the prognostic significance of the lymphocytic infiltrate present in 20 of these tumors. Patients with lymphocytic infiltration of their tumors had a decreased actuarial survival when compared to patients without this infiltrate (p<0.05). Much of the increased mortality occurred in the early post-operative years and tended to be independent of tumor size, cell type, and tumor location. Lymphocytic infiltration of choroidal melanoma appears to identify a group of patients at higher ri~k for early d~ath. after enucleation .for. choro~dal melanoma. (Tf/,~s poster ~s pilys~cally located outside ~ts to']nC area. See "Intraocular Inflammation and Ocular Tumor" Jor other posters on this topic.)
Scientific Poster 89 Corneal Changes in CMV Ocular Infection Herbert L Cantrill, MD; Anthony Novak, MD; J Douglas Cameron; Debra L Skelnik, BS, Minneapolis, MN Fine, filamentous KP not unlike those seen in Fuchs' heterochromic cyclitis are characteristic of CMV ocular infection. These corneal deposits have been seen in patients immunosuppressed for organ transplantation as well as in patients with AIDS. They are not associated with corneal endothelial decompensation. Specular microscopy demonstrates normal morphology and cell counts. The deposits do not respond to treatment with topical corticosteroids, but regress when CMV retinitis is treated with ganciclovir. Light miscroscopy and scanning electron microscopy in two cases demonstrated clumps of macrophages attached to normal appearing endothelium. Postmortem culture of the corneas for CMV virus was negative.
Scientific Poster 90 Cat Scratch Keratitis Ira J Udell, MD, New Hyde Park, NY; Curtin G Kelley, MD, Columbus, OH; Thomas C Wolf, MD, Oklahoma City, OK; David M Meisler, MD, Cleveland, OH; Sidney H Mandelbaum, MD, New York, NY; Robert C Cykiert, MD, New York, NY We treated six patients who developed keratitis ranging from mild to very severe from a direct scratch of the cornea by a cat. All were characterized by multifocal infiltrates and in five of six cases, a poor response to broad spectrum fortified antibiotics. Although three patients clinically improved with topical steroids, two required penetrating keratoplasty (PK). Unusual gram negative organisms were cultured from the excised corneal buttons (one case DF-2 and the other DF-2-like as designated by the Centers for Disease Control). One of the eyes which underwent a PK developed panophthalmitis and subsequent phthisis. None of the patients had the clinical findings typical of Parinaud's oculoglandular syndrome.
Scientific Poster 91 Corneal Topography Using Rasterstereography Joseph W Warnicki, BA; Paul G Rehkopf, CCE; Diane Y Curtin, BA; Robert C ArfJa, MD, Pittsburgh, PA Our new technique for corneal topography, unlike a placido disc system, allows analysis of the entire corneal surface, including the optical axis, peripheral cornea, and adjacent sclera, and works well on non-reflective or irregular surfaces. The tear film is stained with fluorescein, and a grid of parallel lines of cobalt blue light is projected onto the cornea. The image is obtained with a video camera and analyzed with an image processor. The corneal contour and refractive power can then be displayed in multiple forms, such as contour maps, orthogonal projections, or deviations from sphericity. This system analyzes the entire optical axis, and may measure corneal curvature intraoperatively, despite epithelial edema or central corneal sutures.
Scientific Poster 92 Medicated Bandage Lenses for Sustained Gentamicin Release Massimo Busin, MD; Martin Goebbels, MD; Man/red Spitznas, MD, Bonn, West Germany Current therapeutic regimens require very frequent instillation of antibiotics, even every quarter of an hour, up to 100 times a day. As an alternative to topically applied gentamicin eyedrops, the possibility of a sustained gentamicin release by bandage contact lenses was investigated. Ten bandage contact lenses (61.4% HEMA and 38.6% water content) were soaked overnight in a 5 per thousand solution of sterile gentamicin, and fitted thereafter on 10 eyes of healthy volunteers. Gentamicin concentrations in the tear film were determined 10, 30, 60 minutes, 4, 8, 24, 48, 72, and 96 hours after fitting, using agar diffusion bioassay. Bactericidal concentrations (higher than 1.6 ug/ml) were found up to 3 days after fitting. No toxic topical or systemic effects were seen.
Scientific Poster 93 Photokeratoscopy in the Management of Astigmatism Following Penetrating Keratoplasty Da'llilf J Harris Jr, MD; George 0 Waring III, MD; Lind.a L Burk, MD, Atlanta, GA We used photokeratoscopy to direct the selective removal of sutures to reduce astigmatIsm following penetrating keratoplasty in 52 consecutive eyes. All eyes had one running and 12 interrupted sutures. We identified four keratographic patterns th. at helpeq indicate the suture to be removed. Quantitative analysis of the effect of single suture removal was possible in three of these; focal indentation pattern-6.81 diopters average astigmatism reduction, localized flattening pattern-1.92 diopters and symmetrical oval pattern-1.25 diopters. We present clinical series of these keratographic patterns, and demonstrate how they are used in the management of astigmatism following penetrating keratoplasty.
Scientific Poster 94 Corneal Topographic Stability Following Myopic Epikeratophakia Steven A Dingeldein, MD; Stephen D Klyce, PhD; Marguerite B McDonald, MD; Herbert E Kaufman, New Orleans, LA The effectiveness o. f myopic epikeratophakia is dependent on the stability of corneal topography after surgery. We used a computer-assisted methoii to retrospectively analyze the keratoscope photographs obtained postoperatively in 12 eyes of 8 patients following myopic epikeratophakia. Postoperativ~ follow up ranged from three months to one year. Ten eyes had four or more months of follow up; eight of these were stable from three months pO!ltoperative onward. Corneal steepening was seen in two eyes at six and seven months, respectively, both of which required relaxing incisions. Decentration of the optical zone was seen in five of the 12 eyes. The results suggest that corneal topography is stable in most patients following myopic epikera-tophaKia. .
Scientific Poster 95 Factors That Influence Control of Astigmatism By Selective Removal of Interrupted Sutures Following Penetrating Keratoplasty Wooclford S Van Meter, MD; Thomas L Steine1nann, MD; Alice A Mobley, BA, Lexington, KY Twenty eyes in eighteen consecutive patients who had penetrating keratoplasty with combined runmng/interrupted sutures for visual rehabilitation were followed monthly by keratometry, photokeratoscopy, and refraction until visually stable (6.4 ± 4.0 months). Selective sutures were removed based on keratometry, refraction, and topography. Fewer initial interrupted sutures and earlier removal of selected interrupted sutures resulted in more effective control of astigmatism. Average post-operative cylinder was reduced from 7.0 ± 3.3 diopters to 2.9 ± 2.4 diopters with some sutures remaining. There was more residual astigmatism When final suture removal occurred in less than 1 year (9.5±4.6 diopters) compared to removal of all sutures after 18 months (2.1± 1.1 diopters). Delaying removal of final sutures beyond 18 months results in less residual astigmatism following penetrating keratoplasty.
Scientific Poster 9& The 30 Degree Test for Differentiatioll- of Optic Nerve Lesions SandraF Byrne, Miami, FL; Cathy L Wesley, RN, Miami, FL; J Rand.allHughes, BS, Miami, FL; EileenK Novinski, Miami, FL,· Ronald Green, MD, Los Angeles, CA
Standardized Echography (Standardized A-scan and contact B-scan) is an important diagnostic tool in the detection and differentiation of opt. ic nerve disease. Retrobulbar lesions are mainly differentiated with standardized A-scan by assessing echogram width, reflectivity and results of the 30° test. The 30° test is performed with standardized A-scan to differentiate increased subarachnoid fluid from thickening of the optic nerve substance or· its sheaths. Maximal optic nerve diameter in primary gaze is compared with maximal diameter at 30" gaze. A reduction in diameter from primary to 30° by more than 10% occurs if increased subarachnoid fluid is present, whereas if the optic nerve or its sheaths are thickened, there is no significant change.
Scieutifi<; Poster 97 The Draizes James P McCulley, MD, Dallas, TX; John Frazier, PhD, Baltimore, MD; Shan Gail, PhD, Sko/de, IL; Dale Meyer, PhD, Dallas, TX; Alan Goldberg, PhD, Baltimore, MD
An in-depth evaluation was done into the origins and current status of the "Draize Rabbit Eye Test." The Draize refers to at least four different tests dependent upon the industry or group utilizing the test. The aims and approaches by each are different. A survey was made of these industries to determine the needs being filled by the in vivo test and the current status of the development of in vitro alternatives to live animal testing. With this information it is possible to have a sufficient understanding such that one can plan future research toward the development of in vitro alternatives to acute ocular irritancy testing (Draize test).
Scientific Poster 98 Fenestrated Intracorneal Lenses Stephen SLane, MD, Stillwater, MN; Richard L Lindstrom, MD, Mi!lneapolis, M.N; J Douglas 9amer01!, MD, Minneawlis, MN; Ez",zabetn A Mlndrup, BS, M~nneawl'/,S, MN
N ebular opaciti~s noted in corneas with nonpermeable intracorneal lenses have been identified to be composed primarily of lipid. We hypothesize that this lipid is derived from dying or dead keratocytes secondary to inadequate nutrition. 5 mm fenestrated (34 micron fenestrations 20% open surface) polysulfone lenses were surgically implanted in one cornea of a feline model (n = 7) while an identical nonfenestrated impermeable polysulfone lens was implanted in the opposite cornea. All fenestrated intracorneal lens eyes maintained clear media at 8 months. Complications seen in the opposite eye included: nebular interface opacities, anterior corneal thinning, corneal necrosis, and extrusion. The safety margin of nonpermeable aJloplastics is greatly enhanced by fenestration.
Scientific Poster 99 Preservation of N onfreeze Epikeratophakia Lenticules Markus M Gra.~l, MD, New Orleans, LA; Joerg Krumeich, MD, Wattenscheid, West Ge'rmany; Wolfgang Scheidel, MD, Vienna, Austria; Hans D Gnad, MD, Wein, Austria Tissue swelling and morphology of human non freeze epikeratophakia lenticules processed by means of the BKS 1000 refractive set and stored in K-Sol for up to 2 weeks were assessed to evaluate the long-term viability of the processed lenticules, Light and electron microscopy of lenticules cut from fresh or K-Sol-preserved corneal tissue and stored in K-Sol for 10 days at 4°C showed an intact Bowman's membrane and normal stromal lamellae with undamaged keratocytes. Lentieules stored at 4°C reached steady-state hydration status after 4.5 hours, and lenticules stored at 22°C after 8.7 hours. The successful storage of nonfreeze lenticules in K-Sol for up to 10 days at 4°C would make it possible for such tissue to be stored, shipped, and used as needed.
Scientific Poster 100 The ACTSEB Procedure in the Treatment of Resistant Glaucoma Following Aphakic Keratoplasty Verinder S Nirankari, MD; Stanley S Schocket, MD, Baltimore, MD Eight patients with successful aphakic penetrating keratoplasty develoJ)ed severe glaucoma resistant to maximal medical therapy. A total of 11 cyclocryotherapy procedures and six trabeculectomies were unsuccessful. A modified anterior chamber tube shunt to encircling band (ACTSEB) procedur e was done on all eight eyes. The average preoperative lOP was 39 mmHg. Postoperative lOP was ~ 21 mmHg in six and ~ 25 mmHg in two, over an average following of 33 months. Two eyes had to have revisions of their ACTSEB, one graft became. cloudy eight months postoperatively and was successfully regrafted, and one eye develooed 8: late ~horoidal detachment. Indications, techniques 'and resu1ts WIll be dIscussed.
Scientific Poster 101 Evaluation of Levocabastine in the Ocular Histamine and 48/80 Models of Allergy in Humans Mark B Abelson, MD; Eric Mandel, MD; LisaM S1nith, BS, Boston, MA
The efficacy of a new antihistamine, levocabastine, in alleviating the ocular allergic reactions induced by either histamine or 48/80 was evaluated, 0.5% levocabastine was instilled in one eye of 30 volunteers, and vehicle in the contralateral eye. After 15 minutes, half of the subjects received histamine, 25 mg/ml, and half, 48/80, 7.5 mg/ml. The signs and symptoms of allergy were graded clinically after 30 minutes. Levocabastine significantly alleviated itching (p= .01), redness (p= .0156) and chemosis (p= .005) induced by histamine, and itching (p= .032) and redness (p= .029) induced by 48/80. These results suggest that levocabastine may be useful for the treatment of allergic conjunctivitis.
Scientific Poster 102 A New Photothrombotic Treatment for Corneal N eovascularization .-Andrew J W Huang, MD, MPH, Baltimore, MD; Scheffer C G Tseng, MD, PhD, Miami, FL; Brant D Watson, PhD, Miami, FL
Sixteen NZW rabbit corneas with persistent neovascularization fOl' 20 months after chemical debridement were treated with LV. rose bengal (40 mglkg bw) and subsequent argon laser (514.5 nm, 130 mw, 63 urn, 0.2 sec). All vessels were occluded within 10 shots each, and remained so for an 18-week study period. The corneal integrity was notably improved after treatment. With various dosages of rose bengal (40 to 4 mglkg bw), the vessels wei'e effectively occluded at 8 mglkg bw or higher dosage. Only transient alteration of liver functions was noted at 40 mglkg bw. The results indicate this novel photothrombotic technique, is effective and safe in treating corneal neovascularization and has potential clinical applications.
Scielitific Poster 103 Excimer Laser Trephination in Penetrating Keratoplasty Olivia N Serdarevic, MD, New York, NY; Knalil Hanna, MD, Paris, France; Anne-Catherine Gribomont, MD, Brussels, Belgium; Michele Salvodelli, MS, Paris, France; Gilles Renard, MD, Paris, France
The cutting precision of donor and recipient corneas is a major factor in postkeratoplastyastigmatism. In order to improve the quality of corneal trephination, we developed a rotating slit delivery system for PK trephination using the excimer laser at 193 nm. SEM, TEM and light microscopy demonstrate the superior quality of excimer cut buttons and recipient beds as compared with those obtaineu by Francischetti and Hanna suction trephines in human cadaver and rabbit eyes. We -Will present SEM and TEM results of wound healing in PK in 50 rabbits (one eye laser, other eye manual) at 6 h, 12 h, 3 d, 5 d, 2 m, and 6 m postoperatively and discuss the role and evolution of the pseudomembrane as well as c~Jlular migration and proliferation.
Scientifi~ Poster 104 Dramatic Improvement After Plasmapheresis in Atopic Keratoconjunctivitis Associated with the Hyper-IgE Syndrome Milhim I Aswad, MD; Joseph Tauber, MD; Jules Baum, MD, Boston, MA
Ocular findings in the hyper-IgE syndrome (HIE) include vernal conjunctivitis, recurrent phlyctenUlar keratoconjunctivitis, and atopic keratoconjunctivitis complicated by secondary' staphylococcal and herpes simplex keratitis. Longstanding ocular symptoms and signs of chronic atopic keratoconjunctivitis, together with non-ocular components, improved dramatically in a 19-year-old woman with HIE and a 62-year-old man with atopic keratitis following plasmapheresis. We recommend a trial of plasmapheresis in l-ecalcitrant cases of atopic keratoconjunctivitis, especially those associated with HIE.
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Scientific Poster 105 Gentamicin vs. Tobramycin: Is There a Difference of Susceptibility? Paul TurQeon, MD; Regis P Kowalski, MS; Melvin I Roat, MD, P'ittsburgn, P A
Gentamicin (GM) and Tobramycin (NN) have been reported to have equal antibacterial efficacy in most ocular diseases. We reviewed the sensitivity patterns of 2633 clinical ocular isolates (1983 - 1986) and compared the efficacy of GM and NN. Resistance to one but not the other of the studied antibiotics was found among 194 (4.4%) strains. Of gram (+) organisms, 116 of 127 (91.3%) were sensitive to GM but not NN, while 42 of 67 (62.7%) gram (-) organisms were sensitive to NN but not GM. From this significant difference (P < .0001), we conclude that GM was the superior drug for gram (+) organisms, while NN was the better drug for gram (-) organisms.
Scientific Poster 106 Trauma Following Radial Keratotomy (RK) S Lance Forstot, MD; Richard E Damiano, MD, Littleton, CO Six cases of trauma following RK are reported. Trauma occurred two weeks to one year postoperatively. There was severe, direct trauma to the globe in four· cases; mild to moderate trauma in two cases. Two patients with direct trauma opened an incision, had flat chambers and were treated successfully with bandage lenses. A tire iron injury involved lid canalicular lacerations; a pellet gun caused conjunctival and corneoscleral lacerations. In these two and the remaining two cases, all RK incisions remained intact. In all cases, there was no change in pre and post--trauma vision and no significant visual or ocular sequelae from the trauma.
Scientific Poster 107 Atypical Chorioretinitis in the Contralateral Eye of a Patient with Acauthamoeba Keratitis Karla J Johns, MD, Nqshyille, TN
Although systemic dissemirlaJion from extra-ocular acanthamoeba. infections has been well-documented, systemic dissemination from acanthamoeba keratitis has not been reported. We recently treated a 26-year-old man with culture-proven Acanthamoeba polyphagia keratitis who developed abrupt painless visual loss in the fellow eye. Fundus examination revealed an inflammatory perim~cular chorioretinitis. The findings and clinical course stron.gly suggest hematogenous spread from the infected cornea to the contralateral eye.
Scientific Poster 108 Anterior Segment Necrosis Following Cyclocryotherapy for Chronic Herpetic Keratouveitis-A report of six cases. R Aileen Webb, MD; Denis M O'Day, MD; Alan Glick, MD, Nashville, TN
We report an apparently unrecognized syndrome resulting from ocular Herpes simplex infection. Six patients with recurrent herpetic keratouveitls developed glaucoma due to secondary angle closure. One application of cyclocryotherapy limited to 180 0 led to acceleration of the inflammatory process with development of extensive scleral necrosis, followed by corneal and scleral calcification. Only one eye developed frank phthisis. Histopathologic correlation in three cases confirmed the scleral necrosis and calcification. There was also choroidal involvement with extensive anterior uveal necrosis. Although the pathogenesis of these changes is speculative, we believe cyclocryotherapy should be used with caution in such cases.
Scientific Poster 109 The Congenital Endothelial Dystrophies: A Clinical and Pathological Study Colin M Kirkness, MD; Alison McCart'MY, MD; John P Lee, MD; Noel SC Rice, MD; Alec Garner, MD, PhD, London, England
The classification of disorders of the corneal endothelium resulting from maldevelopment of neural crest-derived is still inadequate. Observations of clinical & histological characteristics of 23 patients with congenital hereditary endothelial dystrophy and 8 with posterior polymorphous dystrophy PPD undergoing penetrating keratoplasty reveal mixed anatomical findings. The anterior banded zone of descemet's membrane was normal but the posterior nonbanded zone varied in thickness and in collagen pattern .. Reduplication and epithelialization of endothelium was not confirmed to PPD. We propose that these disorders are late defects in the terminal induction of endothelial cells suggesting a spectrum of diseases rather than 2 distinct entities.
Scientific Poster 110 The Clinical and Histological Appearance of Complications of Polyslllfone Corneal Inlays in Humalls C<}lin M Kirkness, MD, Lo'il4on, England; Alec Garner, MD, PhD, London, Englana; Artiiur D.M'q Steele, .MD, London England; Perry S Binder, MD, San Diego, CA
We have followed six patients with polysulfone corneal inlays one month to three years after surgery. All showed crystalline deposition in the stroma around the inlay, marked visual loss, fluctuation of refractive error (up to 6 Ds) and unpredictable refractive error were common. We performed four penetrating keratoplasties. Splits in descemets membranes were found. Cholesterol and calcium were identified in crystalline fo. rm, similar to findings in animal models. We conclude that polysulfone unfenestrated inlays are not compatible with normal corneal function.
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Scientific Poster 111 Suramin Keratopathy . Edward J Holland, MD, Minneapolis, MN; A.lan G PalesttnfJ" . MD, Bethesda, MD; Chi.Chao Chan, MD, .Betnesda, ltfD; Tou;ntro Kuwahara, MD, Bethesda, Mp; Cy A Stmn, MD, Betnesda, MD; Renato V La Rocca, MD, Bethesda, MD; Robert B Nussenblatt, MD, Bethesda, MD Four patients with adrenocortical carcinoma were treated with high dose intravenous suramin. All patients developed a vortex pattern of corneal epitheli.al deposit~. f!istopathol?gy ?f one case showed intra-epi.thelial aplca~ deposits m .the conJunctlv~, cornea and lens epithehum by OsmIUm-PAS stam. Electron mlcrosc?py showed that these deposits were ~embraneous. lamellar ~odles. No deposits were seen in the retma or choroid. Symamm has been used clinically at lower doses for many years without oCl;llar toxicity. These findings with high dose suramin therapy are similar to other drug-induced lipid storage diseases and are well demonstrated by the recently ueveloped Osmium-PAS staining technique and by electron microscopy.
Scientific Poster 112 Clinicopathologic Correlation in Failed Human Epikeratopl~~ty. ., George T FranfJU!h, MD; Kennetn R Kertyon, MD; T~o:mas Jonn, MD; Laila Hanmnen, BS; Roger F Stmnert, MD; Mu;nael D Wagoner, MD, Boston, MA
Persistent epithelial defects (PED) f?"owing epiker~toplasty (EKP) remain a major cause of graft failure. Electron microscopy was performed on six failed EKP grafts to study epithelial healing following EKP. PEDs were pre.sent in three case~. EpJt~elial abnormalities were demonstrated m all cases, even m climcally normal appearing areas; included were edema (5/6), loss of maturation (5/6), and uiscontinuous basemen~ membran~ (4/6). StroJ'!lal hypocellularity (5/6) and sterile ulceration (2/6) With progressIOn of the ulceration to recipient stroma (1/6) were ~Iso noted. Compared to vision prior to EKP, removal of the f~i1ed EKP grafts resulted in reduction of best corrected visual acUity by more than two Snellen lines in three out of six cases. Results suggest that epithelial abnormality following EKP is longstandin~ and may be complicated by significant structural and functional Visual loss.
Scientific Poster 113 Penetrating Keratoplasty Utilizing Diabetic Donor Corneas Dimitri T Azar, MD; Ilene K Gipson, PhD; Kenneth R Kenyon, MD, Boston, MA '
Ultrastructural alterations have been described in diabetic corneas which may account for abnormalities of wound healing. To ~etermine if these changes interfere with the results of penetratmg keratoplasty (PK), we followed 10 non-diabetic PK patients transplanted with diabetic corneas. An age- and sex-matched control group was selected from PK patients operated uS.ing the same surgical technique and utilizing age-matched donor tissue. The period of follow up ranged from six months to four years. No significant differences between the two groups were found when comparing all the variables that were studied including: superfi.cial punctate keratitis, epithelial defects, filaments, recurrent erOSIOn, stromal edema, neovascularization, superficial ulceration, and graft rejection. Results suggest that using diabetic corneal tissue in PK may not be associated with a higher rate of postoperative complications.
Scientific Poster 114 Human Corneal Endothelial Cell Transplatation Jamie G Lrrpez, MD; Michael S Insler, MD; Delmar R Caldwell, MD, New Orleans, LA
The ability to successfully transplant corneal endothelium would offer a significant advance in the treatment of many corneal dystrophies. To investigate the feasibility of this, we cultured neonatal human corneal endothelium and seeded the cells onto human buttons denuded of their native endothelium. These buttons were subsequently transplanted into Rhe~us and follow~ postoper!l'tively. Pachymetry revealed progressive stromal thmnmg; by SIX months 68% of the transplanted corneas remained clear, with a mean corneal thickness of 0.480 mm. Control eyes showed advanced corneal edema, with thickness in excess of 1 mm. The results reveal that transplanted corneal endothelium can function normally and suggest the possibility of endothelial transplants for therapeutic purpose.
Scientific Poster 115 The Refractive Change Induced by Radial Keratotomy is not Mfected by Intraocular Pressure Robert K Maloney, MD, Baltimore, M!J; Walter J Stark, MD, Baltimore, MD; Russell L McCally, PhD, Laurel, MD
Some authors have attributed fluctuations in visual acuity after radial keratotomy (RK) to fluctuations in intraocular pressure (lOP), We measured central corneal curvature before and after RK on cadaver eyes as lOP was varied from less than 0.5 to 20 mmHg. As lOP increased, the refractive effe.ct of the pr~edure increased nonlinearly. Only 23% of the maximum refractive effect occurred with an lOP of less than 0.5 mmHg. At 10 mmHg, 97% of the maximum effect oC~l;Ired, and ov~r the ph~siologic range of lOP, there was no significant change m refractIOn. We conclude: 1) the action of IO~ is necessary for, c~ntral ~?rneal flattening; but 2) the refractive effect of RK IS msensltlve to changes in intraocular pressure in the physiologic range.
Scientific Poster 116 Phenol-red Thread Test Compared to Schirtner Test in Normal Subjects Penny A Asbell, MD, New York, NY; Bessie Chiang, MD, Verona, NJ; KY Li, MD, Hong Kong
The phenol-red thread test (pRTT) as developed by Hamano et aI. is a method of measuring basal tears by placing specialized thread in the eye for 30 seconds. We looked at 66 normal eyes and determined the reliability of the PRTT and the Schirmer test both with and without anesthesia. Our results indicate that the PRTl' is significantly reproducible with and withou~ anesthe~ia wit,h !" correlation coefficient of 0.67 and 0.75 respectively and IS statistically more reliable than the Schi~mer test. The ~RTT m~y offer an alternative method for measurmg tear production that IS more reproducible and faster with less discomfort to the patient.
Scientific Poster 117 Infectious Crystalline Keratopathy Alice Y Matoba, MD; Dan B Jones, MD, Houston, TX
The term "infectious crystalline keratopathy" refers to a distinctive form of corneal infection characterized by non- suppurative fingerlike infiltration of the mid-stroma in which the classic etiologic agent is either streptococcus of the viridans group or peptostreptococcus. We have identified four patients with the clinical picture of crystalline keratopathy in whom cultures were positive for a variety of organisms including gram negative rods. The spectrum of corneal disease and response to treatment will be discussed.
Scientific Poster 118 Clinically Atypical Granular Dystrophy with ,Pathologic Features of Lattice Dystrophy: A Study of Three Families Robert Foiberg, MD, Iowa City, IA; EdwardiJ Alfonso, MD, Miami, FL; J Oscar Croxatto, MD, Buenos Aires, Argentina; Neil G Dreizen, MD, Washington, DC; Noorjaitan Panjwani, PhD, Boston, MA; Peter R Lawson, MD, Philadelphia, PA; S Arthur Borw:,hoff, MD, Boston, MA; Jules L Baum, MD, Boston, MA; Roberto M eijide, MD, Buenos A ires, A rgentina; Joseph F Morrison Jr, MD, Wilkes-Barre, PA; Vitaliano B Bernardino, Jr! MD, Lang~ornefPA;J?aniel .~ Albert, MD, Boston, MA; Vwleta V Arbizo, MS, Pit~ladelpiaa, PA
Four patients from families in Pennsylvania, Massachusetts, and Argentina were diagnosed clinically as having granular dystrophy. Pathologic examination of the corneal buttons from each patient following penetrating keratoplasty demonstrated two types of deposits: (1) granular deposits in the anterior third of the stroma and (2) deeper fusiform deposits identified as amyloid by histochemistry and electron microscopy, morphologically identical to those seen in lattice corneal dystrophy. Although a relationship between these patients cannot be definitively proven, each family traces its origins to the Italian province of A vellino.
Scientific Poster 119 Serum Autoantibodies in Keratoconjunctivitis Sicca R Linsy Farris, MD, New York, NY; Robert N Stuchell, DMD, Morgantown, WV; Russell Nisengard, DDS, PhD, Btiffalo, NY
Tear osmolarity has been shown to be a more sensitive test for the diagnosis of keratoconjunctivitis sicca (KCS) or dry eye compared to Schirmer test and Rose bengal staining. A history of dry mouth or arthritis in KCS indicates a diagnosis of Sjogren's syn~rome which carries a 40-fold higher risk of developing
-hfe-threatening lymphoma or other serious disease within five years. Forstot and coworkers measured autoantibodies in KCS patients diagnosed by Schirmer test and Rose bengal staining and reported a 31% incidence of SS-A and/or SS-B autoantibOdies. We have measured autoantibodies in 80 patients with KCS diagnosed by tear osmolarity measurements and a history of dry :routh and/or connective tissue disorder. We found only 2.5% .. S-A and 4% SS-B. (Invited From ARVO Meeting)
Scientific Poster 120 Induction of De Novo Synthesis of Crystalline Lenses in Aphakic Rabbits Arlene E Gwon, MD; Karen Mundwiler, AHT; Janet Conway, PhD; Hiro Enomoto, PhD; Judith Spencer, BS; Irving H Leapold, MD, DSc; Mary-Jane Brannin, MA, Irvine, CA Although lens regeneration has been observed in rabbits after lens removal (Stewart, 1960), to our knowledge no analysis has been made of this newly formed material. In our study, endocapsular and standard extracapsular (control) lens extractions were performed on adult rabbits. We found that the presence of intact anterior and posterior capsules was necessary to promote regeneration of the lens material. Using HPLC and gel chromatography, the lens-protein profile of the regenerated material was found to resemble that of normal crystalline lens protein. In addition, histopatholo~ and electron microscopy showed considerable structural similarIty between regenerated and normal lenses. (Invited From ARVO Meeting)
Scientific Poster 121 Pathogenesis of Meibomian Gland Dysfunction: A Tridimensional View Robert W Lambert, PhD, Lo~ ~ngeles, CA; James V Jester, PhD, Potomac, MD; Ronald E Sm'ttit, MD, Los Angeles, CA Hyperkeratinization of meibomian gland epithelium has been sugg~sted as a possible mechanism for meibomian gland dysfunction (MGD) (Jester et aI, Invest ophthalmol 22:666, 1982). We have developed a rabbit epinephrine-induced MGD model and examined normal eyelids (9 rabbits) and those from 12 MGD rabbits at various stages of the disease. SEM observations suggested proliferation in desquamated epithelium in the vicinity of the meibomian gland orifice of experimental tissue. The abundance of this epithelium, previously unreported in MGD lid margins clearly represents an alteration in the normal process of keratinization and may be a factor in the etiology of MGD. (Invited From ARVO Meeting)
Scientific Poster 122 The Effect of Preservatives on Two Species of Acanthamoeba Thomas S Wood, MD, Dallas, TX; Robert E Silvany, Dallas, TX; R Wayne Bowman, MD, Dallas, TX; James P McCulley, Dallas, TX ATCC A . castellanii and A . polyphaga, isolated from human corneal ulcers, were exposed to commercial contact lens solutions and individual preservatives for 24 0 in a culture/filter apparatus of our own design. The suspensions were filtered, rinsed, and cultured at 35°C · with appropriate positive control. Of the commercial products tested, Acanthamoeba is able to survive solutions that contain only sorbic acid and edetate or potassium sorbate and edetate. Of the single preservatives tested, Acanthamoeba is able to survive thimerosal and sorbic acid. Chlorhexidine and hydrogen peroxide are 100% effective in killing both species. Therefore, by using these solution, lens cases and solutIOn bottles could be eliminated as reservoirs of infection. (This poste: is physically located outside j,ts topic area. $~ "OJ?tics, Refractwn and Contact Lenses" for otw posters on tit~ torne.)
Glaucoma and Iris All presenters will attend their posters on Sunday jrcrm 11:30 AM to 1:00 PM, and at various times throughout the Annual Meeting. Individual attendance hours will be indicated on a mock clock at each poster board. See also poster #208.
Scientific Poster 123 Functional Deterioration in Extremely Early Glaucoma and with Aging Tetsushi Yasuma, MD, Nagoya, Japan; Jun Yamazaki, Nagoya, Japan; Noriaki Yamamoto, MD, Nagoya, Japan; Nomo Miyakawa, MD, Nagoya, Japan
Prevention of the glaucomatous functional defects requires earlier detection of glaucomatous changes. Double flash resolution (DFR) and critical flicker fusion frequency (CFF) were measured in 30 patients with extremely early glaucoma, who had no abnor· mality using a Goldmann or Tubinger perimeter. These two tests were also performed in 24 normal subjects consisting of 3 age groups. Ten out of 30 patients with glaucoma showed a signifi· cant deterioration of DFR in the temporal visual field (p<0.05) without any abnormality in CFF. In the normal population, on the other hand, functional abnormality with aging was observed in the upper visual field (p< 0.001). These results suggest that DFR is a promising test for the early diagnosis of glaucoma.
Scientific Poster 124 A Summary Flow Sheet for Glaucoma Data John H Tanton, MD, Petoskey, MI
A summary flow sheet for keeping track of the voluminous data collected on glaucoma patients will be presented, and its use will be explained. This sheet was developed and refined by the author and four colleagues during 20 years of general ophthalmic practice. It has brought order to the task of keeping track of the data on individual glaucoma patients. It helps call quickly back to mind a particular patient's situation by displaying what has happened in the past. It portrays the current status, and points to the tests or procedures needed now or in the near future to keep that particular patient's care current and up-to-date. The sheet may prove useful to others confronted with this same problem.
Scientific Poster 125 Sectorial Features of the Neuroretinal Rim (NRR) in Normal and Glaucomatous Eyes Jost B Jonas, MD, Erlangen, West Germany; Gabriele C Gusek, MD, Erlangen, West Germany; Gottfried, 0 H Naumann, MD, Erlangen, West Germany The neuroretinal rim (NRR) as equivalent of the retinal nerve fibers is s~ecifically altered in glaucoma_ It was evaluated by Littmann s method magnification corrected morphometry of 200 normal and 423 glaucomatous optic disc photographies. In normals, NRR was significantly (p<0.001 Wilcoxon-test) broadest in the inferior optic disc region (0.50 ± 0.15 mm) and smallest in the temporal sector (0.30 ± 0.16 mm). Early glaucomatous NRR loss was more marked in the temporal lower sector compared to the temporal upper one (p<0.001). Glaucomatous NRR notches were located 9.2±9.4 degree temporal to the upper and 11.6±9.8 degree temporal to the lower disc pole with no significant difference between these locations. Glaucoma must be suspected if NRR width is smallest anywhere outside the horizontal temporal sector.
Scientific Poster 126 Long-term Follow-up of Nd:YAG and Argon Laser Iridotomy for Pupillary Block Glaucoma Lucian V Del Priore, MD, PhD, Baltimore, MD; Alan L Robin, MD, Baltimore, MD; Irvin P Pollock, MD, Baltimore, MD Prospective, long-term (20 months) follow-up was obtained in 82 eyes of 41 patients with pupillary block glaucoma in whom Nd:YAG iridotomy was performed in one eye and argon laser iridotomy was performed In the contralateral eye. Only 3 eyes in each group lost more than 2 lines of Snellen acuity within the first 20 months after treatment, and 2 eyes in each group required cataract surgery. No eyes developed clinically significant corneal decompensation. After iridotomy, 10 (24%) argon and 9 (22%) YAG eyes required laser trabeculoplasty for glaucoma control, and 5 (12%) argon and 2 (5%) YAG eyes required filtration surgery_ No significant long-term differences were seen between these two groups of eyes_
Scientific Poster 127 A Multicenter Evaluation of the Efficacy of Levobunolol and Betaxolol Daniel A Long, MD, Gretna, LA; Gordon E Johns, MD, Lama Linda, CA; Raymond SMullen, MD, Riverside, CA; Robert J MI!-Si, MD, San Jose, CA; Arthur.D Charap, MD, PhD, Anajleim Htlls, CA; Cneryl Y Eto, BS, Irmne, CA; Gary D Novack, PhD, Irvine CA We evaluated the ocular hypotensive efficacy of twice-daily 0_25% and 0_5% levobunolol (LBUN), and 0.5% betaxolol (BTAX) in a double-masked, randomized controlled trial in 85 patients with open-angle glaucoma or ocular hypertension. During the three-month study, intraocular pressure (lOP) reductions in the two LBUN groups were significantly greater than in the BTAX group. From a mean baseline lOP of approximately 25 mmHg, overall mean reductions were 6.2 and 6.0 mmHg for the 0.25% and 0.5% LBUN groups and 3.7 mmHg for the BTAX group. No significant among-group differences were noted in the systemic safety variables evaluated. These data suggest that while all three treatments are effective, LBUN provides a greater reduction in lOP than BTAX.
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Scientific Poster 127 A Multi-center Evaluation of the Efficacy of Levobunolol and Betaxolol Daniel A Long, MD, Gretna, LA; Gordon E Johns, MD, Loma Linda, CA; Raymond SMullen, MD, Riverside, CA; Robert J MifSi, MD, ~an Jose, CA; Arthu,,: D Charap, MD, PhD, Anajteim Hills, CA; Cneryl Y Eto, BS, Irmne, CA; Gary D NO'IJack, PhD, IrvineCA
We evaluated the ocular hypotensive efficacy of twice-<iaily 0.25% and 0.5% levobunolol (LBUN), and 0.5% betaxolol (BTAX) in a :double-masked, randomized controlled trial in 85 patients with open-angle glaucoma or ocular hypertension. During the three-month study, intraocular pressure (lOP) reductions in the two LBUN groups were significantly greater than in the BTAX group. From a mean baseline lOP of approximately 25 mm Hg, overall mean reductions were 6.2 and 6.0 mm Hg for the 0.25% and 0.5% LBUN groups and 3.7mm Hg for the BTAX group. No significant among-group differences were noted in the systemic ,safety variables evaluated. These data suggest that while all ;three treatments are effective, LBUN provides a greater reduction in lOP than BTAX.
: Scientific Poster 128 A Masquerader of Visual Field Loss in Glaucoma Barbara Nugent, MD, San Antonio, TX; Stuart A Terry, MD, San Antonio, TX; Patrick S O'Connor, San Antonio, TX; John P Douglas, MD, Cleveland, OH; Diane M Cupples, San Antonio, TX The clinical observation of visual field constriction following pilocarpine has been commonly observed; however, the extent and character of this constriction has not been quantified in the glaucoma patient. Kinetic visual fields were ~rformed on 28 glaucoma patients on pilocarpine therapy. FIelds were repeated 30
:minutes after instillation of 2.5% Neosynephrine. Pupillary and r~fracti,,:e changes were noted. COlT!puter an~lysis revealed a sig-
, mficant mcrease (greater than 50% m some) m the field following Neosynephrine. The importance of these findings in following the glaucoma patient on pilocarpine will be stressed.
. Scientific Poster 129 Laser Sclerostomy Wayne F March, MD, Oklahoma City, OK; Andrew Wneeler, Oklahoma City, OK This poster shows the postoperative appearance of patients who have undergone Laser Sclerostomy, the creation of a permanent
. filtration fistula between the anterior chamber and the subcon-~unctival space by reflectin~ a laser with a gonioscopic lens. The Injection of 20% silver OXIde (Argyrol) into the limbus permits performance of the procedure at lower power either entirely with the YAG laser or with a combination of krypton or argon and YAG lasers. Illustrated are filtration fistulas that have remained patent fOl' over two years, conjunctival blebs which were created at ~everal clock hours, and the complication of conjunctival perforatIon. This procedure would appear effective in selected cases of open angle glaucoma, .
Scientific Poster 130 Pattern Electroretinogram (PERG) as Correlate of Visual and Structural Disturbances in Glaucoma Matthias Korth, MD, West Germany; GottjriedNaumann, MD, West Germany; Folkert Horn, West Germany; Brigitte Storck, West GeT7nany; Jost Jonas, MD, West Germany The PERG as indicator of retinal ganglion cell function obtained from 72 glaucoma eyes was compared with recordings from 116 normal eyes. The normally observed spatial band-pass character of the response was lost in most glaucoma eyes (p= 0.01). Decreases in PERG amplitUde were paralleled by field losses (in dB) in the same retinal area as determined by static quantitative computer perimetry (p= 0.001). 50% of the glaucoma eyes and 27% of the ocular hypertensive eyes had a reduced PERG (p=O.OI) when compared with age-matched normal eyes. A correlation of PERGs with quantitative papillometric data revealed a PERG decrease with increasing C/D ratios and with decreasing neuroretinal rim areas (p=O.OI). These data indicate the high potential value of the PERG in glaucoma diagnosis.
Scientific Poster 131 Periocular and Topical Steroids in the Treatment of Uveal Juvenile Xanthogranuloma Kevin W Treacy, MD, Minneapolis, MN; C Gail Sum1ners, MD, MinneapoHs, MN; Robert D Letson, MD, Minneapolis, MN; Jonathan E Pederson, MD, .Minneapolis, MN Most reports of successfully treated uveal juvenile xanthogranuloma (JXG) have involved systemic steroids, irradiation or excision. We report 5 patients treated with local steroids. All had tumor regression and intraocular pressure control. The 3 patients with hYfhemas had no recurrences. Final visual acuity equalled that 0 the uninvolved eye in all but one case which had poor compliance with amblyopia prophylaxis. This is the largest reported series of successfully treated uveal JXG and the first to demonstrate pel"iocular steroid efficacy. It also demonstrates the importance of gonioscopy in infants with glaucoma, as 2 patients had tumors visible only with gonioscopy .
Scientific Poster 132 The Clillico-Pathological Correlation of a Successful Glaucoma Pump-Shunt Implant Thomas C Wnite, MD, Sioux Falls, SD; J Douglas Cameron, MD, Minneapolis, MN A 62-year-old white male with diabetes mellitus and aphakia with an anterior chamber pseudophakos presented to one of us (TCW) with neovascular glaucoma. A glaucoma pump-shunt was implanted and permitted successful control of the ocular pressure until his death 6 months postoperatively. Histopathology examinations including light microscopiC and scanning electron microscopic demonstrate a patent inlet tube in the anterior chamber, a fibrotic reaction surrounding the silicone implant similar to that which occurs around retinal bands, and an aqueous drainage cavity posteriorly in Tenon's space.
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Scientific Poster 133 Roving-Cluster Analysis of Change in Glaucomatous Visual Fields H Dunbar Hoskins, MD, San Francisco, CA; Scott D MOfjee, MS, San Francisco, CA; Martin N Kidd, San Francisco, CA Regression analysis of 5 sequential Humphrey 30-2 visual fields in 40 glaucoma patients was performed longitudinally through 123 distinct areas of the field including: the entire field; 2 Bjerrum areas; 4 quadrants; 40 roving clusters of 9 spots each; and 76 individual spots. Roving cluster analysis resulted in a 6 fold increase in sensitivity for recognition of visual field loss with no loss of specificity as compared to analysis of the entire visual field. Statistical analysis of smaller areas of the field may be helpful in earlier recognition of incremental change in the visual field.
Scientific Poster 134 Low Tension Glaucoma and Visual Field Changes Richard E Gliklich, Philadelphia, P A; William C Steinmann, MD, MS, Philadelphia, f1; L J~1/ Katz, M.D, Philadel1!hia, PA; Ronald L Gross, MD, Prnladelpitta, PA; Rtcitard P Wtlson, Philadelphia, PA; George L Spaeth, MD, Philadelphia, PA Visual field (VF) changes in "low tension glaucoma" (LTG) have not been well described. We examined the VFs of patients with LTG (intraocular pressure <24mmHg) and 5 years of Octopus perimetry at Wills Eye Hospital (n-35 patients). VFs were assessed for initial stage of visual field loss and for change at 3 and 5 years. The mean age was 64, 72% were female and the mean initial intraocular pressure was 17. Using well-defined criteria for change, 49% were "worse" at 3 years and 59% were "worse" at 5 years. 6% were improved at 5 years. The most common VG finding was a dense paracentral scotoma. These results differed significantly from a comparison group of other types of glaucoma and suggest that LTG is distinct in its pattern of VF changes.
Scientific Poster 135 Ab-Interuo Thermal Sclerostomy Using Nd:YAG Contact Laser to Produce a Filtering Bleb Jonathan C Javitt, MD, Philadelphia, PA; RichardP Wilson, MD, Philadelphia, PA; Stefan S O'Connor, Philadelphia, PA; FumitakaAndo, MD, MOfjoya, Japan; Gholam A Peyman, MD, ChicOfjo, IL; Jay L Federman, MD, Philadelphia, PA
We report the first use of contact Nd:YAG laser focused through a sapphire crystal for the creation of a filtering bleb by ab-interno thermal sclerostomy. A 2 mm clear corneal incision was made in an anesthetized New Zealand Rabbit and the 30 mm long sapphire crystal was passed across the anterior chamber until it was in contact with the opposite angle. Two pulses of 0.8 Joules were required to produce a filtering bleb in 10 of 10 eyes. No damage was noted to the overlying conjunctiva and the procedure time was under 5 minutes. Histological examination revealed a surrounding area of scleral melting that extended only 100 I" from the sclerostomy. This should be compared with the much more extensive tissue disruption surrounding traditional thermal sclerostomy using a cautery.
Scientific Poster 136 Clinical Comparison of the Oculab Tonopen to the Goldmann Applanation Tonometer Sue F Kao, MD; Paul R Lichter, MD; Terry J Bergstrom, MD, Susan Rowe, MD; DavidCMusch, PhD, Ann Arbor, MI
Clinical comparison of the Oculab tonopen (OT) to the Goldmann applanation tonometer (GT) was done on 197 eyes of 103 patients with glaucoma or ocular hypertension, to evaluate the OT's reliability in determining intraocular pressure (lOP) in this patient group. While there was good overall correlation between the two instruments (1'=0.84 OD and 1'=0.87 OS), the OT tended to underestimate the lOP in eyes with elevated, GT-measured lOPs. The overall sensitivity of the OT in detecting GT-measured lOPs of 21 mmHg or higher was 62.1 % OD and 72.4% OS, with corresponding specificities of 92.6% OD and 97.1 % OS.
Scientific Poster 137 Effects of Applanation Tonometry on Automated Perimetry in Normals and Patients with Ocular Hypertension Jmnes Ruben, MD, Sacramento, CA; Richard A Lewis, MD, Sacrmnento, CA; Chris Johnson, PhD, Sacramento, CA; John L Keltner, MD, Sacramento, CA
Applanation tonometry is often performed immediately prior to perimetric testing. In order to determine if threshold perimetry was affected, we tested 12 normal subjects and 12 patients with ocular hypertension on topical beta-blocker therapy. Using the Humphrey Field Analyzer 30-2 program, each patient had field testing performed OU, followed by applanation tonometry OD and subsequent field retesting OU. Analysis of the visual field results did not detect any consistent effect, suggesting that any disturbance of the corneal surface from applanation tonometry has minimal influence on threshold perimetry.
Scientific Poster 138 Is Pigment Dispersion Syndrome an Autosomal Dominant Disorder? John A McDermott, MD, New York, NY; Robert Ritch, MD, New York, NY; Adam Berger, New York, NY
We examined 51 immediate relatives of 23 patients with pigment dispersion syndrome (PDS) with or without glaucoma. Fourteen (27.5%) had PDS with or without glaucoma. None of the 21 children (ages 8 to 20 years) were affected. Of the adults examined, 14/30 (46.7%) were affected (3/4 fathers, 2/8 mothers, 6/10 brothers, 3/8 sisters). These data suggest that PDS is an autosomal dominant gene, the phenotypic expression of which most commonly becomes manifest in early adulthood.
Scientific Poster 139 Pressure Tolerance Testing of the Optic Nerve lIead by a Routine Method of Visually Evoked Cortical Potentials Richard Stodtmeister, MD, Ulm, West Germany; Lutz E Pillunat, MD, Ulm, West Germany; Robert David, MD, Beer Sheva, Israel; Ingo Wilmanns, PhD, Bonn-Venusberg, West Germany The pressure tolerance of the optic nerve head can be tested by recording evoked cortical potentials at stepwisely artificially increased intraocular pressure. 50 healthy subjects invariantly showed a kink in the amplitude/pressure curve (AlP-C) at about 30-50 mmHg lOP as a sign of optic nerve head circulatory autoregulation while 50 patients with manifest primary open angle glaucoma did not show this kink. These findings are independent from the spontaneous intraocular pressure level. Until noW we used steady state evoked potentials measured by a vector voltmeter, a valid and fast and sensitive method but not very common in ophthalmology. By using the routine method of transient visual evoked potentials (1,9 pattern reversals/s, averaging 25 sweeps, sweeplength 500 ms) we made the same examination as with the steady state potentials. In 5 of our 30 healthy volunteers there was no kink in the AIP-C curve. It is concluded that by using averaging techniques the test looses specificity but is helpful in suspected glaucoma patients when the kink in the AIP-C curve is present.
Scientific Poster 140 Evaluation of a New, Portable Tonometer with Digital Display Robert L Stamper, MD, San Francisco, CA; lain D Gardner, FRCS, Oxford, England; Anthony J Bron, FRCS, Oxford, England A portable, pocket-sized, battery-operated tonometer with digital display was compared to the Goldmann applanation tonometer for accuracy, ease of use and patient acceptability in a group of 118 ophthalmic patients with normal corneas. The majority of these patients were randomly assigned as to which instrument was used first. The person using the second tonometer was masked from the results of the first. The accuracy of the new tonometer on one eye of each patient was found to compare favorably to that of the Goldmann tonometer (r = 0.91). Ease of ilse and patient acceptability were also similar to that of the Goldmann.
Scientific Poster 141 Goniophotoablation-Histologic Characteristics Michael S Berlin, MD; Donald S MincTCler, MD; Marvin Martinez, BS; Thanassis Papaioannou, MS, Los Angeles; Theo Seiler, MD, PhD, Berlin, W Germany; Warren Grundfest, MD, Los Angeles, CA Coupling the excimer laser to flexible fibers allows the intraocular delivery of long-pulsed 308 nm radiation. A new glaucoma filtering procedure has been developed in which photoablation from within the eye creates an aqueous outflow channel without initially disrupting the overlying episcleral tissues. From a pilot study in 16 eyes of nine rabbits, histologic examinations were performed from immediately following the procedure to six weeks post-op. Light and electron microscopic examinations demonstrate the extent and position of the ablation effects both in creating a functioning fistula and on neighboring tissues exposed to the ultraviolet radiation. The effects of fiber ~ize (400 and 600 micron diameter) and fluence (2.5 and 3.5 J/cm ) are compared. Goniophotoablation may offer an alternative in the surgical management of glaucoma.
Scientific Poster 142 Static Perimetric Evaluation of the Peripheral Visual.Field in Early Glaucoma Michael V Drake, MD, San Francisco, CA The incidence of peripheral visual field loss in the presence of a normal central field in early glaucoma is uncertain. We evaluated this using an automated perimeter (Octopus 201) with a program that tests both the central and peripheral field (Gl). We tested 50 eyes of glaucoma and glaucoma suspect patients (study group) and 50 eyes of normal controls. None of the study group eyes showed peripheral defects in the absence of central field loss. In fourteen study group eyes (28%) the peripheral exam enhanced or confirmed findings from the central exam. Two of.the control group eyes (4%) showed peripheral defects with a normal central field (false positives). Our findings suggest a high costlbenefit ratio for routine peripheral static testing.
Scientific Poster 143 Progressive Myopia and Acute Glaucoma in Congenital Zonular Dysplasia. A Study of Two Families Enrique S Malbran, MD; Cipriano D'Alessandro, MD; Daniel Charles, MD; J Oscar Croxatto, MD, Buenos Aires, Argentina Patients with congenital zonular dysplasia may present signs and symptoms other than lens displacement due to secondary anatomical alteration of the anteriorse~ment. We present two families, one of them with affected indiVIduals in five successive ge~erations. The vast majority of the patients sought consultation because of progressive myopia and/or intermittent acute intraocular hypertensive crisis which obscured the basic pathologic condition. Upon recognition of the disease the affected patients underwent an uneventful intracapsular cataract extraction. Histopathologic examination of the removed lenses suggested a dysplastic development of lens zonules.
Scientific Poster 144 National Survey of the Prevalence and Risks Factors of Glaucoma in Saint Lucia; West Indies Roger P M(L$on, MD, Washington, DC; Omofolasade Kosoko, MD, New Carrollton, MD; James Martone, MD, Washington, DC; . C1Q.ude L Cowan Jr, MD, WaShington, DC, M Roy Wilson, MD, Los Angeles, CA; Jam,es Gear, MSPH, Washington, DC; Dennis Ross- Degnan, SeD, Roslindale, MA There is a paucity of data available on the epidemiology of glaucoma in blacks. Using a cluster sampling technique, 1695 individuals 30 years of age and older were examined. Visual acuity, intra-ocular pressure measurement, and cup disc evaluation were performed on every participant and every third person underwent automated perimetry. In additiol), persons felt to be at risk because of lOP 21 or greater or c/d ratio ~ 0.7 were evaluated by automated perimetry. 460 high risk individuals were identified and referred for a definitive exam and threshold visual fields. 323 were referred for IOP, 183 for c/d ratio, and 185 for visual fields . Our results suggest an increased risk for glaucoma in this population.
Scientific Poster 145 Long-term Morphological Effects of Antiglaucoma Drugs on the Conjunctiva and Tenons in Glaucomatous Patients Mark B Sherwood, MD, Gainesville, FL; Ian Grierson, PhD, Lo:ndpn, England; Lynn Millar, London, England; Roger A HttciLtngs, FRCS, London, England External bleb scarring is a major cause of filtration surgery failure. Conjunctival/tenons capsule biopsies from two patient groups were quantitatively analyzed by light microscopy: a) 20 patients with a primary glaucoma for whom surgery was a primary treatment modality, and b) 20 patients with a primary glaucoma who had received at least two types of antiglaucoma topi~1 medication, fOl· a minimum of one year prior to surgery. All slides were examined by two masked observers. A significant increase in the number of inflammatory cells and fibroblasts in the conjunctiva and tenons, and a significant decrease in the number of epithelial goblet cells was seen in the group that received long-term drop therapy. These results su~mest that exhaustive medical therapy, before surgery is offered, Increases the number of tissue inflammatory cells which may enhance the risk of external bleb scarring. (Invited Poster)
Scientific Poster 147 Permeability of Human Cornea and Sclera to Sulfonamides Henry F Edelhauser, PhD, Milwaukee, WI; Thomas H Maren, MD, Gainesville, FL
Corneal penetration of sulfonamide carbonic anhydrase inhibitore . for topical treatment of glaucoma was tested in human eye bank tissue and rabbit corneas. Paired corneal epithelia, intact or removed, and excised sclera were perfused in vitro. Corneal permeability (K",) to methazolamide and ethoxzolamide was similar in . both species but greater in man for benzolamide andbromaceta- . zolamide. Human corneas without epithelium had an increased K psimilar to scleral Kp .. Methazolamide (6mM) was studied .in vivo In rabbit and man (prior to cataract surgery)_ Rabbit aqueous conc.(SI'M ± SE) was 3.2 ± 1.4 at 8 miri. and 1.2±0.16 at 1 hr. In man <0.2 was detected at 8 min; at 1 hr. none was detected in 3 cases and 0.4 ± 0.08 was detected in 4 cases. Lower Kp in man than rabbit may result from a 2-fold lower corneal/conjunctival area. (Invited Poster)
!Intraocular Inflammation and Ocular Tumor All presenters will attend their posters on Sunday from 9:00 to 4:30 PM, and at various times throughout the Annual Meeting. Individual attendance hours will be indicated on a mock clock ;,at each poster board. See also poster #ss.
Scientific Poster 148 Echographic Characteristics of Ocular Toxocariasis cW Lee Wan, MD, Pasadena, CA; Miriam R Carw, MD, Los Angeles, CA; Kieth J Pince, PhannD, Long Beach, CA; Ronald L Green, MD, Los Angeles, CA
0, culllr toxoC!!riasis cla,ssiC!!lly presents with one of three distinct cliniC!!1 syndromes: endophthalmitis, posterior granuloma, or peripheral granuloma. We reviewed the echographic findings in nine cases of toxocariasis presenting with one of these syndromes. The echographic features were similar in all C!!ses and consisted of 1) a solid, high-reflective mass lesion, often with some calcification; 2) a vitreous membrane extending from the mllss to the pos'terior pole; and 3) a traction retinal detachment or retinal fold in the posterior pole. Although the clinical presentation of ocular toxocariasis may vary with the 10C!!tion and activity of the disease, all C!!ses tend to have similar echographic findings.
Scientific Poster 149 A New Inexpensive Plaque for Choroidal Melanoma Iodine-125 Plaque Therapy Andrew K Vine, MD; Richard F D-iaz, MD; Randall K TenH aleen, PhD; Allen S Lichter, MD; Barbara B Maxson, DDS; Paul R Lichter, MD, Ann Arbor, MI
We have developed anew inexpensive precious metal alloy plaque for use in customized Iodine-125 plaque therapy. Each plaque is formed from two flat circular gold/palladium foils which are used in dental crown work. Using a simple manual mechanism, the two forms are stamped over a customized acrylic die shaped to the, dimensions of the tumor base plus a 2 mm margin. The formed plaque is gently heated to fuse the two forms. Finished thickness is .10 to .12 mm. Completed plaques consist of a back wall, a 1.8 mm high side wall to limit radiation to the forward direction, and a 1.5 mm wide lip with holes for suture placement. We have successfully used this plaque to treat eight C!!ses of chor?idal malignant melanoma. Advantages include: simple construction from inexpensive components, customized shape, and Iodine seeds are readily visible on orthogonal radiographs.
Scientific Poster 150 Immunocytologic Studies of the Conjunctiva in Graft versus Host Disease George, T Boozalis, MD, Lalee Jackson, TX; Jay S Pepose, MD, PhD, Baltimore, MD; Douglas A Jabs, MD, B01timore, MD; William Green, MD, Baltimore, MD; John R Wingard, MD, Baltimore, ltID; Rein Saral, MD, Baltimore, MD; George W Santos, MD, Baltimore, MD Graft versus host disease (GVHD) is a major compliC!!tion following bone marrow transplantation with frequent involvement of the conjunctiva and ocular surface. We performed immunocyto-10, gic analyses 0, f conjunctival biopsy s,pecimens from patients with acute and chronic,GVHD. All patients with GVHD have an increase in HLA-DR antigen expression on T cells in the conjunctiva; those with acute GVHD w.ith pseudomembranous conjunctivitis have an infiltrate of activated T cells with a predominance of T helper/inducer cells and lesser numbers of T crtotoxic/suppressor cells, macrophages, and B cells. Conjunctiva biopsies may serve an important role in the prognosis and management of GVHD.
Scientific Poster 151 Toxoplasmic Scleritis Joel S Schuman, MD, Richmond, VA; Robert S Weinberg, MD, Richmond, VA; Andrew P Ferry, MD, Richmond, VA; Walter Atlas, AID, R-iehmond, VA; R Kenrwn Guerry, MD, Richmond, VA Toxoplasmosis, the most COmmon infectious C!!uSe of posterior intraocular inflammation, is a rare etiologic factor for scleritis. Four C!!ses of toxoplasmosis with scleritis are presented. Two patients with anterior scleritis and retinitis, diagnosed cliniC!!lly and serologiC!!lly, received mediC!!I therapy with resolution of disease. Two of the patieJitswere immunosuppressed, developed endophthalmitis, refractory to treatment, and underwent enucleation. Pathologic examination revealed Toxoplasma gQndii in retinal tissue with inflammation involving the retina, choroid and sclera. Toxoplasmosis should be considered in the differential diagnosis of scleritis, especially in immunosuppressed individuals.
Scientific Poster 152 Late Clinical and Angiographic Findings in the Vogt-Koyallagi-Harada Syndrome Kirk H Packo, MD, Chicago, IL The acute findings ofthe Vogt-Koyanagi~Haradi Syndrome (VKH) have been well described, but little attention has been paid to the late findings, aside from the "sunset glow fundus." We retrospectively, reviewed 23 cases of VKH in the late stage. Ninety-one percent (91%) of patients had leopard spot pigmentation and atrophic spots. Eighty-two percent (82%) developed the classic "sunset glow." Sixty-five percent (65%) developed a curvilinear pigmented line in the macula not previously described, which we term a "scimitar sign," and correlated with poor acuity. Other findings included peripapillary disciform sC!!rs, nodular choroidal neovascularization, chorioretinal anastomosis and macular edema.
Scientific Poster 153 E!ectron .Microscopy Ai~s Dia&"nosis of Retin~l BlOPsy/VItrectomy Spec1l1lens m Suspected VIral Retinitis Ben J Glasgow, MD; Harry H Brown, md; Gary N Holland, MD; Yossi Sidakaro, MD, PhD; Robert Y Foos, MD, LosAngeles, CA Specific treatment of suspected viral retinitis requires accurate dIagnosis by morphology. Vitrectomy/retinal biopsy specimens were obtained in six cases of suspected viral retinitis. All were analyzed by cytomegalovirus; five were not diagnostic; one was consistent with cytomegalovirus (CMV) infection. Electron microscopy performed on three non-diagnostic specimens showed Herpes virus particles in retinal cells. Homogeneous dense bodies consistent with CMV were observed in one case. In another, thick sections showed ground glass inclusions suggestive of Herpes simplex infection. Electron microscopy can provide a specific diagnosis in selected cases of viral retinitis.
Scientific Poster 154 Immunopathology of Vitreous and Retinochoroidal Biopsy in Posterior Uveitis Leslie S Fvjikawa, MD; Jan-Petter Haugen, MD, San Francisco, CA
Biopsy of ocular tissues may assist in the diagnosis of posterior uveitis and may guide therapy. We used immunopathologic techniques to study vitreous and/or retinochoroidal biopsies from seven patients with posterior uveitis. Three cases of infectious retinitis and four cases of presumed autoimmune uveitis were studied. Results showed T cells in the vitreous and a mixture of T and B cells in the retina-choroid. Monocytes were not prominent but might correlate with granulomatous etiology In two cases (syphilis and ARN). Class II histocompatibility complex antigens were increased on vessels of the retina-choroid in two cases, implicating a local cell-mediated immune response. These results may be helpful in categorizing posterior uveitis, permitting appropriate therapy to be given.
Scientific Poster 155 Epithelial Membrane Antigen (EMA) Stain in Histiocytic Lesions of the Eye and Annexa Zeynel A Karc'ioglu, MD; Barrett G Ham, MD, New Orleans, LA
Immunoperoxidase stains for EMA wasperforrried on a variety of histiocytic lesions, including specimens. from juvenile xanthogranuloma, Erdheim-Chester syndrome, xanthelasma, chalazion, sympathetic ophthalmia, phacomatous uveitis, orbital foreign body reactions, sarcoidosis, sinus histiocytosis with diffuse lymphadenopathy, conjunctival and orbital lymphoid hyperplasias, and orbital lymphomas. Only significant EMA positivity was obtained in malignant lymphoma cases, which may prove useful in histopathologic differential diagnosis of ocular histiocytic lesions.
Scientific Poster 156 Multinuclear Imaging and Spectroscopy of Human Ocular Tumors Nancy H Kolondy, PhD, Boston, MA; Evangelos S GrO(/oudas, MD, Boston, MA; Donald J D'Amico, MD, Boston, MA; Susan J Kohler, PhD, Cambridge, MA; JohannaM Seddon, MD, Boston, MA
Clinical evaluation of uveal melanomas by magnetic resonance (MR) techniques depends upon developing an understanding of the appearance of these tumors in MR images and spectra. We have determined MR characteristics of suspected uveal melanomas by surface coil proton and sodium MR imaging and phosphorous-3! MR spectroscopy of freshly enucleated human eyes. Proton and sodium MR images are complementary; contrast between intraocular tumors and vitreous, lens or subretinal hemorrhage may be varied by using MR pulse sequences that emphasize tissues based on T!, T2 or proton or sodium density values. Phosphorus-3! MR spectra allow differentiation of choroidal melanomas from normal ocular structures based on levels of the membrane metabolites PE, PC, GPE and GPC. (Invited Poster)
N euro-Ophthalmology lill presenters will attend their posters on Sunday from 11:80 AM to 1:00 PM, and at various times throughout the Annual Meeting. Individual attendance hours will be indicated on a mock clock at each poster board. See also poster #68.
Scientific Poster 157 Bilateral Retrobulbar Optic Nerve Infarctions Following Blood Loss: A Clinicopathological ~Case Study Mark W Johnson, MD, Ann Arbor, MI; JonathanD Trobe, MD, Ann Arbor, MI; Marilyn C Kincaid, MD, Ann Arbor, MI
A 59-year-old woman with anemia became totally blind after repeated gastrointestinal bleeding and acute hypotension. Neu
"ropathologic examination was normal apart from bilateral infarctions of the orbital optic nerves. This is the only 'pure" histopathologic study of visual loss following hemorrhage in the recent literature, the single previous case being complicated by arteriosclerosis and vasculitis. We suggest that the locus of optic nerve infarction after hypotension depends on pre-existing risk factors. Hypotension with arteriosclerosis is likely to cause juxtalaminar optic nerve infarction; hypotension combined with anemia favors infarction in the orbital optic nerve, where pial end-vessels are subject to compression from hypoxic edema.
Scientific Poster 158 Retinitis Pigmentosa Presenting as Hemianopsia Respecting the Vertical Meridian Lenworth N Johnson, MD, Hershey, PA; Yaron S Rabinowitz, MD, Hershey, PA; Robert SHepler, MD, Los Angeles, CA
Three cases of retinitis pigmentosa presenting as hemianopsia that respected the vertical meridian are discussed: one monocular temporal, one monocular nasal and one binasal. The first case
'. had an afferent pupillary defect, late onset of bone spicules, and '.an abnormal electroretinogram. The latter two cases did not have ophthalmoscopic evidence of retinal pigmentary degeneration; however, dark adaptation studies were abnormal. None of the three cases had a family history of nyctalopia. Extensive neuroradiological studies including magnetic resonance imaging were normal. Retinitis pigmentosa should be considered in the evaluation of monocular or binocular hemianopsia respecting the vertical meridian.
Scientific Poster 159 Transient Horner's Syndrome Complicating Chest Tube Insertion after Pneumothorax Mario Milazzo, MD, Catania, Italy; Robert Steigerwalt, MD, Rome, Italy; Emilio Calabrese, MD, Catania, Italy; Marco Milazzo, MD, Catania, Italy We report a case of a previously healthy 32-year-old white female presenting with spontaneous pneumothorax of the left lung for which a chest tUDe was inserted resultin~ in miosis and ptosis after three days. A diagnosis of Horner s Syndrome was confirmed pharmacologically. Trauma to sympathetic fibers in the upper thorax by the chest tube was suspected. After removal of the chest tube, the patient fully recovered within two weeks. To our knowledge, this patient represents the first reported case of transient Horner's syndrome complicating the introduction of a chest tube.
Scientific Poster 160 Lyme Disease in Association with Giant Cell Arteritis: A Case Report Loui:; D Pizzarello, MD, Southampton, NY; Frank DiLeo, MD, Southampton, NY; Alan MacDonOld, MD, Southampton, NY; Robert H Semlear, MD, Sag Harbor, NY Lyme disease, a tick-borne infection caused by spirochete Borrel'ia Burgdorferi, manifests itself acutely by rash and fever. This case documents the presence of the spirochete in the blood of a 72-year-old man with sudden, unilateral vision loss. Temporal artery biopsy revealed changes compatible with giant cell arteritis. This IS the second case in which an association between Lyme disease and arteritis has been reported and the first in which the spirochete has been cultured in the blood of a patient with giant cell arteritis. The patient's course as well as appropriate diagnostic tests for Lyme disease will be presented.
Scientific Poster 161 Thickened Optic Nerve Associated with Choroidal Folds Miriam R Cano, MD, Los Angeles, CA; W Lee Wan, MD, Los Angeles, CA; Ronald L Green, MD, Los Angeles, CA Choroidal folds are associated with a variety of ocular and extraocular diseases, or can be idiopathic. Usinf standardized echography, we examined seven cases of choroida folds that demonstrated a thickened optic nerve pattern. Two cases had a solid infiltration of the nerve due to leukemia or eosinophilic granuloma. The remaining five cases were of unknown etiology and demonstrated increased fluid within the optic nerve sheath, evidenced by a positive 30° test. This suggests that in eyes with idiopathic choroidal folds, a thickened optic nerve due to fluid-filled optic nerve sheath, may mimic a solid retrobulbar mass, and cause indentation of the globe.
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Scientific Poster 162 Hydrocolloidal Dressing Protects Skin in Patients Requiring Extended Patching Richard E Wyszynski, MD, Cleveland, OH; Kirk M Morgan, MD, Cleveland, OH; William E Bruner, MD, Cleveland, OH; William Annable, MD, Cleveland, OH
Hydrocolloidal dressings have been used for several years .in ~he management of skin burns and ulcers. We report the applIcatIOn of this dressing as a skin protector for use with patients requiring repeated patching over an extended period of time. We have found that a single application of the dressing can remain in place for about seven days allowing eye patches and shield to be taped to the dressing. We find this dressing particularly well suited to pediatric patients who may require occlusional patching over an extended period of time and in wet or humid conditions. In addition to patient comfort, dermatopathic and mechanical complications of taping to skin are reduced.
Scientific Poster 163 Extruded Drusen of the Optic Nerve Head John F Gillis, MD, San Antonio, TX; H Michael Lambert, MD, LacklandAFB, TX; Anthony C Arnold, Los Angeles, CA
Optic nerve head drusen lie buried within the substance of the papilla in the majority of cases. Drusen are dynamic and anterior extension has been documented, however extension beyond the disc surface has not been described. We present three patients with no evidence of tapetoretinal degeneration in which the drusen of the optic nerve head appear to have extruded from the disc surface, and in one case, extended into the vitreous cavity. A review of the literature concerning optic nerve head drusen is also presented.
Scientific Poster 164 Congested Papillopathy: Echographic and Radiologic Evidence of Calcified Phleboliths Janis R Nobe, MD, Los Angeles, CA; Miriam R Cano, MD, Los Angeles, CA; Mark Borchert, Los Angeles, CA; Ronald L Green, MD, Los Angeles, CA; Alfredo A Sadun, MD, PhD, Los Angeles, CA
Three patients had a clinical presentation and fundus appearance most consistent with benign papillophlebitis. Echographic and radiologic examinations revealed a calcified nodule in the middle of the optic nerve, 3 mm posterior to the lamina cribosa. Two patients had fundi that maintained the appearance of a unilateral, congested optic nerve head with dialated, tortuous retinal veins. The third went on to develop optic atrophy. The central location of the calicification within the anterior optic nerve suggests that each nodule may be a phlebolith within the central retinal vein. Calcified fhleboliths may be an additional cause of unilateral congestion 0 the optic nerve head.
Scientific Poster 165 Correlation of Afferent Pupillary Defect with Visual Field Loss on Automated Perimetry Lenworth N Johnson, MD, Hershey, PA; Rickard A Hill, MD, Hershey, PA The study was designed to ascertain the relationship of visual loBS in the central 30 degrees of vision to the density of the relative afferent pupillary defect (APD). The APD of 24 patients was quantified using a neutral log density filter. The corresponding visual field loss on automated perimetry was expressed as a ratio ' (visual field quotient [VFQ1) of the total decibel sensitivity of the better seeing eye to the aecibel sensitivity of the eye with the APD. A direct correlation was noted such that the log density of ; the APD increased linearly with an increase in VFQ (r=0.65, p;i <0.001). A VFQ greater than 1.7, but without an APD, occurre<i ) in patients with non-organic visual loss.
Scientific Poster 166 Magnetic Resonance Imaging in Pituitary Apoplexy Lenw.orth N Johnson, MD, Hershey, PA; David {.-acomis, MD, Hersney, PA; Alexandar Mamounan, MD, Hersney, PA The diagnosis of pituitary apoplexy, an often fatal disorder, is frequently delayed. Computed tomographic (CT) scan has been shown to be useful in the detection of pituitary apoplexy; however, the value of magnetic resonance imaging (MRI) is yet to be determined. The MRI and CT scans of three consecutive and histopathologically proven cases of pituitary apoplexy were reo. viewed. MRI performed at least 5 days after the onset of symptoms, suggested pituitary apoplexy (hemorrhage) in all three cases, while CT scan documented pituitary hemorrhage in only one case. Increased signal on 11 weighted images was the hallmark on MRI in all three cases. These findin~ suggest that MRI may be superior to CT scan in identifying pItuitary apoplexy, at least in the subacute phase.
Scientific Poster 167 Tuberous Sclerosis, Sacrococcygeal Chordoma, and Aortic Dysplasia: A Newly Recognized Triad. Helen M Hittner, MD; Vincent M Riccardi, MD; Milton L . Wagner, MD; Ed;ith P Hawkins, MD; Frank L Kretzner, PhD, Houston, TX A previously unrecognized triad of tuberous sclerosis, sacrococcygeal chordoma, and aortic dysplasia is reported in two patients (32 yr. male; 10 yr. female). Ocular abnormalities of tuberous sclerosis included a hamartoma of the optic disc (case 1) and a depigmented lesion of the iris and hamartomas of the retina (case 2). The scrococcygeal chordomas were indistinguishable from other chordomas, however, these two patients have had an at¥pically benign course. The aortic dysplasia consisted of abdommal aortic constrictions associated with aneurysmal dilatations. These cases suggest a subset of tuberous sclerosis with typical benign tumors, a tumor of notochord origin, and dysplastic vascular abnormalities.
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Scientific Poster 168 Asymmetry in Congenital Oculo~otor Apraxia Robert A Catalano, MD, Alban,!!, NY; Josepn l! Calhl!~n, MD, Philadelphia, PA; Robertp Rmnecke, MD, Pntladelpn1,a, PA; David G Cogan, MD, Betnesda, MD A 10-m.onth-.old infant presented with apparent unilateral ocular m.ot.or apraxia. Electr.oocul.ography c.onfirmed an inability t.o generate a saccade f.or fixati.on .or in response t.o an OKN .or vestibular ev.oked stimulus t.o the right. Fixati.on and OKN saccades and vestibular ev.oked nystagmus (VEN) were present t.o the left. MRl detected a small cerebellar vermis but n.o localizin~ unilateral abn.ormality. Subsequent review .of 16 children WIth ,?cular m.ot.or apraxia revealed that 5 dem.onstrated asymmetry m the generati.on .of fixati.on saccades. Tw.o .of the five als.o dem.onstrated asymmetry .of BEN and an additi . .onal child had OKN. a~ymmetry. C.ongenital .ocular m.ot.or apraxIa can be asymmetrlc!n up t.o ;.one-third .of patients. MRl in .our patient was n.ot helpful m localizing a CNS abn.ormality.
Scientific Poster 169 Ocular Manifestations of Zellweger Syndrome: A Cascade of Events Associated with a Peroxisomal Disease Frank L Kretzer, PhD; Rekha S Mehta; David G Hunter, MD, PhD; Helen M Hittner, MD, Houston, TX
Five pairs .of eyes were .obtained within .one h.our post m.ortem fr.om patients with Zel\weger syndr.ome wh.o survived fr.om 2.5 t.o 10.5 m.onths and were studied by light and transmissi.on electr.on micr.osc.oPY. Atr.ophic: mit<;JCh.ondria wer~ .obse,rved in th~ cor?eal end.othelium, lens epIthelIum, and retInal plg~ent eplthelI~~. Retinal changes included macr.ophages laden WIth neutral hpld
' within the subretinal space, rod and c.one atr.ophy (which explains the extinguished ERG), Mull~r cell pr.oliferati.on, se!ect~ve degenerati.on .of peripheral ganglI.on cells, and demyelmatI.on .of the .optic nerve (which parallels the abn.ormal VER). The gen~tIc defect in per.oxis.omes results in pr.ogressive ocular degeneratI.on.
Scientific Poster 170 Optic Disc Drusen in Children Darren L H()()1)er, MD, Boston, MA; RichardM Robb, MD, Boston, MA; Robert A Petersen, MD, Boston, MA
Thirty-eight children with pseud.opapilledema due t.o .optic disc drusen (29 bilateral, 9 unilateral) were studied retr.ospectively t.o characterize the early natural hist.ory .of this conditi.on. Average age at first examinati.on was 10 years (range 3-19 years) and the mean f.oll.ow-up was 46 m.onths. Discrete hyaline bodies .or papillary calcificati.on were first n.oted in .one .or b.oth eyes with pseud.opapilledema at a mean age .of 12 years (range 4-35 years) in 36 .of 38 cases. Decreased visual acuity due to drusen occurred in .only 1 eye due t.o subretinal ne.ovascularizati.on. Visual fields .obtained in 31 eyes (19 patients) with pseud.opapilledema sh.owed an enlarged blind spot (9), an inferi.or arcuate/sect.or/.or altitudinal defect (4), .or both (4) in 17 eyes.
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Optics, Refraction, and Contact Lenses All presenters will attend their posters on Sunday jrO?n 9:00 to 4:90 PM, and at various times throughout the Annual Meeting. Individual attendance hours will be indicated on a mock clock at each poster board. See also poster #122.
Scientific Poster 171 Aphakic Reading Adds: An Error in Classical Teaching Robert K Maloney, MD, Balt'imore, MD; Kevin M Miller, MD, Baltimore, MD; David L Guyton, MD, Baltimore, MD
It is traditionally taught in ophthalmic optics that the "effective" bifocal add is greater than the prescribed add in aphakic spectacles . This occurs, it is said, because the reading segment is fabricated on the front surface of the lens, but its effective power should be measured at the back surface; the added back vertex power is significantly greater than the prescribed add_ Ophthalmologists were warned in a scientific exhibits at the 1967 Academy meeting not to overcorrect aphakes at near_ We explain why the effective add is, in truth, exactly equal to the prescribed add and not equal to the power measured at the back vertex. Practitioners who prescribe spectacles by the traditional teaching may leave their aphakes with suboptimal reading vision.
Scientific Poster 172 Refractive Changes Observed during Hyperbaric Oxygen Therapy Thomas J Tredici, MD, Brooks AFB, TX; Lucia Tredici, MI, Houston, TX; Douglas J Ivan, San Antonio, TX; Patrick S O'Connor, MD, San Antonio, TX
Hyperbaric oxygen first used for the treatment of aviator and diver bends is now successfully used in the treatment of gas embolism, gas gangrene, carbon monoxide poisoning, osteomyelitis, and other disorders. While often lifesaving, it also has deleterious side effects; such as, vasoconstriction, peripheral field constriction, recurrence of retrobulbar neuritis, cataracts, and changes in the refractive state of the eye. This poster will discuss the refractive changes (mostly myopic) noted in patients undergoing hyperbaric oxygen therapy at the USAF School of Aerospace Medicine. The rate of onset, amount of change, recovery and the possible cause of these effects will be discussed.
Scientific Poster 173 Improved Visual Acuity and Decreased Glare in Pseudophakic Patients using Low-pressure Sodium Illumination Jonathan C JamU, MD, Philadelphia, PA Low pressure sodium vapor illumination is gaining favor in indus· trial and office settings because of worker reports of decreased' glare and documented decreases in worker absenteeism compared to fluorescent illumination. 30 subjects, 20 of whom were pseudophakic and 10 with no known eye pathology were asked to read a Rosenbaum vision screening card In a room lit with sodium vapor lamps and in a room lit with standard cool white fluorescent lamps. Both rooms were illuminated to 50 lumens per square foot . The pseudophakic subjects read an average of 2 Jaeger lines better in the sodium vapor illuminated room than in the fluorescent illuminated room and subjectively noted less glare (p <105). The normal subjects noted unchanged Jaeger acuity, increascd comfort, and decreased glare.
Scientific Poster 174 Anterior Curve Modification of Corneal Lenses to Change Lens Position and Comfort Douglas J Van Putten, MD, Loma LindlL, CA; Alan J Reizman, OD, Loma LindlL, CA; James I McNeill, MD, Loma Linda, CA Changing the anterior surface of a contact lens influences lens, comfort and position. We modified the anterior surface of ri~d corneal lenses to produce changes in lens weight and junctIon angle. Total lens weight was varied by adding prism ballast. The peripheral junction angle was varied by altering lenticular cap and lens diameter. We found that a lens weight change in the range of 15 to 20 mg objectively affected lens position. Aj'unction angle of more than 3° subjectively affected comfort. unction angles greater than 10° tended to be excessively uncomfortable . Results show that ordering contact lenses by specifying only base curve, power and diameter is not always sufficient.
Scientific Poster 175 Visual Field Constriction in "Brown to Blue Eye" Contact Lenses Michael S Insler, MD, New Orleans, LA; ClijfordHendricks, MD, New Orleans, LA; DonnaM George, RN, New Orleans, LA Visual field testing was performed on ten patients wearing the recently released DURASOFT 3 color soft contact lens. Each patient wore the colored plano lens for a minimum of one hour prior to undergoing standard Goldmann visual field testing. All but one patient had visual field constriction ranging from five to twenty degrees. When the areas inside the three tested isopters wel'e averaged, the amount of field loss ranged from 21% to 47%, Contact lens fitters as well as wearers should be warned of this potential complication.
Scientific Poster 176 Viral Contamination of Soft Contact Lenses
. Gerald W Zaidman, MD, Valhalla, NY; Roger Loria, PhD, RiCh1nond, VA; IA!~iseMontgome;y, MS, RiChmond V~; Esmond . T McKoy, MD, Run.mond, VA; Cn.arles Hogge, MD, Runmond, ' VA ' A.re routine. &te~.ilization tec.hniques effective agains~ potential vIral contammatlon of soft contact lenses? 14 Bausch & Lomb 80ft contact lenses were incubated with human Herpes Simplex Virus Type I and 14 were incubated with Coxsackie virus. Six lenses in each group were Heat sterilized, six lenses were chemically sterilized and two were not sterilized .. Afterwards each lens was ground into a fine powder and suspended in modified Eagle's medium. This solution was added to tissue culture cells, incubated, and plaque assay analysis performed. All assays from lenses that had been contaminated and then sterilized were negative. This indicates that routine methods of contact lens sterilization are adequate to destroy Herpes Simplex and Coxsackie virus.
Scientific Poster 177 Disposable Contact Lenses for Extended Wear Penny A AsbeU, MD, New York, NY _ _
' I -A new soft molding manufacturing method allows for greater precision and reproducibility in the production of hydrogel contact lens. This manufacturing innovation has permitted the development of disposable contact lenses for extended wear usage (EWCL). Imtial experience witH 30 patients showed that 90% were successful users, reporting better visual acuity and greater convenience. Clinical exam noted normal anterior segment, good patient compliance, no problems with contact lens hygiene, greater patient satisfaction and fewer unscheduled visits. This first experienc:e with disposable contact lenses suggests that they add a new dImension to EWCL usage that may be associated with fewer complications.
Scientific Poster 178 Visual . Blur Affects Contrast Sensitivity: Clinical Implications MiChael F Mannor, MD, Stanford, CA; Atul Gawande, Stanford, CA
We measured contrast sensitivity in normal subjects at different levels of visual acuity, induced by blurring vision with convex lens. Optical blur, without retinal disease, reduced contrast sem'litivity over a broad range of spatial frequencies. We conclude that it can be clinically hazardous to interpret contrast sensitivity results inpatients with reduced acuity relative to standard values based on nonnal acuity. By taking the relationship to acuity into account, contrast sensitivity testing can distinguish between deficits are equivalent to the loss of acuity. and those which indicate more distinctive ocular pathology. (Invited Poster)
Orbit and Plastic Surgery All presenters will attend their posters on Sunday from 11 :80 AM to 1 :00 PM, and at various times throughout the Annual Meeting. Individual attendance hours will be indicated on a mock clock at each poster board.
Scientific Poster 179 Use of Split Thickness Dermal Graft in the Repair of Corneal Scleral Perforations Due to Necrotizing Disease . . . Joseph A Mauriello, Jr, MD, Newark, NJ; Philip M Fwre, MD, Newark, NJ; Donald J Cinotti, MD, Newark, NJ; Kathryn S Pokorny, PhD, Newark, NJ
Donor sclera, autogenous fascia lata, periosteum, and cartilage have been used to repair corneoscleral perforations due to necrotizing disease. We have use~ split-thickness dermal grafts to repair (1) bilateral corneal perforations in a patient with a severe lye burn, and (2) scleral perforations in a second patient with rheumatoid scleritis; both had excellent results. The dermal graft has advantages over other materials in that (1) it self-epithelializes and does not need to be covered by conjunctiva, (2) it is supple, hearty, and flourishes on avascular surfaces such as cornea and sclera, and (3) being autogenous, it is not antigenic.
Scientific Poster 180 Use of Vicryl Mesh in Orbital Floor Fracture Repair Joseph A Mauriello, Jr, MD, Newark, NJ; Richard McShane, MD, Montclair, NJ
Autogenous and nonautogenous implants have been used in orbital floor fracture repair. Autogenous implants have a decreased incidence of infection and extrusion compared to nonautogenous implants, but have the disadvantages of a second surgical site and variable resorption. We have used absorbable Vicryllayered mesh in 15 patients with 18 months follow-up with no complications: (1) as a thin absorbable lining to prevent prolapse of tissue into the fracture, (2) in conjunction with autogenous grafts to provide a scaffold for fibrosis, (3) in children where nonautogenous implants should be avoided, and (4) for correction of mild enophthalmos when the mesh is used in several layers.
Scientific Poster 181 Radiography of the Lacrimal System Using Topical CT Dacryocystography L Neal Freeman, MD, Baltimore, MD; S James Zinreich, MD, Baltimore, MD; Nicholas T Iliff, MD, Baltimore, Ml) A new technique (topical CT dacryocystography) is described in which computed tomography of the lacrimal apparatus is performed following topical instillation of a contrast agent into the conjunctival cul-de-sac. Twelve patients with suspected lacrirrud drainage abnormalities were examined both clinically and with this method. The clinical and radiographic examinations were correlated and specifically compared. Nasolacrimal patency, delayed excretion, partial stenosis, postoperative morphology, and sinusitis were readily identified. Mild punctate keratopathy in some patients was the only observed side effect. Thill technique may become a valuable adjunct in the evaluation of patients with possible lacrimal drainage system abnormalities.
Scientific Poster 182 Blepharopigmentation: A Light Microscopic, Ultrastructural and X-ray Microanalytic Study Kenneth B Simons, MD, Tucson, AZ; Raymond R Heyde, MD, Los Angeles, CAl Claire Payne, Tucson, AZ Blepharopigmentation or permanent eyeliner is a popular cosmetic procedure currently performed via a variety of methods. All methods attempt to implant ferrous oxide pigment into the dermis. We performed histopathologic studies on a series of three eyelid specimens, including two by a previously undescribed multi-needle pigment delivery system. Lightmicroscopy revealed the epidermis to be pigment free and the dermis to contain pigment in clumps. Transmission EM demonstrated that the pigment was largely in macrophages. Energy-dispersive x-ray microanalysis showed that in addition to iron, talc and titanium particles were also present. These findings suggest that the pigment is tolerated by the eyelid despite the fact that current pigments are contaminated.
Scientific Poster 183 Osseointegration in Orbital Prosthetics Je!fr61j A Nerad, MD, Iowa City, IA; William LaVelle, MD, Iowa C'Lty, IA; Michp.el D Maves, MD, Iowa City, IA; Eliza!Jeth A Fyler, Iowa C'Lty, fA; Per-Ingvar Branemark, MD, PhD, Goteburg, Sweden Osseointegration research and bone biology and reconstruction by Branemark in Gteborg, Sweden has led to the concept of permanent anchoring of prostheses in. 1iving tissue. Specifically bone ma¥ be un~ted directly with titanium iY!lpl8;nts .. This so-called os, seomtegratlOn process allows exposed titanium Implants anchored to bone to protrude through the skin without infection or extrusion. Successful permanent osseointegration of imp,lants used to anchor dental appliances into the mandible and maXIlla have been used for over fifteen years. These successes have led to the use of tir,sue integration systems in extraoral prosthetic applications including the orbit, ear, nose, face and for fixation of hearing aids. Details of this technique are outlined and examples of orbital and facial prostheses are presented.
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Scientific Poster 184 Bony Orbital Cyst with Fibrous Dysplasia DamB Lyon, MD, Charlottesville, VA; StmJenA Newm.an, MD, Charlottesville, VA Fibrous dysplasia often involves the bone of the base of the skull. Multiple ophthalmic complications have been reported in cases with orbitocranial involvement. Cystic lesions of the orbital wall are less common. These may expand, rapidly producing an acute increase in proptosis. We have seen three patients with fibrous dysplasia and cysts of the bony orbit. Rapid expansion resulted in progressive proptosis and retinal striae in one case. MRI scanning was done in another patient and provided an extremely useful means for diagnosis of such cysts.
Scientific Poster 185 Symptoms of Upper Versus Lower Canalicular Obstruction John V Linberg, MD; Charles A Moore, MD, Morgantown, WV The need for surgical repair of monocanalicular obstructions is controversial. We used temporary punctal rlugS of hydroxy.lpropyl cellulose to investigate the symptoms 0 upper and lower monocanalicular obstruction in 19 normal eyes. 56% of experimental upper canalicular obstructions and 63% of lower obstructions resulted in symptoms of epiphora, crusting,· discomfort or blurred vision. The difference between these symptom rates is statistically insignificant (p< ,01). The significant incidence of symptoms suggests that repair of single upper or lower canalicular lacerations is appropriate. Similar symptom rates with upper and lower canalicular obstruction suggests that each has an important role in lacrimal drainage.
Pediatric Ophthalmology and Strabismus All presenters will attend their posters on Sunday from 3:00 to 4:30 PM, and at various times throughout the Annual Meeting. Individual attendance hours will be indicate on a mock clock at each poster board.
Scientific Poster 186 Inferior Rectus Recession for Vertical Tropia Following Cataract Surgery Christine L Burns, MD, Hudson, FL
Four patients with persistent vertical tropias ranging from 6 to 16 diopters following cataract surgery underwent inferior rectus recession for relief of constant diplopia. Deviations were stable and fusible with prisms preoperatively. In at least one case, ver· tical traction bands tethered the eye downward. Most patients regained single binocular vision in all fields of gaze and did not require prisms. Persistent significant vertical deviations follow· ing cataract surgery successfully treated with inferior rectus recession have not been previously reported. The use of traCtion sutures on the vertical recti during cataract sUl·gery; the effect of subconjunctival antibiotic injection andlor hematoma and the presence of dissociative visual factors prior to cataract surgery are evaluated.
Scientific Poster 187 Anterior Segment Ischemia Following Three Rectus Muscle Surgery RichardA Saunders, MD, Charleston, SC; Michael S Phillips, MD, Charleston, SC
Nine patients underwent simultaneous or staged detachment of the vertical and medial rectus muscles in the treatment of 6th nerve palsy or Duane's retraction syndrome_ In five of these (ages 32, 34, 41, 45 and 65 years), clinically significant anterior segment ischemia developed postoperatively. Known medical risk factors were present in only one patient_ Other than corectopia, there were no llPparent sequelae, with all involved eyes returning to preoperative visual acuity levels within 9 weeks of surgery. Antel'ior segment ischemia may be a complication of strabismus surgery in adult patients when the superior, inferior. and medial rectus muscles are detached from the globe.
Scientific Poster 188 Sutureless Muscle Surgery in Rabbits CathleenM Cronin, MD, Maywood, IL; David Mittelman, MD, Maywood, IL; David O'Morcnoe, MD, Riverside, IL; Robert FOOdy, MD, Maywood, IL; Nick Mama/is, MD, Maywood, IL
A fibrin platelet glue was compared with 5-0 vicryl sutures in rabbit muscle surgery. Sixteen rabbits had bilateral superior rectus recessions with the right superior rectus "glued" to the sclera and the left superior rectus sutured to the sclera. Tissue reaction, determined by gross inspection and histology, and bond stren~th were assessed from 6 hours to 2 months post-op. Tissue reactlOll was minimal and showed no difference between the "glued" and sutured muscles. Bond strength however, did show a statistically significant difference. The sutured muscle was an average of two times stronger than the "glued" muscle at all time periods post-op.
Scientific Poster 189 A New Occluder for Performing the Cover Test AlejandroA Vila-Coro, MD, Madrid, Spain; Antonio A Vila-Coro, MD, Houston, TX
Small angle strabismus and heterophorias are difficult to detect with the cover test using an opaque occluder. A new occluder for pel"fol'ming the cover test is presented. It is composed of a filter that reflects 82% and transmits 18% of the incident light. A light source on the patient's side of the occluder illuminates the occluded eye and allows the examiner to see the covered eye through the filter, while the patient's view through the covered eye is significantly attenuated. This arrangement allows direct ob:,;ervation of heterophorias and facilitates detection of small angle ocular misalignments. .
Scientific Poster 190 Exposure of the Inferior Oblique from the Anatomic Viewpoint Caleb Gonzalez, MD, New Haven, CT There is no agreement as to the best way to expose the inferior oblique (IO) for myectomy·type surgery. Eighteen cadaver dissections and 51 strabismus operations were done to find the best area to expose the IO from the anatomic viewpoint. Drawings of the anatomy and photos of the surgical exposures were made. In its lateral trajectory the IO makes a dog-leg turn with its most anterior part just lateral to the inferior rectus crossing. The top of the dog-leg turn is the only part of the 10 anterior to the equator making it the most accessible for surgery. The IO in this area can be directly exposed by an inferior fornix incision through conjunctiva and anterior Tenon's capsule or still easier, faster and more predictable · through an inferior "hockey-stick" Iimbal incision.
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Scientific Poster 191 Sequential Cranial Computed Tomography in Infants with Retinal Hemorrhages Joseph Giangiacomo, Ml!, Columbia, MO; JemshedA Knan, MD, Boston, MA; VanceM Tnompson, MD, Columbia, MO; Clive Levine, MD, Columbia, MO Five shaken infants presented with lethargy, vomiting, irritability and intraocular hemorrhage and sequential cranial computed tomography (CT). In three of the five infants the initial computed tomography head scan was either normal or demonstrated subtle abnormalities. Subsequently all three developed subdural hemorrhages which were demonstrated by subdura aspiration. Repeat
.' CTs of the head showed progressive ventricular dilation and bilat. eral fronto-parietal subdural hematomas. The retinal hemorrhag; es preceded the clinical and radiological reco~ition of subdural , hemato~a. The initial head CT of the remaining two children ;.showed Intracerebral hemorrhages, cerebral edema and subser quently subdural hematoma.
'Scientific Poster 192 . Discriminant Analysis of Exodeviations: Short-term Results Jeffrey M Lehmer, AB, Los ~ngeles, CA; J Bronwy~ ~ate7nan, M'p! Los Ange(es, CA; Marsnall M Parks, MD, Wasn~ngton, DC; Runam L Ell'Wt, MD, Santa Ana, CA In a retrospective study, computer-based stepwise discriminant analysis was used to predict the short-term results of surgery in exodeviations. Four hundred twelve patients from 1 to 18 years of a~e at the time of initial bilateral lateral rectus recession were studied 6 to 8 weeks postoperatively analyzing deviations at distance, near, and combined distance/near fixations. Analysis of t~n inde~!1dent variables indicated that: (1) a smaller preoperative deVlation at near (p < .001) and a lower preoperative clinical AC/A ratio (p < .016) were associated with a favorable outcome at distance; (2) a smaller preoperative deviation at near (p < .001) and a youn~erage at diagnosis (p < .005) strongly correlated with a deSirable outcome at near; and (3) a smaller preoperative deviation at near (p < .001) was associated with smaller postoperative distance/near deviations. Results support the importance of preoperative near deviation for predicting short-term prognosis.
,. Scientific Poster 193 Congenital Posterior Orbital Cephalocele
'RobertA Gordon, AJD, F:ittsburgh, PA; ZeynelA Karcioglu, ¥D, New Orleans, LA; Josepn Nadell, MD, New Orleans, LA; Yu}t Numauuchi, New Orleans, LA; PhilipM Hmdel, MD, New Orleans, LA We report two children with the posterior variety of congenital ?rbital cephalocele (CPOC). High resolution computerized imagIng tomography (CT) was essential for the diagnosis in both patients. In one case, Metrizamide enhanced CT demonstrated intracranial communication. One patient, whose lesion was heterotopic and associated with a malformed, microphthalmic eye, required enucleation in combination with excision of the CPOC; the other case underwent surgery by a craniofacial team. Ophthalmologists need to be aware of the unique clinical and CT characteristics of CPOCs so that proper, individualized management can be undertaken, thereby avoiding potentially disastrous complications.
Scientific Poster 194 Hydrogel Extended-Wear Contact Lenses (EWCL) for the Correction of Aphakia in Children: Corneal Studies Randy J Epstein, MD, Chicauo, IL; Alcides Fernandes MD Atlanta, GA; J Allen Gammon, MD, RiyOJik, SaudiA~abia' EWCL in adults are associated with an increased coefficient of variation (CV) of corneal endothelial cell area, which may reflect physiologic instability. To determine if similar changes occur in infants, we performed wide-field specular microscopy on an unselected, consecutive series of children wearing EWCL for the correctioI,1 of neonatal aphakia. The 3 groups consisted of 20 eyes of 11 ch!ldren, mean age 22 months, including 8 unoperated, 10 aphaklc-EWCL corrected, and 2 aphakic-spectacle corrected eyes. After a mean of 15 months of extended wear, significant differences in pachometry were noted (.59, .67, and .60 mm, respectively). Morphometric analysis of digitized specular photomicrographs failed to reveal significant differences in endothelial cell density (5354, 5820, and 6487 cells/mm"Z) or CV (.27, .32, and .33). We conclude that hydrogel EWCL used for the correction ?f aphakia in infants are not associated with morphologic changes m the cornea.
Scientific Poster 195 Familial High Hypermetropia With Posterior Microphthalmos Steven Fauien, MD, Gainesville, FL; Harry MEngel, MD, Gainesville, FL
Three siblings from a family of five children exhibited extreme hypermetropia, posterior microphthalmos, and pseudopapilledema. The refractive error ranged from nine to 16 diopters. Ametropic amblyopia was severe in each affected child. Both parents and the unaffected children showed minimal refractive error. Familial high hypermetropia with posterior microphthalmos and pseudopapilledema has not been previously reported. An autosomal recessive pattern is postulated.
Scientific Poster 196 Contrast Sensitivity Functions in Amblyopic Children Lawrence E Leguire, PhD, Columbus, OH; Gary L Rogers, MD, Columbus, OII; Don L Bremer, MD, Columbus, OH
The Vistech CSF test board (6500) was used to determine whether differences. eX.ist b~tween strabismic (S~) and anisometropic (A A) amblyopia In children. The amblyoPlc and nonamblyopic eyes of fifty children, between the ages of 3--112 and 7 years were tested with the CSF. Large and significant differences were found between the CSFs in the amblyopic and nonamblyopic eyes for both types of amblyopia, and these differences increased with the severity of the amblyopia. The shape of the CSF was similar between SAs and AAs for the amblyopic eye and for the nonamblyopic eye. However a comparison of the CSFs between the amblyopic and nonamblyopic eyes, a measure of "binocular vision," showed that the SAs exhibited a greater amount of binocularity.
Scientific Poster 197 Ophthalmic Manifestations of the Sly Syndrome, MPS-Vll Deborah M Alcorn, MD, Baltimore, MD; W R Green, MD, Baltimore, MD; Irene H Maumenee, MD, Baltimore, MD The lysosomal disease mucopolysaccharidosis (MPS) type VII, or Sly syndrome, is caused by (3 -glucuronidase deficiency and results in the storage of chondroitm 4- and 6-sulfates and heparin sulfate_ Twenty patients with MPS VII have been described, but no detailed ophthalmologic description has been given_ We report the ophthalmic findings in a child with biochemically proven and characteristic features of MPS VII. He exhibited a normal corneal diameter with mild diffuse stromal haze_ He had mild constriction of retinal vessels and RPE migration. His ERG was in the low normal range. There was a bilateral disc swelling secondary to hydrocephalus. Electron microscopy of a conjunctival biopsy disclosed single-membrane-bound cytoplasmic inclusions containing fibrillogranular material, characteristic of MPS.
Scientific Poster 198 Quantitative Re-recessions of the Medial Recti for Late Recurrent Esotropia James L Mims, III, MD, San Antonio, TX; Robert C Wood, San Antonio, TX Most strabismus surgeons agree that re-recession of the medial recti is often the most appropriate surgery for late recurrent esotropia if the first surgery was a bimedial recession and if more than 6 months have elapsed since the first surgery. We devised a method to determine how much more recession should be done based on a previously established dose response curve (mm of recession vs. Prism Diopters of effect). The curve is entered at the point (mm) where the muscle is found to have been previously recessed and the amount of re-recession required to achieve the additional desired effect is computed from the curve. Also a 1 mm resection effect of the re-recession surgery is assumed. 21 of 25 cases were aligned (±8PD) 6 months after re-recession surgery using this system.
Twenty-four premature infants were followed for ROP for two years. Eleven cases (22 eyes) had at least stage 2 ROP when first seen. Nine cases (18 eyes) progressed from stage 2 or 3 to stage 5 in 1 to 4 weeks even when treated with cryotherapy or scleral buckling. We evaluated the possible risk factors for this unusual (and unrecognized) rate of progression, and the following proved significant: gestational age less than 28 weeks, more fibrous than vascular proliferation over the ridge, immature anterior segment, remarkable subretinal exudation, and vitreous liquefaction and condensation. Other well-known risk factors were present to varying degrees. Early identification and treatment will be emphasized.
Scientific Poster 200 Acute Retinal Lesions in Battered Babies: Clinicopathological Correlation of Macular Craters Mark J Greenwald, MD, Chicago, IL
In the eyes of five infants who were victims of physical abuse we found postmortem evidence of mechanical deformation of the posterior retina, including breaks in internal limiting membrane fragmentation of pigment epithelium, and tears in Bruch's mem: brane. Most striking was the presence in five eyes of retinal f?lds or ridges surrounding the macula in a crater-like configuratIOn. All eyes had hemorrhages involving the retina, vitreous, and/or optic nerve; none showed signs of injury to external or anterior segment structures. The pathological findings corresponded to fundus lesions seen clinically in three infants. Our observations support the view that acute vitreoretinal traction generated by violent shaking causes retinal damage in battered babies.
Scientific Poster 201 Ophthalmic Evaluation of Survivors of Acute Lymphoblastic Leukemia Darren L Hoover, MD, Boston, MA; Lois E H Smith, MD, PhD, Boston, MA; Stewart J Turner, MD, Wichita Falls, TX; Stephen E Sallen, MD, Boston, MA; Richard D Gelber, PhD, Boston, MA
Eighty-two survivors of Acute Lymphoblastic Leukemia (ALL) had prospective eye examinations to determine the ocular sequelae of the disease and its treatment. All patients had completed or nearly completed a 25 to 31 month protocol which included either 3.4 or 10.2 gm of systemic prednisonelsq mlyear and cranial irradiation (total 1800 to 2800 rads). The mean interval from the end of treatment to the eye exam wae 32 months. Only 1 patient had reduced vision attributable to the ALL. Ocular morbidity attributed to the treatment only included posterior subcapsular cataracts (PSC) which occurred in 52%. None of the 15 survivors of ALL examined who received neither long-term prednisone nor irradiation developed PSC (p<O.OI). Eyes with PSC had a median visual acuity of 20/20 (range 20/15-20/50).
Socioeconomics and Practice Management All presenters will attend their posters on Sunday fram 11 :90 AM to 1 :00 PM, and at various times throughout the Annual Meeting. Individual attendance hours will be indicated on a mock clock at each poster board.
Scientific Poster 202 Ophthalmologists Famous for Other Activities ;fonn D Bullock, MD, Dayton, OH Ophthalmologists have excelled in many different filed of endeav
'or including athletics, music, racing, politics, language, physics, chemistry, religion, business, philanthropy, and literature. Ophthalmology boasts Olympic Medalists, World Record-holders, a Nobel laureate, a Pope, a National Hero and Martyr, Business Tycoons, and Men of Letters, among others. An examination of this small group of people, like studying the rays of light at a focal p<>int, reflects the impressive breadth of interest and ability that all ophthalmologists share and can martial in the care of their patients.
Scientific Poster 203 A Computerized System for Residency Evaluation Thomas J Smith, MD; Mark Si7non, BA, Lexington, KY
We have developed a computerized approach which has helped us to analyze the activity of our residency program. One hour per day of secretarial time is required for maintenance of the database. Monthly, quarterly, and yearly reports are automatically generated listing numbers and diagnoses of patients seen, as well as surgical cases and complications. The program will run on any IBM compatible microcomputer and is written in compiled dBase III. It is menu driven and requires no computer expertise. Any resident inadequacies or inequalities in terms of clinic patients seen, exposure to the full spectrum of diagnostic categories, surgical case loads, or complications are immediately apparent and may be promptly corrected. In addition the reports are formatted in order to comply with the requirements and diagnostic groupings of the American Board of Ophthalmology allowing more efficient and effective preparation for residency review.
Scientific Poster 204 Computerized database to identify patient populations for clinical research Joseph M Miller, MD, Baltimore, MD
Identification of appropriate patient populations is an important component of clinical research. We have developed a computerized database (CLINDEX) which stores for each patient 10 diagnoses, 12 procedures, 12 medications, examination values and demographic data. It is written in dBase III + (Ashton-Tate) for the IBM XT/AT microcomputer, and assumes no computer expertise. Diagnosis (ICD-9) and procedure (CPT) code descriptions, as well as referring physician data are linked to the patient record. Data files may be shared by related database programs. The design strategy is presented and a fully functional, compiled version of CLINDEX is available at no charge.
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Trauma All presenters will attend their posters on Sunday from 9:30 to 4:30 PM, and at various times throughout the Annual Meeting. Individual attendance hours will be listed on a mock clock at each poster board.
Scientific Poster 205 Ruptured Globe Following Blunt Trauma After Radial Keratotomy: A Case Report Kenneth B Simons, MD, Tucson, AZ; RudJ>lph P Linsalata, MD, Scottsdale, AZ Radial keratotomy (RK) is a commonly performed, controversial refractive surgical procedure. A number of serious complications have been reported both intraoperatively and postoperatively. This case report documents the first known occurrence of a ruptured globe subsequent to blunt trauma. Best visual acuity preoperatively was 20/20 and was 20/70 without correction. The patient underwent a four-incision RK and on the fourth postoperative day, acuity was 20/40 without correction. On post-op day 24, the patient was struck by an elbow with rupture of the globe. The eye was primarily repaired and subsequently enucleated. Light microscopy revealed marked disorganization of the internal ocular structures. The histopathology and clinical correlation of this unique case will be discussed.
Scientific Poster 206 Ocular Dangers in the Garden: A New Menace -Nylon Line Trimmers Anthony J Lubniewski, MD, Webster Groves, MO; R Joseph Olk, MD, St Louis, MO; M Gilbert Grand, MD, St Louis, MO Nylon line lawn trimmers represent an increasingly frequent source of potentially serious ocular trauma. Recent case reports implicate nylon line fragments as sources of ocular injury to operators of these instruments. We report 5 cases of ocular trauma associated with use of trimmers, and document new mechanisms of injury including projectiles other than nylon line fragments, and injury to bystanders. Two patients required evisceration or enucleation after developing endophthalmitis, one culture exhibiting propionibacterium acne. Our retrospective 40-month review of 87 cases of penetrating and perforating ocular trauma revealed trimmer-associated injuries to be a major cause of ocular trauma.
Scientific Poster 207 Ocular Lawnmower Injuries C Douglas Witherspoon, MD, Birmingham, AL
As many as 140,000 lawnmower injuries may occur yearly in the U.S., and lawnmower projectiles have been described as a COIll-. mon source of hyphema. Despite this apparent frequency, no series of ocular injuries from lawnmowers has been published in over 25 years. We present a series of 7 cases; final vision ranged from no light perception to 20/20 with final vision better than 20/100 in 4 eyes. Factors associated with poor visual outcome included massive choroidal hemorrhage, endophthalmitis, rhegmatogenous retinal detachment, and optic nerve injury. AI· though the prognosis of these injuries has improved since earlier reports, the importance of prevention by safety glasses cannot be overstated. "
Scientific Poster 208 Serotonin in Human Aqueous Humor Xavier Martin, MD; Mary C Brennan, MS; PaulR Lichter, MD; Ann Arbor, MI
Neurotransmitters may playa role in the regulation of intraocular pressure. Serotonin, for example, has been found in corneal nerves and in the retina, but its presence in aqueous humor has not been determined. Such a determination is essential to the further study of serotonin as a substance involved in intraocular pressure regulation. Using high performance liquid chromatography with electrochemical detection, we identified and measured serotonin in aqueous samples from cataract patients. We found a mean concentration of serotonin of 42.45 ng/ml (SD = ± 15.76) in the aqueous humor of 12 cataract patients. This high concentration implies a function for serotonin conceivably related to aqueous humor dynamics and warrants further investigation. (This poster is physically located outside its topic area. See "Glaucoma and Iris" jor other posters on this topic.)
