Bálint Kovács

Improvement of Visual Functions and Fundus Alterations in Early Age-Related Macular Degeneration Treated with a Combination of Acetyl-L-Carnitine, n-3 Fatty Acids, and Coenzyme Q10

The aim of this randomized, double-blind, placebo-controlled clinical trial was to determine the efficacy of a combination of acetyl-L-carnitine, n-3 fatty acids, and coenzyme Q10 (Phototrop®) on the visual functions and fundus alterations in early age-related macular degeneration (AMD). One hundred and six patients with a clinical diagnosis of early AMD were randomized to the treated or control groups. The primary efficacy variable was the change in the visual field mean defect (VFMD) from baseline to 12 months of treatment, with secondary efficacy parameters: visual acuity (Snellen chart and ETDRS chart), foveal sensitivity as measured by perimetry, and fundus alterations as evaluated according to the criteria of the International Classification and Grading System for AMD. The mean change in all four parameters of visual functions showed significant improvement in the treated group by the end of the study period. In addition, in the treated group only 1 out of 48 cases (2%) while in the placebo group 9 out of 53 (17%) showed clinically significant (>2.0 dB) worsening in VFMD (p = 0.006, odds ratio: 10.93). Decrease in drusen-covered area of treated eyes was also statistically significant as compared to placebo when either the most affected eyes (p = 0.045) or the less affected eyes (p = 0.017) were considered. These findings strongly suggested that an appropriate combination of compounds which affect mitochondrial lipid metabolism, may improve and subsequently stabilize visual functions, and it may also improve fundus alterations in patients affected by early AMD.

Substance P released from sensory nerve endings influences tear secretion and goblet cell function in the rat

The aim of this study was to present morphological and functional evidence to evaluate whether tear secretion is influenced by neuropeptides released from sensory nerve endings of the conjunctiva. Following unilateral electrical stimulation of the trigeminal ganglion, tears were collected at both sides and assessed for volume and protein concentration; as well as gel electrophoresis and luminol chemiluminescence with immunostaining to immunoglobulin A and lysozyme measurements. Goblet cell density (goblet cells/100 basal cells) was recorded during histopathological examination of removed lids. Rats were pretreated with atropine to block parasympathetic; guanethidine to block sympathetic neuronal pathways; or hexamethonium to block synaptic transmission in ganglia. Capsaicin was used to deplete neurotransmitters from sensory nerve endings or SR140333 to block substance P tachykinin NK1 receptor mediated responses. Effects of inadequate electrode position or incidental lesion of trigeminal ganglion were examined by placing the electrode in false position, or no stimulation at a correct position. Electrical stimulation resulted in 380% increase of tear secretion (p < 0.001) and 30% decrease of goblet cell density (p < 0.001) on the the stimulated side compared to the unstimulated side. Atropine, guanethidine and hexamethonium pretreatments had no effect (p > 0.05), but capsaicin and SR140333 inhibited the effect of stimulation (by 96% and 72%, respectively, p < 0.001). Inadequate stimulation did not increase the tear secretion (p < 0.05). Protein concentration decreased, whilst tear volume and total secreted protein increased (p < 0.005) after stimulation. Electrophoresis showed no difference in protein pattern between stimulated and control side and analysis of equivalent amount of tear protein with luminol chemiluminescence indicated no difference in immunoglobulin A and lysozyme ratio following stimulation (p>0.05). We conclude that antidromic electrical activation of conjunctival sensory nerve endings significantly increases water, mucus and protein phases of tear. It is suggested that the sensory neuropeptide substance P plays a pivotal role in this neurogenic regulatory mechanism.

Vitrectomy with internal limiting membrane removal for clinically significant macular oedema

BackgroundLittle has been published on internal limiting membrane (ILM) removal for clinically significant macular oedema (CSME) in eyes not improving following maximal laser treatment.MethodsRetrospective review of the charts and intraoperative video films of 30 consecutive eyes of 27 patients undergoing vitrectomy, ILM peeling, and gas tamponade by a single surgeon.ResultsThe average patient was 52 years old; 56% were males. The oedema was caused by diabetes in 87% of the eyes, 42% of which had proliferative disease. The oedema was diffuse in 16 eyes (53%) and cystoid (CME) in 14 (47%). In 21% of eyes, spontaneous vitreous detachment was present or the eye had already undergone vitrectomy. All but one eye had at least 6 months of follow-up (mean 12 months). The oedema resolved completely in 26 eyes (90%) and partially in 3 eyes (10%). The visual acuity improved at least two Snellen lines in 19 eyes (66%) and one line in 4 eyes (14%); the average improvement was 4 lines. The acuity was unchanged in three eyes (10%) and worsened in three eyes (10%), all due to cataract. Among the 14 eyes with CME, 11 (79%) became completely dry and the visual acuity improved in 11 eyes (79%). No ILM-related complication was encountered in any eye.ConclusionsVitrectomy with ILM peeling is a promising approach to eyes with CSME. It appears to offer visual improvement at a much higher rate than laser therapy and with a longer-lasting effect than that of intravitreal triamcinolone. A larger study is necessary to confirm these preliminary findings.

Phacoemulsification on previously vitrectomized eyes: results of a 10-year-period.

Purpose To provide an overview of intraoperative and postoperative complications during phacoemulsification cataract surgery and to evaluate the visual results in patients having pars plana vitrectomy (PPV) with 10 years of follow-up. Methods Retrospective evaluation of intraoperative and postoperative complications and postoperative visual results in 134 consecutive patients who underwent phacoemulsification after PPV. Of 11,498 eyes treated with phacoemulsification, 143 (1.2%) had previous PPV during the 10-year period (January 1, 1995-December 31, 2004). A total of 134 eyes were included in this study. Results The phacoemulsification procedure seemed to be difficult where there was a deep or fluctuating anterior chamber (93%) and primary posterior capsule opacification (19%). The most frequent intraoperative complications were posterior capsule rupture (9%) and incomplete capsular rhexis (5%). Postoperative intraocular pressure elevation (7%), retinal detachment (6%), and posterior capsule opacification (8%) occurred most frequently during the mean follow-up period of 18.2 months (1.5–110 months). Best-corrected visual acuity (BCVA) increased two or more Snellen E lines in 55% of the cases or became better than or equal to 0.5 in 10% of the cases. Conclusions Despite the well-known difficulties encountered in vitrectomized eyes such as zonular damage, increased mobility of the lens-iris diaphragm, and altered intraocular fluid dynamics, phacoemulsification proved to be a safe procedure in the hands of experienced surgeons.

Bilateral Cataract in Acrodermatitis Enteropathica

Bilateral cataract was found in a case of acrodermatitis enteropathica. A possible role of zinc deficiency in causing cataract might be assumed.

‘Closed Technique Surgery’ for Ciliary Sulcus Fixation of Secondary Implanted PC-IOL

Objective: Secondary implantation of PC-IOLs with ciliary sulcus fixation in intracapsular aphakes. Study Design: Retrospective study of postoperative results ranging from 6–41 months (mean: 16.9 months). Setting: The Department of Ophthalmology, Medical University of Pecs, Hungary. Patients: Ten intracapsular aphakic patients who had undergone a secondary PC-IOL implantation. Main Outcome Measures: To compare pre-operative and post-operative best corrected visual acuity, and to document post-operative complications. Results: Eight out of 10 patients had a post-operative V.A. of 0.5 or better. Mild vitreous haemorrhage was found in two patients as well as cystoid macular oedema in another two patients. Conclusions: The ‘closed technique surgery’ presented offers a safe alternative to anterior chamber lens implantation in intracapsular aphakes. The advantages of our method are the following; corneoscleral wound is made only after the suture is inserted, less manipulation within the eye, less endothelial cell damage, easy-to-do surgery.

Degree of conversion and BisGMA, TEGDMA, UDMA Elution from flowable bulk fill composites

The degree of conversion (DC) and the released bisphenol A diglycidyl ether dimethacrylate (BisGMA), triethylene glycol dimethacrylate (TEGDMA) and urethane dimethacrylate (UDMA) monomers of bulk-fill composites compared to that of conventional flowable ones were assessed using micro-Raman spectroscopy and high performance liquid chromatography (HPLC). Four millimeter-thick samples were prepared from SureFil SDR Flow (SDR), X-tra Base (XB), Filtek Bulk Fill (FBF) and two and four millimeter samples from Filtek Ultimate Flow (FUF). They were measured with micro-Raman spectroscopy to determine the DC% of the top and the bottom surfaces. The amount of released monomers in 75% ethanol extraction media was measured with HPLC. The differences between the top and bottom DC% were significant for each material. The mean DC values were in the following order for the bottom surfaces: SDR_4mm_20s > FUF_2mm_20s > XB_4mm_20s > FBF_4mm_20s > XB_4mm_10s > FBF_4mm_10s > FUF_4mm_20s. The highest rate in the amount of released BisGMA and TEGDMA was found from the 4 mm-thick conventional flowable FUF. Among bulk-fills, FBF showed a twenty times higher amount of eluted UDMA and twice more BisGMA; meanwhile, SDR released a significantly higher amount of TEGDMA. SDR bulk-fill showed significantly higher DC%; meanwhile XB, FBF did not reach the same level DC, as that of the 2 mm-thick conventional composite at the bottom surface. Conventional flowable composites showed a higher rate of monomer elution compared to the bulk-fills, except FBF, which showed a high amount of UDMA release.

[Metabolic therapy for early treatment of age-related macular degeneration].

Currently, age-related macular degeneration is one of the most common eye diseases causing severe and permanent loss of vision. This disease is estimated to affect approximately 300-500 thousand Hungarians. While earlier no treatment was available, in the recent decade an antioxidant therapy became very popular using combinations of high dosage antioxidant vitamins C, E, beta carotene and zinc. Based on theoretical concepts and mostly in vitro experiences, this combination was thought to be effective through neutralizing reactive oxygen species. According to a large clinical trial (AREDS) it reduced progression of intermediate state disease to advanced state, but did not influence early disease. This original combination, due to potential severe side effects, is not on the market anymore. However, the efficacy of modified formulas has not been proved yet. Recently, the metabolic therapy, a combination of omega-3 fatty acids, coenzyme Q10 and acetyl-L-carnitine has been introduced for treating early age-related macular degeneration through improving mitochondrial dysfunction, specifically improving lipid metabolism and ATP production in the retinal pigment epithelium, improving photoreceptor turnover and reducing generation of reactive oxygen species. According to a pilot study and a randomized, placebo-controlled, double blind clinical trial, both central visual field and visual acuity slightly improved after 3-6 months of treatment and they remained unchanged by the end of the study. The difference was statistically significant as compared to the base line or to controls. These functional changes were accompanied by an improvement in fundus alterations: drusen covered area decreased significantly as compared to the base line or to control. Characteristically, all these changes were more marked in less affected eyes. A prospective case study on long-term treatment confirmed these observations. With an exception that after slight improvement, visual functions remained stable, drusen regression continued for years. Sometimes significant regression of drusen was found even in intermediate and advanced cases. All these findings strongly suggested that the metabolic therapy may be the first choice for treating age-related macular degeneration. Currently, this is the only combination of ingredients corresponding to the recommended daily allowance, and at the same time, which showed clinically proved efficacy.

Alteration of the blood-retina barriers in cases of viral retinitis.

SummaryThis paper presents three cases of serologically documented viral retinitis, and the great value of fluorescein angiography in outlining the structural abnormalities and the site of the lesions.Of our series in the case of influenza retinitis, the fluoroangiographic findings showed dye leakage from retinal vessels in the posterior pole. The dye leakage did not appear completely in the sites of macular edema. This edema was similar to the clinical appearance of cotton-wool spots and was arranged in a star-like pattern.One of the cases of cytomegalovirus retinitis (Case 3), a previously healthy adult with dysfunction of the cellular immune system, seems to be a further example of an inflammation in the inner retina presenting cotton-wool spots at the early stage.Case 2, a previously healthy adult, fulfilled the criteria for Vogt-Koyanagi-Harada syndrome. The patient had serologically documented cytomegalovirus infection with dysfunction of the cellular immune system. The fluorescein angiographic examination showed alteration both in the inner and the outer blood-retina barriers as it is characteristic in cases of Harada syndrome. The cytomegalovirus infection might be assumed to play a role in the clinical picture as well as in the etiology of this disease.

Arm to retina circulation time determination by simultaneous bilateral fluorescein angiography

Arm to retina circulation time and retinal circulation time were measured in different pathological processes of 33 patients by a simultaneous bilateral fluorescein angiography method. Difference in the ARCT was found in 8 out of 33 patients. In three out of six patients with proven carotid artery occlusion or stenosis and five others with ocular circulatory disease, there was a significant prolongation in the ARCT to the affected side. In two out of six patients with transient visual loss (amaurosis fugax) in the history the same result was found. In ocular circulatory diseases the most frequent findings on the involved side were a delay in the arrival of dye (ARCT) in venous occlusion and a prolongation of the venous recirculation (RCT) in retinal arterial diseases. The localized optic nerve circulatory disturbances did not cause any change in the ARCT and RCT. This method may successfully be employed in the study of the circulation of the internal carotid artery and ophthalmic artery.