Jan A. Kylstra

Pulmonary alveolar proteinosis: prospective clinical experience in 23 patients for 15 years

Twenty-three patients, including three children, with pulmonary alveolar proteinosis (PAP) were studied over a 15 year period. Based on the overall course and outcome they were divided into two groups. Group I (24%) had spontaneous remission and received no treatment. Group II (76%), because of progressive dyspnea and deterioration of pulmonary function tests, underwent lung lavage. Of those who underwent lung lavage and were followed, 76% had a favorable response (Group II-a) and a significant number of them developed a complete remission, while 21% (Group II-b) had no response to lung lavage. Group I had higher arterial PO2 and lower alveolar-arterial oxygen partial pressure difference [P (A-a)O2] than Group II (72±5 and 38±3 vs 57±4 and 51±3,p<0.05). Similarly, the values of arterial PO2 and P(A-a)O2 were better in Group II-a than Group II-b (57±4 and 51±3 vs 40±6 and 65±11). In lavage material of 16 patients studied, macrophages appeared unusually enlarged and their number (% of differential count) was significantly lower (60±4%) than normal (90–95%). In contrast to previous reports, there was no evidence of active infection related to unusual or opportunistic organisms. No death related to PAP was observed. This prospective long term follow-up of large series of patients with PAP documents the overall course, prognosis and management of this illness.

A numeric index based on spatial frequency for the tortuosity of retinal vessels and its application to plus disease in retinopathy of prematurity.

Background In retinopathy of prematurity (ROP), tortuosity of vessels near the posterior pole of the fundus is an important clinical sign, yet clinicians have difficulty estimating how tortuous the vessels are. Methods The authors have devised an objective, numeric index of retinal blood vessel tortuosity that is especially sensitive to the structural changes in vessels that occur in ROP, but it is not particularly sensitive to non-ROP changes. Computer software is used to calculate the index from fundus images; the quality of these images is typical of photographs or video-cassette frames that the authors record in the premature nursery. Results The index reliably segregates tortuous vessels from nontortuous ones and separates eyes that reach ROP treatment threshold from eyes that do not. Conclusions The index forms an objective measure of the ROP disease state. Its calculation requires only segments of vessels and thus, is potentially adaptable to imaging systems that automatically extract vessel portions from fundus images.

Ocular and associated neuropathologic observations in suspected whiplash shaken infant syndrome. A retrospective study of 12 cases

We examined the eyes of 12 infants who died with the clinical and pathologic diagnosis of the shaken baby syndrome. The ocular histopathologic findings and the neuropathologic findings were compared. Preretinal, intraretinal, and subretinal hemorrhages were observed; hemorrhages of the superficial retinal layers and subsensory retinal space predominated. Retinal hemorrhages were found in 12 cases, intracranial hemorrhage was found in 11 cases, and cerebral edema was found in 10 cases. The intraretinal and periretinal hemorrhages were most prevalent at the posterior pole. Five cases had retinal folds. There was a low incidence of optic disc edema and choroidal hemorrhage.

The relationship between retinal vessel tortuosity, diameter, and transmural pressure

Increases in retinal vein tortuosity are thought to be caused by increases in vascular transmural pressure. We have attempted to determine the relationship between retinal vessel tortuosity, diameter, and transmural pressure by examining the effects of changes in transmural pressure on latex tubes with fixed ends. As the transmural pressure is raised, tube diameter increases, but tortuosity does not begin increasing until a critical pressure is reached. Above the critical pressure, tortuosity increases more rapidly than diameter. Our results support the above hypothesis and also suggest that at high transmural pressures, retinal vessel tortuosity is a more sensitive indicator than is the diameter of changes in retinal venous transmural pressure, but diameter is more sensitive than tortuosity at lower pressures.

Corneal epithelial defects following vitrectomy surgery using hand-held, sew-on, and noncontact viewing lenses.

PURPOSE To compare the incidence of corneal epithelial defects following vitrectomy surgery with Charles hand-held infusion lenses, Landers sew-on lenses, and the Oculus BIOM noncontact lens system. METHODS We performed a retrospective chart review of 234 patients who underwent initial vitrectomy surgery by one surgeon. We determined the presence and duration of postoperative epithelial defects and identified predisposing factors. RESULTS There were more corneal epithelial defects noted postoperatively in eyes with hand-held infusion lenses (23.8%) compared with eyes with sew-on lenses (8.6%; P = 0.010) and eyes with noncontact lenses (0%; P < 0.001). There were also more defects in sew-on versus noncontact lenses (P = 0.014). Diabetic patients had more postoperative epithelial defects with hand-held infusion lenses (32.1 %) than with sew-on lenses (8.8%; P = 0.011) or with noncontact lenses (0%; P < 0.001). The average operative time for patients with epithelial defects (169 minutes) was longer than for patients without defects (117 minutes) (P < 0.001). The risk of these defects remained significant after controlling for both length of surgery and diabetes status. CONCLUSIONS Corneal epithelial defects were more common after vitrectomy surgery using hand-held infusion lenses than after surgery using sew-on lenses and did not occur with the noncontact lens system. In addition, reducing the operative time may independently reduce the risk of epithelial defects, regardless of lens type.

Clinical Predictors of Scleral Rupture After Blunt Ocular Trauma

We conducted a two-part study to define better the clinical predictors of scleral rupture after blunt trauma. In part 1 we ascertained the prevalence of scleral rupture among a population of patients examined in an ophthalmic emergency room with severe blunt ocular trauma over a six-month period. Scleral rupture was diagnosed in ten of 283 patients (3.5%). In part 2 we compared the clinical findings in 29 patients with scleral rupture to those of 273 patients with no scleral rupture after blunt trauma. We noted that eyes with visual acuity of light perception or less, an intraocular pressure of 5 mm Hg or less, an abnormally deep or shallow anterior chamber, or a media opacity preventing a view of fundus details by indirect ophthalmoscopy, should be considered ruptured when severe intra- or periocular hemorrhage is present. This diagnostic algorithm had a sensitivity of 100.0% (98.7% to 100.0%), specificity of 98.5% (97.1% to 99.9%), and a positive predictive value of 71.4% (66.3% to 76.5%).

Hydraulic compression of mice to 166 atmospheres.

Hydraulic uniform compression elicited tremors, uncoordinated limb movements, and tonic convulsions in liquid-breathing mice at pressures ranging from 50 to 100 atmospheres. Such abnormal muscular activity was observed neither in control animals nor in mice caudally to a spinal transection. Uniform compression of isolated preparations of mouse muscle in saline failed to contract at pressures up to 200 atmospheres.

Intraocular Pressure Increase Associated With Epsilon-Aminocaproic Acid Therapy for Traumatic Hyphema

We treated five patients receiving epsilon-aminocaproic acid who demonstrated sudden and accelerated clot dissolution with accompanying increases in intraocular pressure 24 to 96 hours after discontinuing treatment. All of these patients required additional ocular hypotensive medications and one patient required anterior chamber washout for persistently increased intraocular pressure. These findings suggest that certain patients with hyphema may be at risk for significant intraocular pressure increases following cessation of epsilon-aminocaproic acid therapy.

Entoptic perimetry screening for central diabetic scotomas and macular edema

OBJECTIVE The aim of this study was to compare entoptic perimetry, using conventional television, to Amsler grid and patient-reported visual loss for the detection of functional diabetic maculopathy and macular edema. DESIGN Observational case series. PARTICIPANTS A single eye from each of 104 consecutive patients with diabetes in an academic retina clinic. INTERVENTION Each eye was screened by Amsler grid, entoptic perimetry, and Humphrey 10-2 threshold visual field testing (HVF 10-2; Humphrey Instruments Inc., San Leandro, CA) in random order. Eyes were then examined clinically. MAIN OUTCOME MEASURES The presence or absence of new visual decline since the patients last clinical examination, the presence or absence of central visual field abnormalities using an Amsler grid, entoptic perimetry, HVF 10-2, and the presence or absence of clinically significant macular edema (CSME). RESULTS The sensitivities and specificities for the detection of central diabetic scotomas as evidenced by HVF 10-2 abnormalities were: subjective impression, 31 of 90 eyes (34.4%) and 11 of 14 eyes (78.6%); Amsler grid, 29 of 90 eyes (32.2%) and 13 of 14 eyes (92.9%); and entoptic perimetry, 58 of 90 eyes (64.4%) and 11 of 14 eyes (78.6%). Entoptic perimetry was statistically more sensitive than both subjective impression (P < 0.001) and Amsler grid (P < 0.001), but the specificities were statistically indistinguishable. The sensitivities and specificities for the detection of CSME were: subjective impression, 6 of 24 eyes (25.0%) and 52 of 80 eyes (65.0%); Amsler grid, 9 of 24 eyes (37.5%) and 59 of 80 eyes (73.8%); and entoptic perimetry, 17 of 24 eyes (70.8%) and 44 of 80 (55.0%) eyes. These results are also statistically significant, with entoptic perimetry being more sensitive and less specific than both subjective impression (P = 0.007 and P = 0.011, respectively) and Amsler grid (P = 0.008 and P < 0.001, respectively) in this subset of patients. CONCLUSIONS Entoptic perimetry is 87% more sensitive than the subjective impression of visual decline (P < 0.001) and 100% more sensitive than Amsler grid (P < 0.001) for the detection of central scotomas in diabetic patients. For the detection of CSME, entoptic perimetry is 183% more sensitive than subjective impression (P = 0.007) and 89% more sensitive than Amsler grid (P = 0.008). Hence, entoptic perimetry, performed using conventional television, has the potential to be an effective, inexpensive, and widespread adjunct to surveillance examinations for the early detection of diabetic maculopathy.

Postoperative Complications Following Vitrectomy for Proliferative Diabetic Retinopathy with Sew-On and Noncontact Wide-Angle Viewing Lenses

BACKGROUND AND OBJECTIVE To compare the occurrence of vitreous hemorrhages and retinal detachments following vitrectomy surgery with sew-on lenses to a noncontact wide-angle lens system. PATIENTS AND METHODS Retrospective review of 180 patients who underwent primary vitrectomy for proliferative diabetic retinopathy. The occurrence of persistent and recurrent vitreous hemorrhages as well as postoperative retinal detachments in the two groups was determined. RESULTS There was no statistically significant difference in the occurrence of persistent vitreous hemorrhages between the sew-on (55%) and the wide-angle (42%) lens systems (P = 0.099). Likewise, recurrent vitreous hemorrhages were similar in both the sew-on (15%) and the wide-angle (17%) lens systems (P = 0.838). However, postoperative detachments were more frequent in the sew-on group (9%) than in the wide-angle (1%) group (P = 0.046). CONCLUSION In patients with proliferative diabetic retinopathy, using a wide-angle noncontact lens system significantly reduced the incidence of postoperative retinal detachments, but not persistent or recurrent vitreous hemorrhages.