Päivi Puska

Switching from a preserved to a preservative‐free prostaglandin preparation in topical glaucoma medication

Purpose:  The purpose of this study was to investigate the tolerability and intraocular pressure (IOP) reducing effect of the first preservative‐free prostaglandin tafluprost (Taflotan®) in patients exhibiting ocular surface side‐effects during latanoprost (Xalatan®) treatment.

Photosensitivity in lupus erythematosus, UV photoprovocation results compared with history of photosensitivity and clinical findings

Photosensitivity, one of the presenting symptoms in lupus erythematosus (LE), is still poorly defined and varying prevalence figures have been reported. The possibility of a coexisting photodermatosis, especially polymorphous light eruption (PLE), has often not been taken into account. We report the results of ultraviolet A (UVA) and B (UVB) photoprovocation tests in 67 clinically photosensitive patients who had confirmed discoid LE (DLE), systemic LE (SLE) or subacute cutaneous LE (SCLE). The results are compared with a detailed history of photosensitivity and with clinical and serological findings. A pathological photoprovocation reaction, graded as weak, moderate or strong, was induced with either UVA or UVB in 69% of patients with LE, in 100% of those with SCLE, in 70% of those with SLE and in 64% of those with DLE, but in none of 14 controls. Only 16% of the pathological reactions were strong and long‐lasting, resembling LE lesions, while 48% were moderate or weak and transient, clinically like PLE. Fifty‐three per cent of the provocation reactions which were biopsied showed a PLE‐like histology or a non‐specific inflammatory reaction, and most of them were clinically moderate or weak reactions of short duration. In the remaining, mostly clinically strong or long‐lasting reactions, the histology was consistent with LE. A history of sunlight sensitivity did not predict a pathological photoprovocation result but a positive association between the presence of SSA/Ro or SSB/La antibodies and a pathological photoprovocation reaction was found. We have shown that PLE coexists with LE and that both PLE‐ and LE‐like lesions can be induced with UV radiation in LE patients.

Unilateral exfoliation syndrome: conversion to bilateral exfoliation and to glaucoma: a prospective 10-year follow-up study.

PurposeThis prospective 10-year follow-up study was conducted to examine conversion of nonglaucomatous eyes with unilateral exfoliation syndrome (EXS) to bilateral EXS and to glaucoma. Risk factors for conversion to a bilateral condition and to glaucoma were studied. PatientsSixty-three nonglaucomatous subjects (mean age, 68.6 ± 6.2 years) with unilateral EXS were enrolled. Of these patients, 56 were followed-up (89%). The effects of age, initial intraocular pressure (IOP), IOP difference between the fellow eyes, angle pigmentation, amount of exfoliation material, pupillary dilatation, optic disc topography, and phenylephrine-induced pigmentary dispersion on occasional conversion to the bilateral form and to glaucoma were studied by multivariate survival analysis. ResultsIn 10 years, 38% had converted to bilateral EXS. Conversion to exfoliation glaucoma (EG) was 32% in the initially exfoliative eyes and 38% in the initially nonexfoliative (non-EXS) fellow eyes. Primary open-angle glaucoma developed in 3.5% of the non-EXS eyes. In the initially EXS eyes, a significant association was found between the initial IOP and conversion to EG (relative risk = 1.471, P = 0.0001). When initial IOP was removed from the model, the pupillary dilatation values (relative risk = 0.488, P = 0.035) and the differences in IOP between the fellow eyes (relative risk = 1.224, P = 0.0181) were associated with conversion to EG. None of the factors studied was associated with conversion to the bilateral form. ConclusionIn unilateral EXS, factors associated with conversion to EG were initial IOP, pupillary dilatation value, and difference in IOP between the fellow eyes. No risk factors for conversion to bilateral EXS were found.

Occurrence of polymorphous light eruption in lupus erythematosus.

Photosensitivity is a well–known manifestation of lupus erythematosus (LE). Since there are no strict criteria for photosensitivity, varying prevalence figures have been reported. Also, distinction from polymorphous light eruption (PLE) can be difficult. The purpose of this study was to characterize photosensitivity in more detail and to determine the occurrence of PLE in a series of well–documented LE patients. A questionnaire was answered by 337 LE patients seen at dermatology departments in Finland and Sweden, and 63 of the patients were invited for interview. According to the questionnaire. LE lesions were made worse by sunlight in 242 (72%) patients. Symptoms consistent with PLE were reported by 165 (49%) patients. Detailed personal interviews supported the results from the questionnaire, and revealed that PLE had started 2–45 years before the onset of LE in 23 of 37 patients with both diagnoses, and more than 7 years before in 18 of 37 (49%). PLE proved to be common in patients with both systemic and cutaneous LE. The two conditions may often coexist and, in about half of the cases, PLE preceded LE. These two diseases may share pathogenic factors, PLE might predispose to LE in a subgroup of PLE patients.

Optic disc changes in normotensive persons with unilateral exfoliation syndrome: a 3-year follow-up study

Abstract · Background: If, at the time of glaucoma diagnosis, the intraocular pressure (IOP) is higher and the initial field loss more advanced in glaucomatous eyes with than without exfoliation, the cause of the optic disc damage has been suggested to be the high IOP associated with the exfoliation syndrome (EXS). We decided to investigate whether EXS alone, without the contributory effect of measured raised IOP, is a risk factor for optic nerve damage. · Methods: Twenty-two non-glaucomatous, normotensive persons with clinically unilateral EXS were examined for IOP, visual fields (Octopus G1) and disc topography (Imagenet, Topcon) and followed up for 3 years. · Results: At the start, the paired exfoliative (E) and non-exfoliative (NE) eyes did not differ in IOP, disc, rim, or cup areas, or cup volumes. They differed in R/D (rim/disc) radius ratio in the inferior section of the optic disc. During the follow-up period, the IOP increased in the E and the NE eyes, and changes indicative of nerve fiber loss were measured in both eyes. In those (n=14) in whom the IOP in the two eyes was equal throughout the follow-up period, disc changes took place only in the E eye. · Conclusion: The exfoliative process in itself may be a risk factor for optic disc changes.

Prospective evaluation of external ocularmicrobial growth and aqueous humor contamination during cataract surgery

PURPOSE To analyze the route of aqueous humor contamination leading to the development of postoperative endophthalmitis. SETTING Department of Ophthalmology, University of Helsinki, Finland. METHODS Forty-nine eyes of 49 patients (31 having phacoemulsification and 18 extracapsular cataract extraction [ECCE]) participated in the study. Four bacterial cultures were taken: preoperative conjunctival swab, lid margin culture, intraoperative lacrimal lake sample, and immediate postoperative anterior chamber fluid sample. RESULTS Preoperative lid margin cultures were positive in 59.2% of eyes, conjunctival cultures in 69.4%, and lacrimal lake cultures in 24.9%. Four aqueous humor samples (8.2%) showed bacterial growth in the anterior chamber aspirate: 3 in the phacoemulsification and 1 in the ECCE group. The bacteria isolated in this study, Staphylococcus epidermidis and Propionibacterium acnes (2 positive isolates each) were sensitive to the preoperative topical antibiotics used. No aqueous humor sample or any from other locations showed gram-negative microbe growth. The most frequently recovered microbes in all samples collected from the 3 other sources were S epidermidis and other coagulase-negative staphylococcus species, followed by P acnes and other propionibacterium species. Staphylococcus aureus, and diptheroids. CONCLUSION The ocular surface significantly contributed to the transmission of microbes into the eye during cataract surgery. These microbes could not be eradicated by topical preoperative antibiotics. However, no patient developed postoperative endophthalmitis. Natural defense mechanisms appear to fend off a minor inoculum with these microbes of relatively low pathogenicity.

Exfoliation syndrome as a risk factor for cataract development: Five-year follow-up of lens opacities in exfoliation syndrome

Purpose: To ascertain whether the exfoliation syndrome (EXS) is a risk factor for cataract development. Setting: Helsinki University Eye Hospital, Helsinki, Finland. Methods: This prospective study examined the development of lens opacities using the Lens Opacity Meter. Visual acuity and refraction were measured in both eyes of 63 nonglaucomatous patients with clinically unilateral EXS. After 5 years, 46 patients were available for follow‐up. Case histories of 14 patients were recorded. Results: During the 5 year study, the rate of conversion to bilateral disease was 22% and to exfoliative glaucoma, 30%. At the beginning of the study, the mean lens opacity was 23.5 opacity units (OU) ± 6.7 (SD) in EXS eyes and 22.9 ± 7.2 OU in fellow, initially nonexfoliative (NE) eyes; the difference was not significant. After 5 years, the mean opacity was 30.0 ± 8.8 OU in EXS eyes and 26.9 ± 8.3 OU in NE eyes (P < .001). In patients who remained unilaterally affected, the EXS eye had a higher opacity value than the NE eyes at the start of the study (23.6 ± 7.3 OU and 22.7 ± 7.2 OU, respectively) (P < .05) and after 5 years (29.9 ± 9.0 OU and 27.0 ± 8.5 OU) (P < .01). There was a significant myopic change in refraction over time in both groups. The mean refraction in EXS eyes was +1.02 ± 2.48 diopters (D) at the start and + 0.11 ± 3.06 D after 5 years (P = .0001) and in NE eyes, +0.99 ± 2.25 D and +0.43 ± 2.55 D, respectively (P < .01). At the start of the study, the mean difference in refraction between fellow eyes (refraction in NE eye ‐ refraction in EXS eye) was –0.27 ± 1.00 D. After 5 years, it was +0.32 ± 1.44 D (P = .016), showing a greater myopic change in EXS eyes. Conclusion: The results show that EXS is a risk factor for lens opacification.

Association of LOXL1 gene with Finnish exfoliation syndrome patients

In this study, three single-nucleotide polymorphisms (SNPs) on the lysyl oxidase-like 1 (LOXL1) gene associated with exfoliation syndrome (XFS) and exfoliation glaucoma (XFG) were investigated in the Finnish population. A case–control study of 59 sporadic patients with XFS, 82 with XFG, 71 with primary open-angle glaucoma (POAG) and 26 individuals without these disorders from the southern Finnish population, and a family study of an extended family with 28 patients with XFS or XFG and 92 unaffected relatives from Kökar islands, Southwestern Finnish archipelago, were conducted. Anonymous blood donors (n=404) were studied as population-based controls. Three SNPs, rs1048661 (R141L), rs3825942 (G153D) and rs2165241, of the LOXL1 gene were genotyped by PCR sequencing. Association and linkage analyses were carried out. In both case–control and family materials, significant association for allele G of rs1048661 (P=2.65 × 10−5; P=0.0007), allele G of rs3825942 (P=2.24 × 10−8; P=0.49) and allele T of rs2165241 (P=2.62 × 10−13; P<0.0001) was found in XFS/XFG. However, linkage was not observed for LOXL1 risk alleles. The corresponding three-locus haplotype GGT increased the risk of XFS/ XFG nearly 15-fold relative to low-risk haplotype GAC (odds ratio (OR): 14.9, P=1.6 × 10−16). In conclusion, the earlier reported polymorphisms of the LOXL1 gene showed significant association also in the Finnish population.

Corneal thickness and corneal endothelium in normotensive subjects with unilateral exfoliation syndrome

Abstract Purpose: To examine the central corneal thickness (CCT) and corneal endothelium in both eyes of patients with unilateral exfoliation syndrome (EXS). To determine the effect of CCT on the measurement of intraocular pressure (IOP). Methods: In this cross-sectional clinical study, comparisons were made of CCT (Humphrey Ultrasonic Pachometer), corneal endothelial cells (Keeler-Konan contact specular microscope) and IOP (Goldmann applanation tonometer) between the exfoliative (E) and fellow non- exfoliative (NE) eyes in 40 normotensive patients with unilateral EXS. The CCT was used to obtain a corrected value for the IOP. Results: The E eyes had significantly higher values for CCT (0.528±0.030 vs 0.523±0.032 mm, P<0.01) and IOP (15.7±3.6 vs 14.4±2.9 mmHg, P<0.001) than the fellow NE eyes. The paired E and NE eyes did not differ in endothelial cell density (2779±540 vs 2870±386 cells/mm2), in the coefficient of variation of cell size (0.25±0.03 vs 0.26±0.03) or in the frequency of hexagonal cells (80.5±6.5 vs 82.0±5.0%). After correcting IOP for CCT, the E eyes still had significantly higher IOP than the NE eyes (15.1±4.4 vs 14.2±3.7 mmHg, P<0.05). Conclusion: Normotensive eyes with early EXS did not have quantitative (cell density) or qualitative (variation in cell size, frequency of hexagonal cells) morphological changes in corneal endothelium, but had higher values for IOP and CCT. After correcting IOP for CCT, the E eyes still had significantly higher IOP than the fellow NE eyes.

Transscleral Contact Krypton Laser Cyclophotocoagulation for Treatment of Glaucoma

PURPOSE To evaluate the usefulness of the krypton laser for transscleral contact cyclophotocoagulation. METHODS Transscleral contact krypton laser cyclophotocoagulation was performed in 62 eyes of 57 patients with therapy-resistant glaucoma. A minimum follow-up for 6 months was obtained for 59 eyes. The krypton laser was delivered via a fiberoptic probe with compression of the sclera by the probe. The energy used was 4 to 5 J per application at the tip of the probe with an exposure time of 10 seconds. RESULTS The intraocular pressure (IOP) decreased from the baseline mean of 34.8 +/- 11.0 mmHg to 20.4 +/- 8.3 mmHg within 10 days, to 22.6 +/- 12.5 mmHg at 1 month, to 21.3 +/- 11.3 mmHg at 3 months, and to 20.9 +/- 9.1 mmHg at 6 months postoperatively. Intraocular pressures of 8 to 24 mmHg were obtained in 62% of the eyes at 1 month, 60% at 3 months, and 73% at 6 months postoperatively with one or more cyclophotocoagulations but no other hypotensive procedures. The corresponding success rates after 6 months were 82% for eyes in which the procedure was performed to preserve vision and 50% for eyes in which the procedure was performed to relieve pain. No clinical signs of scleral injury or cyclodestruction-related loss of vision were detected. CONCLUSIONS Krypton laser cyclophotocoagulation appears to be an effective and well-tolerated means of lowering IOP in therapy-resistant glaucoma. An advantage of the method is that standard retinal krypton photocoagulators can be used for the procedure.