Biomedical subjects
C H Dohlman
Publications and source records attributed to C H Dohlman.
Paraproteinemic crystalline keratopathy.
Paraproteinemic crystalline keratopathy is an uncommon complication of multiple myeloma and other plasma cell dyscrasias. A case of 16 years' duration was associated with an IgG kappa monoclonal gammopathy and recurrent uveitis. The corneal changes were unusually extensive and distributed throughout all corneal layers. The deposits consisted of diffuse, small, polymorphic aggregates, which were iridescent in the superficial cornea, mat elsewhere, and associated with a diffuse stromal haze; specular microscopy showed additional features. Both corneas were thickened. The deposits failed to stain histochemically, except patchily with Masson Trichrome. There was extensive immunohistochemical labeling for IgG, kappa, and surprisingly, lambda. Ultrastructurally, pleomorphic deposits were found in every corneal cell; paracrystalline deposits with internal banding were seen only in the basal epithelium. Keratocytes and endothelial cells were damaged and reduced in number. Disease recurred in a corneal graft. Three main types of paraproteinemic keratopathy can be distinguished. The deposits probably represent various metabolic products of the monoclonal protein. This is not necessarily a benign condition; hematologic control may be necessary on purely ophthalmological criteria.
Dry eyes--aspects of pathophysiology.
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Treatment of superior limbic keratoconjunctivitis by thermocauterization of the superior bulbar conjunctiva.
Superior limbic keratoconjunctivitis (SLK) is a chronic and recurrent inflammatory disease of the superior tarsal, bulbar and limbal conjunctiva that often responds to topical treatment with silver nitrate. As an alternative treatment in 11 patients (13 eyes), we applied thermal cautery to the inflamed superior bulbar conjunctiva following subconjunctival injection of 2% xylocaine. The overall positive response rate to thermocautery was 73% (8 patients). Of the positive responders, 63% (5 patients) had been considered silver nitrate treatment failures. Keratitis sicca was additionally noted in 55% of the patients studied. Impression cytology of involved superior bulbar conjunctiva was nearly devoid of goblet cells during the acute stage of the disorder. Following successful cauterization, goblet cells returned. Thus, thermocauterization of the superior bulbar conjunctiva appears to be a safe and effective mode of therapy for SLK.
Idoxuridine-induced conjunctival cicatrization.
Four patients had idoxuridine-induced conjunctival cicatrization similar to ocular cicatricial pemphigoid develop, but in the treated eye only. Three of the four patients had chronic, recurrent herpes simplex epithelial and stromal keratitis. The fourth patient had Sjögren's syndrome. All received idoxuridine (0.1% drops and/or 0.5% ointment) and topical corticosteroids from one to 3 1/2 years. Substantial morbidity resulted that included visual loss, stromal ulceration, corneal scarring, and keratinization. Conjunctival biopsy specimens showed cicatrization with a mixed inflammatory cell reaction and absence of goblet cells. Results of direct immunofluorescent microscopy of the conjunctiva were either negative or nonspecific for autoantibody. No circulating autoantibody was detected in any of the four patients.
Iridoplasty for prevention of post-keratoplasty angle closure and glaucoma.
Twenty patients who had iridoplasties performed at the time of penetrating keratoplasty were followed for a minimum of nine months. Although 12 patients had peripheral anterior synechiae (PAS) preoperatively, only four developed progressive PAS and secondary angle closure glaucoma postoperatively. Our experience suggests that iris suturing, by producing a mechanically rigid iris diaphragm, may prevent postoperative anterior synechiae and appositional angle closure.
Medroxyprogesterone on corneal ulceration. Its effects after alkali burns on rabbits.
The effect of medroxyprogesterone acetate treatment in preventing or retarding corneal ulceration after alkali burns was studied in rabbits in an attempt to correlate dose and response. The eyes were treated for 21 days with a 0.01% or 1% suspension administered topically four times a day or medroxyprogesterone acetate, 4 mg or 30 mg, given subconjunctivally on alternate days. None of these regimens was noticeably effective, although at times there was a trend toward retarding ulceration. Thus, it was not possible to confirm earlier reports of substantial efficacy of medroxyprogesterone. Corneal stroma with epithelial defects and/or ulcers persistently showed infiltration with neutrophils in the superficial stroma within the epithelial defect, implicating the tears as the source of the inflammatory cells.
Corneal donor material selection.
The authors conducted the first long-range study to demonstrate possible negative effects on the recipients of corneal transplantation from donors who had died of a systemic malignancy or of chronic neurologic disease. The results are reported of a long-term retrospective analysis of 73 patients who received 86 grafts from donors with various systemic malignancies. These patients were followed for a mean of 127 months. There was no evidence of the transfer of the same malignancy to any of the recipients. There was no increased incidence of malignancy or earlier mortality in our patient population when compared with a reference population. Graft infection, endophthalmitis, or local tumor growth was not observed. The authors state that at the present time there is no basis for excluding donors dying of systemic malignancy as a source of material for use in keratoplasty. The authors examined the case histories of six patients who received grafts from donors who had died of a neurological disease with a suspected viral etiology. In a follow-up period ranging from 120 to 174 months, no evidence of neurologic disease developed in any of the patients. The sample was too small to provide data necessary for drawing conclusions concerning the safety of the use of material from this source. The authors strongly advise excluding any patient with a neurologic disease of suspected viral etiology as a source of corneal donor material.
Posterior subcapsular cataracts induced by topical corticosteroids following keratoplasty for keratoconus.
Posterior subcapsular cataracts studied in 86 eyes of 86 patients transplanted for keratoconus were retrospectively studied. The follow-up period ranged between one and four years with a median of 18 months. Twenty-eight eyes developed posterior subcapsular cataracts. The development of posterior subcapsular cataracts was significantly related to the total cumulative steroid dose and the total time steroids were administered (p less than 0.01). Age, surgical technique, and rejection episodes could not be significantly correlated with development of a posterior cataract. The progression of the cataract appeared to be slow, and if topical steroids were discontinued the lens changes appeared to stabilize and progressed in only one patient. The effect of an early posterior subcapsular cataract on visual acuity was minimal in the early stages.
Recurrent keratoconus after keratoplasty.
A 35-year-old woman who had undergone bilateral penetrating corneal grafts for keratoconus had keratoconus in the eye that had received a graft 16 years earlier. A second penetrating keratoplasty was performed, and the excised button was examined with light and electron microscopy. Both the light and electron microscopic findings were consistent with the clinical diagnosis of keratoconus. Keratoconus in a graft for the same disease should be added to the list of late complications of successful keratoplasties.
Corneal wrinkling induced by ultra-thin soft contact lenses.
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Effect of bilateral and unilateral grafts on the incidence of rejections in keratoconus.
We studied results of 124 keratoplasties in 100 keratoconus patients; 61 men and 39 women varying in ages from 11 to 69 years with an average age of 30 years. Twenty-four patients had bilateral grafts with a 27% incidence of rejection, and 76 patients had unilateral grafts with a 13% incidence of rejection (P less than .01). Data analysis of the first year after the graft of first eyes and subsequent years after the graft of first and second eyes, however, revealed a nearly fourfold increase of rejections following second grafts, with a 17% increased chance of rejection for the first graft after the second was implanted. Only two of the bilateral and two of the unilateral grafts were irreversibly lost because of graft reaction. The major complication was the formation of posterior subcapsular cataract, which occurred in approximately 32% of the patients. The final postkeratoplasty visual acuities were significantly improved. In the patients who did not develop a cataract, 86% achieved visual acuity of 6/12 (20/40) or better. In the patients who did develop cataracts, 68% achieved visual acuity of 6/12 (20/40) or better.
Oversize corneal donor grafts in penetrating keratoplasty.
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Effect of topical corticosteroids on ulceration in alkali-burned corneas.
Dexamethasone sodium phosphate was administered topically to one eye of rabbits with bilateral alkali corneal burns, and saline solution was administered to the contralateral eye. Topical steroids were also administered in animals with moderate corneal ulcers and were found to enhance the severity of ulceration when given during the second and third weeks following the burn. If the corticosteroids were given daily in the first six days or in the fourth and fifth weeks following the burn, they did not have an adverse effect on the cornea. Corticosteroids can be used intensively during the first week following an alkali burn, without increasing the risk of corneal melting. The mechanism for the enhancement of corneal ulceration is not a direct augmentation of collagenase activity, but probably involves the inhibition of repair processes.
Corneal donor material selection.
Histologic study of eyes used as donor material for corneal transplant revealed one instance of massive leukemic infiltration with leukemic keratic precipitates on the fellow eye. In another eye, microabscesses composed of acute and chronic inflammatory cells containing Crytococcus neoformans were present. In a third patient metastatic anaplastic cells were present in the choroid. We think donor eyes are absolutely unacceptable if death was caused by any chronic neurologic disorder, unless clearly secondary to trauma. Eyes from patients with septecimia, hepatitis, jaundice and any evidence of any active viral infection, syphilis, and positive serology are also unacceptable. Extreme caution should be used in selecting eyes of patients with ocular or systemic malignancy, long-term diseases, particularly if immunosuppressive agents were used, where a history of eye disease exists, including corneal disease or dystrophy, iritis, absolute glaucoma or acute glaucoma, and eyes with a history of previous intraocular surgery.
Penetration routes of topically applied eye medications.
Tritium-labeled hydrocortisone acetate and pilcarpine hydrochloride solutions were topically applied to the eyes of rabbits. In one group of animals, the drugs were excluded from contact with the cornea by a cylindrical well glued to the eye surface. In another group, the drug solutions were allowed contact with the entire anterior surface of the eye. Total application time in all cases was five minutes, then the eyes were flushed with saline. Samples of aqueous humor, stroma, and iris-ciliary body were taken after five, 20, 35, 65, and 125 minutes and counted in a liquid scintillation counter. With hydrocortisone, up to 70 times more drug reached the stroma when the cornea was exposed; 40 times more reached the iris. Peak stromal levels occurred by 20 minutes, dropping to one third of peak value by two hours. With pilocarpine, about five times more drug reached the iris-ciliary body when corneal access was allowed; the level peaked in about five minutes. These results illustrate the important role of tear film distribution and blinking in delivering remotely applied drugs over the cornea with subsequent entry to interior sites.
Punctal occlusion in keratoconjunctivitis sicca.
Occlusion of the lacrimal puncta is a useful and underutilized procedure in the treatment of keratoconjunctivitis sicca. When artificial tears no longer ameliorate symptoms and the Schirmer tests are 2 mm/5 min or less (repeatedly), combined with positive rose bengal staining, punctal occlusion is indicated. Diathermy is the most practical technique for permanent closure, whereas various punctum plugs can be applied for a temporary effect.
Surface activity determination of aqueous tear components in dry eye patients and normals.
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