Biomedical subjects
Publications and source records attributed to H Bettelheim.
Direct and indirect Doppler ultrasonography (DUSG) of the carotid arteries contribute to the differentiation between extracranial and intracranial carotid occlusion. Ocular symptoms and DUSG findings in intracranial carotid occlusion are discussed. Six relevant case reports are presented.
During the past 5 years 412 patients (189 male, 223 female) presenting with vascular disorders were examined with Doppler ultrasonography (DUSG) of the orbital vessels. DUSG was used as a screening method for detecting additional lesions of the carotid system. The 412 patients were divided into 5 groups according to their clinical symptoms: Group I: amaurosis fugax; group II: occlusions of the central retinal artery; group III: venous circulatory disorders of the retina; group IV: AION and optic disk vasculitis; group V: symptoms of chronic ocular ischemia. DUSG disclosed a high percentage of additional carotid lesions in groups I and II. In retinal venous disorders, in idiopathic non-arteritic AION and in optic disk vasculitis DUSG findings usually were negative. In contrast to this, DUSG furnished valuable diagnostic information in arteritic AION, where nearly 50% of DUSG findings were positive. Carotid angiography, echo-flow examination of the carotid system and temporal biopsy were used as reference methods.
Twenty-three patients presenting with clinical and angiological signs of temporal arteritis were examined by ODG and DUSG. While the results of ODG were positive in all 23 patients, DUSG failed to furnish diagnostic evidence of temporal arteritis. Findings with DUSG were positive in only 9 out of 23 patients. DUSG is less suitable than ODG as a means of diagnosing temporal arteritis.
This paper presents a survey of the clinical, aetiological, pathogenetic, diagnostic and therapeutic features of vascular optic neuropathies.
A new fluoroimmunoassay and radial immunodiffusion were used for quantification of albumin and IgG in 30 human aqueous humour samples. Advantages and results of both methods are compared.
The author discusses the possibilities of registering the ocular pulse. With the help of sphygmography, the so-called pressure pulse can be registered. These techniques yield information about carotid arterial occlusive disease. The purpose of plethysmography is to measure the extent of intraocular blood flow. Yet quantitative determination of the intraocular blood flow rate is not yet possible. The author gives a critical review of the various methods and their limitations.
In 67 patients suspected to suffer from cerebral vascular disorders or arterial occlusive disease results of ophthalmodynamometry and ophthalmodynamography were compared with those of carotid angiography. Especially in patients with angiographically substantiated carotid stenosis the results of ODM and ODG were extraordinarily poor. The findings of ODM and ODG proved to be non indicative in 29 out of 35 cases. The authors discuss the possible reasons of these disappointing results.
Aqueous humor (a.h.) was sampled in 67 patients operated on for cataract by intracapsular lens extraction at the start and finish of surgery. Twenty eight of these patients received pretreatment with acetyl-salicylic acid (ASA), to a total of 2.5 g, beginning 18 hours prior to surgery. A serum sample was drawn immediately following the operation from 55 patients. Using radial immunodiffusion, albumin and IgG were measured in primary and secondary a.h. and in serum. The group pretreated with ASA showed a significantly smaller relative increase of IgG (P < 0.05). The increase of the proteins, however, showed no dependence on their serum-level and the only side-effect of the treatment was an unexplained rise in serum-albumin. The possible clinical application of patients with a high risk of postoperative complications is briefly summarized.
Thirty-eight patients with amaurosis fugax were examined ophthalmologically. In 12 of these cases carotid occlusion was diagnosed by ophthalmodynamography and Doppler ultrasonography of the orbital vessels. Angiographic substantiation was possible in nine of these patients. The pathognomonic importance of amaurosis fugax for occlusive carotid disease is clearly shown by these findings. The plasma concentration of platelet specific proteins was examined in 32 patients and found to be pathologically increased in 13 cases. Spontaneous aggregation of platelets and circulating platelet aggregates were only found in a few patients. Due to the lack of coincidence between the event of amaurosis fugax and the time when platelet function tests were made no definite conclusions may be drawn from these results. Yet disturbances of platelet function must be taken into consideration in the pathogenesis of amaurosis fugax.
In 71 patients that underwent intracapsular extraction of the cataract it was possible to collect aqueous humor (a.h.) in sufficient quantities at the beginning and at the end of the operation. Using radial immunodiffusion albumin, IgG and alpha-1-antitrypsin were measured in the samples. In secondary a.h. huge variations in the concentrations were apparent. The primary permeability of the blood-aqueous barrier and the time between sampling had no influence on the relative increase of the proteins. No statistically significant difference was found between normotensives and hypertensives and patients with or without myopia of higher degree (over 6 diopters). The relative increase of proteins according to their difference in molecular weight followed the same pattern as described for anterior uveitis. In patients for whom an enzymatic zonulolysis with trypsin was used for the extraction, the relative increase of IgG was significantly smaller than in those that did not receive this treatment (P less than 0.005). The possible sources contributing to the formation of secondary a.h. are discussed.
51 patients with renal transplants were examined ophthalmologically 31,1 (1--77) months after the transplantation. 80,4 p. c. showed ocular complications: cataract formation in 43,1 p. c. of the patients examined and increased intraocular pressure values between 22 and 30 mm Hg in 3 patients are to be attributed to the systemic immunosuppressive therapy. Further ocular changes were recurrent subconjunctival haemorrhages due to increased vascular rigidity, calcium phosphate deposits in the conjunctiva due to persistant secondary hyperparathyroidism and fundus changes (pigmentary irregularities in the foveal regions, narrow arterial vessels). Although marked arterial hypertension was observed in 21 patients after the transplantation, no signs of hypertensive retinopathy could be found. Despite the high incidence of ocular complications after renal transplantation the risks of immunosuppressive therapy must be considered as tolerable: cataract formation and increased intraocular pressure do not impair the positive effect of renal transplantation on ocular functions. Regular ophthalmological control examinations of renal transplant patients are advisable.
16 renal transplant recipients underwent ophthalmological examination 11.4, 19.4 and 61.3 months after renal transplantation. The most common side effects of immunosuppressive therapy were steroid-induced cataract formation, steroid glaucoma, and recurrent subconjunctival haemorrhages. Posterior sub-capsular cataracts may develop as early as 2 months after surgery, reach their highest incidence within 2 years and may be reversible under low dosage steroid therapy. 75.5% of 57 ophthalmologically examined patients showed ocular complications or changes, but visual function was not severely disturbed. Despite hypertension in 23 cases, no hypertensive retinopathy was observed. In the light of these findings we assume that kidney transplantation has a positive influence on ocular functions, and especially on fundus changes dating from the time of regular dialysis treatment.
The injection of a suspension of hydrocortisone into a keloidal scar of the nose of a 72 year-old man and of a foamy solution of hydroxypolyethoxydodecane into a little haemangioma situated above the right eyebrow of a 29 year-old woman was followed by sudden blindness of the homolateral eye in each case. This is basically explained by the involuntary injection of embolizing material into the anastomoses between the external and internal carotid arteries within the orbit. Therefore, the injection of embolizing material into the skin of the face should be avoided.
In aqueous humors and sera from 44 patients with cataracts, albumin, IgG, and alpha-1-antitrypsin were measured using radial immunodiffusion. The mean concentrations of the three proteins were significantly smaller than values found in aqueous humors taken post mortem, but corresponded well to values found in cerebrospinal fluid. No statistically significant difference was found between men and women, normotensives and hypertensives, and patients with or without myopia of high degree (greater than 6 diopters). A slight increase in protein concentrations in older patients and a relative decrease of alpha-1-antitrypsin is described. The aqueous humor-serum quotients of the different proteins showed a higher correlation than did the concentration of the proteins in aqueous humors.
Doppler Ultrasonography of the orbital vessels is a simple non invasive technique for the qualitative determination of velocity and direction of blood flow within the supratrochlear and supraorbital arteries. In temporal arteritis characteristic findings can be obtained with this method. The amplitudes of ultrasonograms are markedly reduced and the waveforms considerably distorted. Sometimes there is a complete absence of velocity signals from the orbital vessels. When the superficial temporal artery is compressed abnormal reactions are almost always elicited, whereas the compression of the homolateral carotid artery yields normal results. In temporal arteritis, the diagnostic value of Doppler ultrasonography of orbital vessels seems about as great as that of Hager ophtalmodynamography.
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With Doppler ultrasonography of the orbit the blood flow in the supratrochlear and supraorbital arteries can be determined transcutaneously. The technique yields reliable informations about the state of the carotid system. It is especially suitable for assessing carotid obstruction. Besides it has proved to be of particular diagnostic value in temporal arteritis. The authors describe and discuss the technique of orbital Doppler ultrasonography and present typical findings in carotid lesions and in temporal arteritis.
Neurological disturbances were seen in patients who underwent open heart surgery with prolonged extracorporeal circulation. These were found mainly in patients older than 50 years and when episodes of hypotension lower than 50 mm Hg occurred during cardiopulmonary perfusion. A method of recognizing cerebral hypoperfusion would be most helpful to prevent brain damage. According to the experimental and clinical findings of Hager the method of ophthalmodynamography allows some conclusion of analogy in relation to the reaction of the brain vessels. The intraoperative ophthalmodynamogram was recorded in 8 patients undergoing surgery using extracorporeal circulation. The ophthalmodynamograms seen during surgery on the beating heart showed changes associated with surgical manipulation. When the arterial pressure fell the orbital pulsation was decreased. The orbital pulsation stopped when the spontaneous heat beat was replaced by extracorporeal circulation. There was no change attributable to the perfusion pressure produced by the roller pump. Cessation of the orbital oscilogram during extracorporeal circulation does not indicate a cerebral hypoperfusion. No neurological lesion was seen in our patients. We were able to show that amplitude of the ophthalmodynamogram is influenced more by the blood pressure amplitued than the mean arterial pressure.