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The purpose of this study was to determine the occurrence and severity of diabetic retinopathy and to clarify its association with the duration of diabetes and several other factors in an outpatient diabetic population. The material consisted of 328 diabetics, mainly (77%) C-peptide negative, type 1 diabetics. The mean age of the patients was 45 years, and the mean duration of diabetes was 15 years. Retinal changes were assessed by ophthalmoscopy and widefield fundus photography. All retinopathy was confirmed in 59% and proliferative retinopathy (PR) in 20% of the patients. The frequency of diabetic retinopathy was 15% in patients with diabetes for less than five years but 100% in those with diabetes for 30 or more years. In type 1 diabetics PR was seen only after 10 or more years' duration but, after 20 years' duration it was seen in half of the patients with type 1 and in one-third of the patients with type 2 diabetes. The patients with diabetic nephropathy often had PR. In type 1 diabetics with onset of the disease less than 30 years peripheral sensory neuropathy, coronary disease, hypertension and leg-vessel disease were also often associated with PR. Because one reason for visual handicapping in diabetes is the delay of the diagnosing of vision-threatening lesions screening for treatable retinopathy should be intensive after 10 years' duration and in poorly-controlled diabetics even earlier.

Gallium citrate Ga67 scanning of the head and thorax of 3 patients with sarcoidosis is presented. Two patients had a progressive pulmonary sarcoidosis of recent onset and in one patient, with a chronic course of the disease, the lung changes had resolved. All 3 patients had a conjunctival sarcoid change confirmed by biopsy and a lacrimal gland affection suggested by clinical examination. A highly increased Ga67 uptake in the lacrimal and parotid glands as well as in the nasopharynx was found in all patients, and an increased lung uptake was found in the newly detected cases. It is concluded that gallium scanning is a sensitive method for detecting minute ophthalmic changes in sarcoidosis. It also reveals chronic localized ocular affection in cases in which the lung changes are no longer detectable. The mechanism and specificity of gallium uptake in sarcoidosis is also discussed.

Objective To analyze the clinical features of primary intraocular lymphoma (PIOL) and to describe cytochemical and immunocytochemical findings of the vitreous specimens as well as the reasons for delayed diagnosis of PIOL. Design Prospective noncomparative study. Participants Eleven patients referred to the uveitis or medical retina units, Department of Ophthalmology, University of Helsinki, were diagnosed as having PIOL between 2000 and 2005. The median follow-up of the patients was 32 months. Methods Clinical features and diagnostic workup of uveitis were described. Twelve vitrectomies were performed on 9 patients. The first 5 biopsies were fixed in an equal volume of 50% alcohol. The specimens of the next 7 vitrectomies were handled without alcohol, and tissue culture medium was added to the samples. Main Outcome Measures Clinical features of PIOL, intervals from ocular symptoms and from first ophthalmological examination to diagnosis, and the role of a proper handling of the vitreous sample in the diagnosis of PIOL. Results Six females (54%) and 5 males (46%) (median age, 61 years) were included. Ten patients had ocular symptoms for 1 to 30 months (median, 8) before the first contact with an ophthalmologist. Uveitis was bilateral in 9 patients. Vitreitis was seen in all patients, and it was severe in 8. Fundus lesions dominated in 3 patients. Six patients lost useful vision in one eye before the diagnosis of PIOL. Cytologic and immunohistochemical stainings prepared of the unfixed vitreous specimens showed PIOL in 6 patients. The samples fixed in alcohol were nondiagnostic in 4 patients, and in them, verification of diagnosis was based on brain biopsy (3) or cerebrospinal fluid (1) findings. Seven patients died due to primary nervous system lymphoma. Conclusions Diagnosis of PIOL is difficult but can be improved. Severe bilateral vitreitis in an elderly patient is a characteristic finding of PIOL. Alcohol fixation may jeopardize the identification of PIOL cells in the vitreous sample. Optimal handling of the vitreous specimens and examination of the slides by an experienced cytopathologist are critical in the diagnostic workup of PIOL.

Purpose: To describe a patient with a long disease history who was finally diagnosed with neurosarcoidosis and to discuss the reasons behind the delayed diagnosis. Case Report: A 58-year-old man with sick sinus syndrome and bradycardia, which was treated with a pacemaker, developed first right and then left facial palsy. Subsequently, multiple cranial nerve palsies developed and later spontaneously resolved. Neurosarcoidosis was suspected at that stage, but excluded because the patient had no typical sarcoid lung changes, his serum and cerebrospinal fluid angiotensin converting enzyme activity levels were normal and a computed tomography scan disclosed no central nervous system changes. During follow-up, the patient developed extremely dry eyes and mouth, suggesting Sjogren's syndrome. Rheumatology consultation did not reveal any autoimmune or visceral features typical of Sjogren's syndrome and autoantibodies were negative. However, both labial salivary gland and conjunctival biopsies revealed non-caseating granulomas, and neurosarcoidosis was diagnosed. Conclusions: Neurosarcoidosis is a relatively rare disease with a somewhat poor longterm prognosis in one-third of cases, although the neurological manifestations often diminish or disappear in response to glucocorticoid treatment. Diagnosis is often a clinical challenge, especially in the absence of pulmonary changes or other features typical of sarcoidosis. The labial salivary gland and conjunctiva provide helpful biopsy sites for histopathological confirmation of the diagnosis.

Objective: To study the infectious backround of patients with a history of acute anterior uveitis (AAU) and healthy control subjects. Methods: Sixty four patients with previous AAU and 64 sex and age matched controls were studied. Serum antibodies to Salmonellae , Yersiniae , Klebsiella pneumoniae , Escherichia coli , Proteus mirabilis , Campylobacter jejuni , and Borrelia burgdorferi were measured using enzyme linked immunosorbent assay (ELISA), and antibodies to Chlamydia trachomatis and Chlamydia pneumoniae by microimmunofluorescence test. Peripheral blood mononuclear cells (PBMCs), separated by density gradient centrifugation, were studied for Salmonella and Yersinia antigens by means of an immunofluorescence test, and for C pneumoniae DNA with a polymerase chain reaction (PCR). Results: Neither prevalence nor levels of single microbial antibodies studied differed between the patients and control subjects, or between subgroups of patients created on the basis of clinical characteristics. In logistic regression analysis, the high number of recurrences (>10) of AAU was independently related to the presence of single or multiple bacterial antibodies (p=0.04). None of the PBMC samples of the patients were positive for Yersinia or Salmonella antigens. C pneumoniae PCR was positive in a patient who was negative for C pneumoniae antibodies. Conclusion: Although neither the prevalence nor the levels of single microbial antibodies studied differed between the patients and the controls, current data suggest that the presence of single or multiple antibodies in patients with many recurrences of AAU compared with patients with none or few recurrences may be a sign of repeated infections, antigen persistence, or raised innate immune responsiveness.

Purpose: To compare the effectiveness of intravenous (i.v.) methylprednisolone pulse therapy and oral prednisone when used as the initial treatment of patients with mild or moderate thyroid-associated ophthalmopathy. Methods: Thirty-three consecutive patients with thyroid-associated ophthalmopathy in Helsinki and Turku University Hospitals were randomly assigned either i.v. methylprednisolone pulse therapy (group A, n Ω18) or oral prednisone (group B, n Ω15). Treatment outcomes were measured by subjective changes in the grade of diplopia and quantitatively in several ophthalmic variables at 3 and 12months. Any decision to proceed with additional treatment at 3months was made on clinical grounds. The study was open in respect of both the initial treatment and the need for additional therapy. Results: No significant differences in the grade of diplopia, proptosis or soft tissue activity scores were noted between groups A and B from 0 to 3months. However, group A required additional forms of therapy at 3months less frequently than did group B (p Ω0.038). Conclusions: Our data suggest that i.v. methylprednisolone pulse therapy and oral prednisone are equally effective as initial treatments for thyroid-associated ophthalmopathy where diplopia, proptosis and signs of soft tissue inflammation are concerned. When additional treatment is required, i.v. methylprednisolone pulse therapy may be more effective than oral prednisone. However, the study’s limitations meant that any decision to give additional treatment after the initial therapy was made on clinical grounds.

To examine the occurrence and characteristics of uveitis in patients with recently diagnosed juvenile chronic arthritis (JCA).A prospective observational case series.The study covered the new cases detected with JCA (426 children), all of whom were referred to an ophthalmologic consultation during 1989 to 1996 at the Pediatric Department of the Rheumatism Foundation Hospital, Heinola, Finland.The children with JCA were followed by ophthalmologic and pediatric examinations two to four times a year. The type and course of arthritis and presentation and characteristics of uveitis were examined prospectively.Uveitis was detected in 104 of 426 children (24%). Two thirds of all patients and the same proportion of those with uveitis were girls. Proportionally, uveitis was found to be as common among children with oligoarthritis (27%) as among those with seronegative polyarthritis (25%). Antinuclear antibodies (ANA) were detected significantly more frequently in patients with uveitis (66%) than among those without uveitis (37%) (P0.001). The uveitis was asymptomatic in 99 cases; only 5 children had episodes of acute anterior symptomatic uveitis. Uveitis was found before or within 3 months from the onset of recent arthritis in 51 of 104 children (49%) and later on in 53 of 104 children (51%). The mean age at diagnosis of uveitis was 5.9 years (range, 1.1-17.7; median, 4.9 years). The mean period from the diagnosis of JCA to the diagnosis of uveitis was 1.1 years (range, -2.4-6.5; median, 0.3 years). The mean age at diagnosis of JCA was 4.8 years (range, 0.6-15; median, 3.2 years) among those with uveitis and 7.3 years (range, 0.9-16; median, 6.7 years) among those who did not have it (P0.001). Uveitis was ongoing in 63 children at the end of the follow-up period. The mean follow-up time was 4.5 years (range, 0-9.7) for all children and 5.6 years (range, 1.3-9.6) for those with uveitis. In most instances, the visual prognosis was good. In 25 of 104 patients (24%) one or more complications of uveitis were found, but in only three children did the visual acuity decrease to 20/60 or less, and none became blind. All the other patients had visual acuityor = 20/40.In this patient group, uveitis in JCA frequently appeared very early after the onset of arthritis. The uveitis was significantly more common in patients with an early onset of arthritis combined with ANA positivity. The proportion of children with uveitis was as large in those with polyarthritis as in those with oligoarthritis, with no predilection to girls.

AIMS—To determine whether HLA-B27 typing helps the clinician in the diagnostic examination of uveitis in a HLA-B27 rich population and also whether the clinical picture of HLA-B27 positive unilateral acute or recurrent anterior uveitis (AAU) is distinguishable from the idiopathic negative form. METHODS—During a 3 year period 220 consecutive patients with undetermined uveitis at onset were examined in the Helsinki University Eye Clinic. HLA-B27 antigen was tested for 85% of the patients. Other laboratory or x ray examinations were performed on the basis of the anatomical classification of uveitis and the biomicroscopic features characteristic of uveitis associated systemic diseases. RESULTS—HLA-B27 antigen was found significantly more often in patients with anterior (71%) and acute/recurrent unilateral (79%) uveitis than in patients with intermediate, posterior panuveitis (7%), and chronic (7%) or bilateral (12%) forms. Of the 16 cases of HLA-B27 negative unilateral AAU, five showed biomicroscopic features representing uveitis entities. The remaining 11 cases did not differ in any respect from the cases of HLA-B27 positive unilateral AAU. CONCLUSION—HLA-B27 antigen helps the clinician in the diagnostic examination of unilateral AAU. Positive test results serve as a clue to search for spondyloarthropathies, and negative results indicate the need to look for specific uveitis entities and other systemic diseases. The occurrence of HLA-B27 positivity in conjunction with uveitis entities other than unilateral AAU is of the same level or less than in the population of Finland in general.

Objective To delineate the clinical manifestations of ocular Lyme borreliosis, while concentrating on new symptoms and findings and the phase of appearance of ophthalmologic disorders. Design Observational case series. Participants Ten patients with Lyme borreliosis-associated ophthalmologic findings previously reported from the Helsinki University Central Hospital in addition to 10 new cases that have since been diagnosed. Intervention/testing The patients underwent medical and ophthalmologic evaluation. The diagnosis of Lyme borreliosis was based on medical history, clinical ocular and systemic findings, determinations of antibodies to Borrelia bugdorferi by enzyme-linked immunosorbent assay and immunoblot analysis, the detection of DNA of B. burgdorferi by polymerase chain reaction, and exclusion of other infectious and inflammatory causes. Main outcome measures Ocular complaints, presenting ophthalmologic findings, and the stage of Lyme borreliosis were recorded. Results Four patients presented with a neuro-ophthalmologic disorder, five had external ocular inflammation, 10 patients had uveitis, and one had branch retinal vein occlusion. One patient developed episcleritis and one patient developed abducens palsy within 2 months of the infection incident. In the remaining 14 patients in whom the time of infection was traced, the ocular manifestations appeared in the late stage of Lyme borreliosis. Two patients with a neuro-ophthalmologic disorder and one with external ocular inflammation experienced severe photophobia, whereas the main reported symptom of the patients with uveitis was decreased visual acuity. Four patients with external ocular disease and one with a neuro-ophthalmologic disorder experienced severe periodic ocular or facial pain. Retinal vasculitis developed in seven patients with uveitis. Conclusions Lyme borreliosis can cause a variety of ocular manifestations, which develop mainly in the late stage of the disease. Photophobia and severe periodic ocular pain can be characteristic symptoms of Lyme borreliosis. In the differential diagnosis of retinal vasculitis, Lyme borreliosis should be taken into account, especially in endemic areas.

· Background: A study was carried out to evaluate indirect enzyme-linked immunosorbent assay (ELISA), immunoblot analysis, and polymerase chain reaction (PCR) in the diagnostic work-up of ocular Lyme borreliosis. · Methods: Twenty patients with ocular Lyme borreliosis were examined. IgG and IgM antibodies to Borrelia burgdorferi were measured by ELISA in serum, and in cerebrospinal fluid (CSF) when indicated, and immunoblot analysis of B. burgdorferi IgG antibodies in serum was performed. A nested PCR was used to detect a segment of a gene coding for B. burgdorferi endoflagellin. The samples used in PCR testing were serum and CSF and in isolated cases conjunctiva and vitreous. · Results: Seventeen patients had elevated Borrelia antibodies in serum or CSF by ELISA. Seven patients, including two with negative ELISA, had a positive immunoblot. Seven of the 13 patients in whom PCR was examined during clinically active disease had a positive PCR result. Immunoblot analysis gave a negative result from the sera of five PCR-positive patients. · Conclusions: For efficient diagnosis of ocular Lyme borreliosis, immunoblot analysis and PCR should be used in addition to ELISA. A positive PCR seems to be associated with a negative immunoblot.

We present a 33-year-old man with a seven-year history of lid swelling, conjunctival chemosis and injection, and proptosis in both eyes. Enlargement of all extraocular muscles in both eyes was visualized on MRI. He did not respond to oral prednisone, although the symptoms and the signs resolved promptly with intravenous methyl-prednisolone given after orbital irradiation.

Purpose The authors report sequential fluorescein angiographic and color photographic findings of the fundi and response to treatment in a patient with chronic Lyme neuroretinitis. Methods A Lyme enzyme-linked immunosorbent assay with purified 41-kd flagellin as antigen was used to detect immunoglobulin G and immunoglobulin M antibodies to Borrelia burgdorferi in serum, cerebrospinal fluid, and vitreous. The changes were documented by fluorescein angiography and color photography tests performed during a 5 1/2 year follow-up. Results The diagnosis of Lyme neuroretinitis was based on the history of erythema migrans and positive Lyme enzyme-linked immunosorbent assay tests from cerebrospinal fluid and vitreous and by the exclusion of other infectious and systemic diseases and uveitis entities. Fluorescein angiography results disclosed bilateral chronic neuroretinal edema with areas of cystoid, patchy, and diffuse hyperfluorescence peripapillary and in the macular areas. The hyperfluorescent lesions enlarged despite a 9-month period of antibiotic therapy. Conclusion Lyme borreliosis may cause neuroretinitis with unusual angiographic findings. Chronic Lyme neuroretinitis may be unresponsive to antibiotic therapy.

Purpose: To describe ocular involvement and response to treatment in a patient with human immunodeficiency virus (HIV) infection with severe progressive disseminated histoplasmosis (PDH). Methods: We report a 35-year-old HIV-infected patient seen in our clinics over a period of 4 years. During antiretroviral treatment (ART), the HIV load became undetectable at 3 months; however, CD4 T-cell count increased slowly and rose to 100 cells ⁄ll. Histoplasma capsulatum was cultured from skin pustules, cerebrospinal fluid (CF) and aqueous humour. Results: The patient developed central nervous system (CNS) involvement 2 months and panuveitis in both eyes 4 months after the initiation of ART. With intravenous liposomal amphotericin B followed by oral voricanozole, the chorioretinal lesions of the right eye (RE) became inactivated and magnetic resonance imaging (MRI) lesions of CNS disappeared. Relapse of the inflammation in the anterior segment of the left eye (LE) resulted in a total closure of the chamber angle and severe glaucoma. Despite medical therapy, two cyclophotocoagulations, total vitrectomy and repeated intravitreal amphotericin B injections, LE became blind. Histoplasma capsulatum was cultured from the aqueous humour after antifungal therapy of 16 months’ duration. Conclusion: PDH with intraocular and CNS manifestations was probably manifested by an enhanced immune response against a previous subclinical disseminated infection. It seems difficult to eradicate H. capsulatum from the anterior segment of the eye in an immunocompromised patient.

To analyze the clinical features of primary intraocular lymphoma (PIOL) and to describe cytochemical and immunocytochemical findings of the vitreous specimens as well as the reasons for delayed diagnosis of PIOL.Prospective noncomparative study.Eleven patients referred to the uveitis or medical retina units, Department of Ophthalmology, University of Helsinki, were diagnosed as having PIOL between 2000 and 2005. The median follow-up of the patients was 32 months.Clinical features and diagnostic workup of uveitis were described. Twelve vitrectomies were performed on 9 patients. The first 5 biopsies were fixed in an equal volume of 50% alcohol. The specimens of the next 7 vitrectomies were handled without alcohol, and tissue culture medium was added to the samples.Clinical features of PIOL, intervals from ocular symptoms and from first ophthalmological examination to diagnosis, and the role of a proper handling of the vitreous sample in the diagnosis of PIOL.Six females (54%) and 5 males (46%) (median age, 61 years) were included. Ten patients had ocular symptoms for 1 to 30 months (median, 8) before the first contact with an ophthalmologist. Uveitis was bilateral in 9 patients. Vitreitis was seen in all patients, and it was severe in 8. Fundus lesions dominated in 3 patients. Six patients lost useful vision in one eye before the diagnosis of PIOL. Cytologic and immunohistochemical stainings prepared of the unfixed vitreous specimens showed PIOL in 6 patients. The samples fixed in alcohol were nondiagnostic in 4 patients, and in them, verification of diagnosis was based on brain biopsy (3) or cerebrospinal fluid (1) findings. Seven patients died due to primary nervous system lymphoma.Diagnosis of PIOL is difficult but can be improved. Severe bilateral vitreitis in an elderly patient is a characteristic finding of PIOL. Alcohol fixation may jeopardize the identification of PIOL cells in the vitreous sample. Optimal handling of the vitreous specimens and examination of the slides by an experienced cytopathologist are critical in the diagnostic workup of PIOL.

Chronic scarring-type uveitis is a frequent extra-articular manifestation of juvenile idiopathic arthritis. It occurs in about 20% of children with this disease, commencing typically within a few years from its onset. The risk of uveitis is greatest in antinuclear antibody-positive girls with early onset oligoarthritis. The classic clinical picture is chronic bilateral anterior uveitis, usually asymptomatic until substantial damage to intraocular structures occurs. In view of the asymptomatic nature of the condition, routine screening of juvenile idiopathic arthritis patients 2-4 times a year is crucial to prevent complications. The treatment consists of topical corticosteroids and mydriatics, in severe cases with immunosuppressive agents, and surgical management of complications. Although the prognosis of uveitis is improving, there are cases refractory to standard regimens. Patients in whom uveitis commences prior to the onset of arthritis present a special problem.

To compare the effectiveness of intravenous (i.v.) methylprednisolone pulse therapy and oral prednisone when used as the initial treatment of patients with mild or moderate thyroid-associated ophthalmopathy.Thirty-three consecutive patients with thyroid-associated ophthalmopathy in Helsinki and Turku University Hospitals were randomly assigned either i.v. methylprednisolone pulse therapy (group A, n = 18) or oral prednisone (group B, n = 15). Treatment outcomes were measured by subjective changes in the grade of diplopia and quantitatively in several ophthalmic variables at 3 and 12 months. Any decision to proceed with additional treatment at 3 months was made on clinical grounds. The study was open in respect of both the initial treatment and the need for additional therapy.No significant differences in the grade of diplopia, proptosis or soft tissue activity scores were noted between groups A and B from 0 to 3 months. However, group A required additional forms of therapy at 3 months less frequently than did group B (p = 0.038).Our data suggest that i.v. methylprednisolone pulse therapy and oral prednisone are equally effective as initial treatments for thyroid-associated ophthalmopathy where diplopia, proptosis and signs of soft tissue inflammation are concerned. When additional treatment is required, i.v. methylprednisolone pulse therapy may be more effective than oral prednisone. However, the study's limitations meant that any decision to give additional treatment after the initial therapy was made on clinical grounds.

Aim: To determine the presence of systemic inflammation and innate immune responsiveness of patients with a history of acute anterior uveitis but no signs of ocular inflammation at the time of recruitment. Methods: Tumour necrosis factor α (TNF-α) production in response to bacterial lipopolysaccharide (LPS) was studied using whole blood culture assay; levels of TNF-α in culture supernatants, and soluble interleukin 2 receptor (sIL-2R) in serum were determined by chemiluminescent immunoassay (Immulite); monocyte surface expression of CD11b, CD14, and CD16 and the proportion of monocyte subsets CD14 bright CD16 − and CD14 dim CD16 + were studied with three colour whole blood flow cytometry; and serum C reactive protein (CRP) levels were determined using immunonephelometric high sensitivity CRP assay. Results: The CRP level (median, interquartile range) was significantly higher in 56 patients with previous uveitis than in 37 controls (1.59 (0.63 to 3.47) μg/ml v 0.81 (0.32 to 2.09) μg/ml; p=0.008). The TNF-α concentration of the culture media per 10 5 monocytes was significantly higher in the patient group than in the control group in the presence of LPS 10 ng/ml (1473 (1193 to 2024) pg/ml v 1320 (935 to 1555) pg/ml; p=0.012) and LPS 1000 ng/ml (3280 (2709 to 4418) pg/ml v 2910 (2313 to 3358) pg/ml; p=0.011). The background TNF-α release into the culture media was low in both groups. CD14 expression of CD14 bright CD16 − monocytes, defined as antibody binding capacity (ABC), was similar for the patients and controls (22 839 (21 038 to 26 020) ABC v 21 657 (19 854 to 25 646) ABC). Conclusions: Patients with previous acute anterior uveitis show high innate immune responsiveness that may play a part in the development of ocular inflammation.

A 15-year-old girl developed retinitis pigmentosa-like fundus changes in the left eye and optic neuropathy in the right eye as well as cerebral demyelination as a result of late Lyme borreliosis (LB). The diagnosis was confirmed by polymerase chain reaction, which detected a Borrelia burgdorferi specific segment of a gene coding for 41 kD endoflagellin, both in the vitreous and the cerebrospinal fluid. The diagnosis was delayed because testing for Borrelia antibodies in serum and cerebrospinal fluid yielded negative results. However, later on, another laboratory reported the antibodies of the patient's pretreatment serum to be positive for LB.

Purpose: Molecules bearing the immunogenic HNK-1 epitope are present in the inner connective tissue layer and epithelia of the ciliary body. We investigated whether autoantibodies to these molecules can be detected in patients with intermediate uveitis, which affects the ciliary body. Methods: Serum was collected from 9 patients with intermediate uveitis, and from 6 controls with idiopathic iritis and 3 controls with sarcoid uveitis, representing nongranulomatous and granulomatous uveitis, respectively. The sera were used as polyclonal antibodies to immunostain 3 formalin-fixed, paraffin-embedded normal human donor eyes by the avidin-biotinylated peroxidase complex method. Results: No immunostaining in the ciliary body could be detected using the sera from patients with intermediate uveitis or from the controls. Serum within blood vessels was nonspecifically immunolabelled with the secondary anti-human antiserum. Conclusion: No autoantibodies against the HNK-1 epitope or other antigens of the ciliary body could be demonstrated in patients with intermediate uveitis. It is unlikely that such autoantibodies against the HNK-1 epitope have a role in intermediate uveitis.

A prospective study of amblyopic children was carried out in 1982-1992 in the ophthalmology unit of a community health center, a referral center for 14,000 preschool children. Five hundred and twenty-six children in 1982-1983 were referred to an ophthalmologist because of a suspicion of amblyopia, strabismus or other visual disorders. Amblyopia was diagnosed in 109 children. In 18 children amblyopia was on an organic basis and among them 4 children had X-chromosomal retinoschisis. Risk factors for functional amblyopia were convergent strabismus, spherical equivalent of the refractive error of 3.5 dioptres or more or anisometropia of 1.0 dioptres or more. The children with established functional amblyopia (91 children) were treated with a full-time occlusion, or, at the age of younger than 18 months, with 0.5% atropin, and, at the minimum of 6 years, with pleoptics when indicated. One hundred amblyopic children were followed for a minimum of 4 years, reinstituting the occlusion therapy if visual acuity deteriorated. Seventy-two children with functional amblyopia (79%) were available for a detailed ophthalmological examination 9.7 years, on the average, after the initial examination. Only three of these children (4%) had visual acuity of less than 0.4 at that time. Well-functioning child health centers and school health care, as well as the availability of ophthalmological services, are important for a good final visual result of amblyopic children.

Phenotypes of the infiltrating mononuclear cells of the lower fornix conjunctiva of nine patients with sarcoidosis and six controls were studied using monoclonal antibodies and a modified immunoperoxidase method. Four patients had sarcoidosis of recent onset (duration of 2 years or less) and five patients had a chronic disease (duration of 3 or more years). The inflammatory cells in the sarcoid conjunctival specimens were predominantly T lymphocytes, the vast majority of which were of T helper/inducer subtype expressing Leu-3a + 3b positivity. The ratio of T helper/inducer cells to T suppressor/cytotoxic cells was 3.9 on average but only 0.9 in controls. Epithelioid cell granulomas were seen in three specimens in one case of recent onset and in two chronic cases comprising a marked amount (more than 15 cells/visual field) of cells bearing phenotypes of macrophages, T cells, T helper/inducer cells and HLA-DR antigen, and in smaller quantities of T suppressor/cytotoxic cells. The mean number of all immunocompetent cell subtypes of specimens from newly diagnosed patients exceeded that of specimens from chronic patients. We believe that the sarcoid immune reaction in the conjunctiva is a dynamic process in which proliferation of immunocompetent mononuclear cells precedes the stage of granuloma formation.

A prospective study of amblyopic children was carried out in 1982-1992 in the ophthalmology unit of a community health center, a referral center for 14,000 preschool children. Five hundred and twenty-six children in 1982-1983 were referred to an ophthalmologist because of a suspicion of amblyopia, strabismus or other visual disorders. Amblyopia was diagnosed in 109 children. In 18 children amblyopia was on an organic basis and among them 4 children had X-chromosomal retinoschisis. Risk factors for functional amblyopia were convergent strabismus, spherical equivalent of the refractive error of 3.5 dioptres or more or anisometropia of 1.0 dioptres or more. The children with established functional amblyopia (91 children) were treated with a full-time occlusion, or, at the age of younger than 18 months, with 0.5% atropin, and, at the minimum of 6 years, with pleoptics when indicated. One hundred amblyopic children were followed for a minimum of 4 years, reinstituting the occlusion therapy if visual acuity deteriorated. Seventy-two children with functional amblyopia (79%) were available for a detailed ophthalmological examination 9.7 years, on the average, after the initial examination. Only three of these children (4%) had visual acuity of less than 0.4 at that time. Well-functioning child health centers and school health care, as well as the availability of ophthalmological services, are important for a good final visual result of amblyopic children.

To determine the prevalence of antibodies to Chlamydia pneumoniae, C. trachomatis, and C. pneumoniae heat shock protein (Cpn Hsp60) in patients with acute anterior uveitis (AAU) and in sex- and age-matched healthy control subjects.Altogether 64 patients with previous AAU were examined at the Helsinki University Eye Hospital from September through December 1999. Serum specimens from the patients and sex- and age-matched healthy control subjects were tested for antibodies to C. pneumoniae and C. trachomatis by a specific microimmunofluorescence test and for antibodies to Cpn Hsp60 by enzyme immunoassay (EIA).The prevalence of antibodies to C. pneumoniae (69% vs. 72%) and C. trachomatis (11% vs. 6%) did not differ significantly between the patients and control subjects, nor did the level of IgG antibodies to Cpn Hsp60 (median EIA unit, 65 vs. 48). The levels of IgA antibodies to Cpn Hsp60 were significantly higher in the patients with AAU than in the control subjects (median EIA unit, 18 vs. 10; two-tailed Wilcoxon signed rank test, P = 0.0001).The high frequency of IgA antibodies to Cpn Hsp60 in patients with past AAU indicates that such patients may have persisting or recurrent infections due to C. pneumoniae. This finding suggests that C. pneumoniae may play a role in the pathogenesis of AAU.

Purpose To establish a diagnosis, in a group of patients we studied the characteristics of ocular Lyme borreliosis. Methods During a two-year period, 236 patients with prolonged external ocular inflammation, uveitis, retinitis, optic neuritis, or unexplained neuro-ophthalmic symptoms were examined for Lyme borreliosis. Antibodies to Borrelia burgdorferi were measured by indirect ELISA and western blot. Cerebrospinal fluid was also analyzed by polymerase chain reaction. Results Ocular Lyme borreliosis was diagnosed in ten patients on the basis of medical history, clinical findings, and serologic test results. Results of ELISA disclosed that five patients were seropositive, two patients showed borderline reactivity, and three patients were seronegative. Four of the five patients with borderline or negative results by ELISA had a positive result by western blot analysis. In one seropositive patient, polymerase chain reaction verified a gene of B. burgdorferi endoflagellin from the vitreous and cerebrospinal fluid specimen. In five of the six patients with known onset of the Borrelia infection, the ocular disorder appeared as a late manifestation. Abnormalities of the posterior segment of the eye, such as vitreitis, retinal vasculitis, neuroretinitis, choroiditis, and optic neuropathy were seen in six patients. Bilateral paralytic mydriasis, interstitial keratitis, episcleritis, and anterior uveitis were seen in one patient each. Conclusions Late-phase ocular Lyme borreliosis is probably underdiagnosed because of weak seropositivity or seronegativity in ELISA assays. Ocular borrelial manifestations show characteristics resembling those seen in syphilis.

In a series of 281 patients with histologically confirmed sarcoidosis, 79 initially had ophthalmic sarcoid manifestations. Of 22 patients with uveitis, 21 were seen regularly as long as the inflammation was active, and 71 of the 79 patients (90%) underwent a follow-up study five to 16 years (mean, nine years) later and using the same protocol. In the 21 patients with uveitis, the disease exhibited either a monophasic course (eight patients) with favorable visual outcome or a relapsing course (13 patients) with severe visual loss in five eyes. Thirty-three patients showed chronic ophthalmic changes at the follow-up examination, including conjunctival granulomas (13 patients), lacrimal gland involvement (22 patients), uveitis (four patients), and involvement of lacrimal passages (three patients). In 15 of these 33 patients, the general physical examination and the chest x-ray showed no evidence of systemic sarcoidosis. However, the serum angiotensin converting enzyme level was increased in a significantly greater proportion of these 15 patients than in the patients assessed as totally recovered from sarcoidosis.

Six patients with generalized histologically confirmed sarcoidosis developed optic nerve involvement, two at the onset and four during the chronic course of the disease. Two patients had granulomata of the prelaminar part of the optic nerve, two patients had optic disc oedema with an unusual appearance, one had a retrobulbar optic neuritis and one a glaucomatous cupping of the optic nerve head. Four patients had no visual complaints at the time the sarcoid optic nerve abnormality was detected. The wide variety of the ophthalmos-copical appearance of the sarcoid optic nerve affection and the patients' neuro-ophthalmic and otherclinical findings is discussed. The fluoresceinangiography of thegranulomatosis of the optic nerve showed an early hypofluorescence typical of a sarcoid mass lesion.

To the Editor. —In an article in the JulyArchives(1981;99:1198-1201), Harris et al described two patients with sarcoidosis of the lacrimal sac and reported that there were only seven cases, including theirs, reported in the literature so far. Because they seem to have missed my study 1 concerning 281 patients with histologically verified sarcoidosis, among whom I found five patients to have sarcoidosis of the lacrimal sac or ducts, I would like to describe some features of my cases and comment on some points in the article by Harris et al. All my patients with sarcoidosis of the lacrimal sac or ducts were elderly women with a chronic florid course of the disease. They all had or had had numerous manifestations of the disease (Table). All had unilateral or bilateral lacrimal obstruction, and three of them also had long-standing nasal obstruction. Dacryocystorhinostomy was carried out on three patients, but