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Objective: To test whether diabetic polyneuropathies (DPNs), retinopathy, or nephropathy is more prevalent in subjects with impaired glycemia (IG) (abnormality of impaired fasting glucose [IFG], impaired glucose tolerance [IGT], or impaired HbA(1c) [IA1C]) than in healthy subjects (non-IG).Research Design and Methods: Matched IG and non-IG volunteers were randomly identified from population-based diagnostic and laboratory registries, restudied, and reclassified as non-IG (n = 150), IG (n = 174), or new diabetes (n = 218).Results: Frequency (%) of DPN in non-IG, IG, and new diabetes was 3 (2.0%), 3 (1.7%), and 17 (7.8%) narrowly defined (no other cause for polyneuropathy) and 19 (12.7%), 22 (12.6%), and 38 (17.4%) broadly defined. Mean and frequency distribution of composite scores of nerve conduction and quantitative sensation tests were not significantly different between IG and non-IG but were worse in new diabetes. Frequency of retinopathy and nephropathy was significantly increased only in new diabetes. In secondary analysis, small but significant increases in retinopathy and nephropathy were found in IGT, IFG, and IGT combined groups.Conclusions: In population studies of Olmsted County, Minnesota, inhabitants, prevalence of typical DPN, retinopathy, and nephropathy was significantly increased only in subjects with new diabetes-not in subjects with IG as defined by American Diabetes Association (ADA) criteria of abnormality of IFG, IGT, or IA1C. For atypical DPN, such an increase was not observed even in subjects with new diabetes. In medical practice, explanations other than IG should be sought for patients with atypical DPN (chronic idiopathic axonal polyneuropathy) who have IG. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the rate of infectious endophthalmitis associated with intravitreal injection of bevacizumab, ranibizumab, and pegaptanib sodium., Methods: A retrospective review of patients who received intravitreal injections of bevacizumab, ranibizumab, and pegaptanib sodium was undertaken. Cases of clinical diagnoses of endophthalmitis or suspected endophthalmitis resulting from intravitreal injection were identified and reviewed. From these data, the risk per injection was estimated., Results: Three patients developed endophthalmitis after the intravitreal injection. The risk per injection was 0.00077 (0.077%). The rate of endophthalmitis was 1 per 1,291 injections., Conclusion: A similar risk of endophthalmitis per injection compared with some trials was obtained in this study. Although no definite risk factors could be identified, intravitreal injections performed by nonretina specialist physicians may be a risk factor for the development of endophthalmitis.

Objective: The degree to which chronic glycemic exposure (CGE) (fasting plasma glucose [FPG], HbA1c [A1C], duration of diabetes, age at onset of diabetes, or combinations of these) is associated with or predicts the severity of microvessel complications is unsettled. Specifically, we test whether combinations of components correlate and predict complications better than individual components., Research Design and Methods: Correlations and predictions of CGE and complications were assessed in the Rochester Diabetic Neuropathy Study, a population-based, cross-sectional, and longitudinal epidemiologic survey of 504 patients with diabetes followed for up to 20 years., Results: In multivariate analysis, A1C and duration of diabetes (and to a lesser degree age at onset of diabetes but not FPG) were the main significant CGE risk covariates for complications. A derived glycemic exposure index (GE(i)) correlated with and predicted complications better than did individual components. Composite or staged measures of polyneuropathy provided higher correlations and better predictions than did dichotomous measures of whether polyneuropathy was present or not. Generally, the mean GE(i) was significantly higher with increasing stages of severity of complications., Conclusions: A combination of A1C, duration of diabetes, and age at onset of diabetes (a mathematical index, GE(i)) correlates significantly with complications and predicts later complications better than single components of CGE. Serial measures of A1C improved the correlations and predictions. For polyneuropathy, continuous or staged measurements performed better than dichotomous judgments. Even with intensive assessment of CGE and complications over long times, only about one-third of the variability of the severity of complications is explained, emphasizing the role of other putative risk covariates.

Background: Already there is evidence that simultaneous pancreas and kidney (SPK), or pancreas after kidney (PAK) transplantation, in patients with type 1 diabetes mellitus and end-stage kidney disease prevents worsening of diabetic polyneuropathy, but neuropathic improvement is delayed and incomplete., Methods: In 85 patients with type 1 diabetes mellitus who underwent SPK or PAK transplantations, we performed sequential neuromuscular evaluations before, every 3 months after, and yearly after transplantation, quantitating muscle weakness separately from overall severity of polyneuropathy., Results: We found that, on average, the weakness subscore of the Neuropathy Impairment Score of the lower limbs [NIS(LL)-W] was significantly worse at 3, 6, 9, and 12 months (by about 5 points) than at baseline. By contrast, for these times after transplantation, a composite score of nerve conduction abnormalities, an independent measure of severity of polyneuropathy, was not significantly worse and, in fact, was significantly improved. In multivariate analysis, length of hospital stay correlated with the increased weakness., Conclusions: We conclude that: (1) increased neuromuscular impairment after transplantation is mainly due to muscle weakness and not to worsening polyneuropathy; (2) in multivariate analysis, duration of hospitalization after transplantation was significantly associated with this increased weakness; (3) increased weakness is probably due to development of myopathy, which may be related to graft rejection, immunosuppression, sepsis, and intercurrent infections; (4) in future transplantation trials, weakness should be evaluated separately from neuropathic status, and the lowest efficacious dosages of immunotherapy should be used; and (5) essentially all diabetic patients reported that SPK or PAK transplantation was worthwhile because it freed them from diabetic lifestyle concerns.

Purpose: To describe the clinical presentation and course of Whipple disease in an adult., Methods: A 34-year-old man with phthisis bulbi in the right eye secondary to uveitis-induced neovascular glaucoma presented with severe acute posterior uveitis in the left eye. He underwent esophagogastroduodenoscopy and jejunal biopsy for evaluation of anemia. The posterior uveitis was treated with a subtenon injection of triamcinolone., Result: The diagnosis of Whipple disease was confirmed by polymerase chain reaction analysis of the jejunal biopsy that demonstrated Tropheryma whippelii rDNA., Conclusion: Although Whipple disease is typically evident with malabsorption, it can also present as uveitis without prominent gastrointestinal symptoms.

Purpose: To treat large-cell lymphoma in a patient with chronic lymphocytic leukemia and bilateral vitreous cells., Methods: The patient underwent a diganostic vitrectomy., Results: Biopsy of the vitreous specimen disclosed large B-cell lymphoma. Large B-cell lymphoma occurring in patients with chronic lymphocytic leukemia is referred to as Richter's syndrome., Conclusions: Large-cell lymphoma of Richter's syndrome can occur in the eye. This case expands the clinical spectrum of organ involvement in Richter's syndrome.

Our purpose was to study the relationship between carotid artery occlusive disease and aqueous flow in human subjects. Aqueous humor flow was measured by fluorophotometry in seven patients with unilateral carotid artery disease documented by oculoplethysmography. The mean (+/- SD) flow was 2.03 +/- 0.38 microliter/min in the affected eyes, 2.44 +/- 0.66 microliter/min in the unaffected contralateral eyes, and 2.56 +/- 0.61 microliter/min in a group of 14 age-matched controls. A statistically significant difference (p < 0.05) in the aqueous flow rate was seen between the affected and unaffected eyes and between the affected and control eyes. Aqueous flow in the unaffected and control eyes was not statistically different. The anterior chamber volumes and intraocular pressures were also not significantly different among groups. Severe carotid artery disease may reduce aqueous humor formation by lowering ciliary body blood flow to a point beyond which the eye cannot compensate.

Objective: To measure and compare corneal endothelial morphologic characteristics and function in subjects with diabetes mellitus types I and II., Design: Forty-nine patients with diabetes mellitus type I and 60 patients with diabetes mellitus type II were recruited from the active practice of the Mayo Clinic, Rochester, Minn. Thirty-one normal subjects, divided by age into two overlapping groups of 20 each, served as controls. Corneal endothelial permeability and corneal autofluorescence were measured by fluorophotometry. Central corneal endothelial photographs were taken with a wide-field specular microscope, which also measured the corneal thickness., Results: Neither the type I nor the type II diabetics differed from their controls in endothelial permeability and endothelial cell density. The type I diabetics had polymegethism, pleomorphism, increased corneal thickness, and increased corneal autofluorescence compared with their controls. Similar measured values were found in the type II diabetics, but they did not differ significantly from those of their age-matched controls. The type II diabetics were older than the type I diabetics, and the older control group showed changes similar to those seen in the diabetics; these changes were presumably associated with aging. The severity of retinopathy was significantly correlated only with corneal autofluorescence., Conclusion: The corneas of patients with type I diabetes mellitus exhibit abnormalities in endothelial cell morphologic characteristics and corneal autofluorescence. The changes resemble those that occur with aging in normal subjects, making them difficult to discern as abnormal in type II diabetics, who are usually older. We found no abnormalities in endothelial permeability in either type I or type II diabetics.

Purpose: We measured aqueous dynamic variables in subjects with diabetes mellitus and correlated them with severity of retinopathy and metabolic control to determine whether diabetes affects the anterior circulation of the eye as it affects the posterior (retinal) circulation., Methods: Sixty-one subjects with diabetes mellitus type 1 and 60 subjects with diabetes mellitus type 2 were recruited from the active practice of the Mayo Clinic. Thirty-two normal subjects, divided by age into two overlapping groups of 20 each, served as contemporaneous control subjects. The diabetic subjects were stratified into four groups according to severity of retinopathy. Aqueous humor flow was measured by clearance of topically applied fluorescein with a spectrofluorophotometer; outflow facility was measured by tonography; and intraocular pressure was measured by applanation tonometry., Results: In type 1 diabetics, the mean intraocular pressure was slightly greater (14 +/- 3 mm Hg), compared with control subjects (12 +/- 2 mm Hg [P = .002]), while aqueous humor flow was slightly less (2.5 +/- 0.6 microliter/min), compared with control subjects (2.9 +/- 0.5 microliter/min [P = .023]). In type 2 diabetics, the intraocular pressure was 14 +/- 3 mm Hg, which did not differ from that of control subjects (14 +/- 3 mm Hg [P = .258]). Aqueous humor flow in type 2 diabetics (2.5 +/- 0.7 microliter/min) did not differ significantly from that of the control group (2.5 +/- 0.7 microliter/min [P = .961]). Tonographic facility of outflow was not significantly different in type 1 and type 2 diabetics and the control subjects. There was no significant correlation in aqueous humor flow, intraocular pressure, or tonographic facility of outflow to severity of retinopathy or hemoglobin A1c in either type 1 or type 2 diabetics., Conclusions: The dynamics of aqueous humor are not affected to any clinically significant extent in the early or middle stages of diabetic retinopathy. However, there is a tendency toward less aqueous humor flow in the advanced stages of retinopathy.

Purpose/methods: We examined a 23-year-old woman who had a sudden onset of floaters after self-induced emesis., Results/conclusions: Examination showed a dense vitreous hemorrhage originating from a rupture site in the wall of the superotemporal branch vein. We postulate a preexisting weakness in the retinal vein wall as a predisposing factor to rupture. This mechanism may explain some cases of vitreous hemorrhage associated with a Valsalva maneuver.

The magnitude of the health problem from diabetic neuropathies remains inadequately estimated due to the lack of prospective population-based studies employing standardized and validated assessments of the type and stage of neuropathy as compared with background frequency. All Rochester, Minnesota, residents with diabetes mellitus on January 1, 1986, were invited to participate in a cross-sectional and longitudinal study of diabetic neuropathies (and also of other microvascular and macrovascular complications). Of 64,573 inhabitants on January 1, 1986 in Rochester, 870 (1.3%) had clinically recognized diabetes mellitus (National Diabetes Data Group criteria), of whom 380 were enrolled in the Rochester Diabetic Neuropathy Study. Of these, 102 (26.8%) had insulin-dependent diabetes mellitus (IDDM), and 278 (73.2%) had non-insulin-dependent diabetes mellitus (NIDDM). Approximately 10% of diabetic patients had neurologic deficits attributable to nondiabetic causes. Sixty-six percent of IDDM patients had some form of neuropathy; the frequencies of individual types were as follows: polyneuropathy, 54%; carpal tunnel syndrome, asymptomatic, 22%, and symptomatic, 11%; visceral autonomic neuropathy, 7%, and other varieties, 3%. Among NIDDM patients, 59% had various neuropathies; the individual percentages were 45%, 29%, 6%, 5%, and 3%. Symptomatic degrees of polyneuropathy occurred in only 15% of IDDM and 13% of NIDDM patients. The more severe stage of polyneuropathy, to the point that patients were unable to walk on their heels and also had distal sensory and autonomic deficits (stage 2b) occurred even less frequently--6% of IDDM and 1% of NIDDM patients.(ABSTRACT TRUNCATED AT 250 WORDS)

We performed specular microscopy, anterior segment ocular fluorophotometry, corneal pachymetry, and tonometry on 14 patients with chronic type I diabetes and nonproliferative retinopathy and on 14 age-matched control subjects. The eyes of patients with diabetes had an increased coefficient of variation of endothelial cell area, a decreased percentage of hexagonal endothelial cells, increased corneal autofluorescence, and increased intraocular pressure, which confirmed previous studies. There was no difference, however, in corneal thickness or endothelial permeability to fluorescein. Thus, we were unable to detect any abnormality in endothelial function in these diabetic corneas in the unstressed state, despite structurally abnormal endothelial cells.

Neovascularization of the disc (NVD) was present in 9 of 163 patients with pars planitis. In all cases, NVD was unilateral and observed in eyes with recent exacerbation of the inflammatory process. To reduce intraocular inflammation, all nine eyes were treated with varying combinations of topical, periocular, and systemic corticosteroids. In addition to corticosteroids, one eye received Argon laser photocoagulation, two eyes underwent peripheral cryotherapy, and one eye was treated with both Argon laser photocoagulation and peripheral cryotherapy. With decrease or disappearance of intraocular inflammation, NVD resolved in all cases without recurrence during follow-up study, which ranged from 6 to 189 (mean, 81) months. Rhegmatogenous retinal detachments developed in two eyes treated with peripheral cryotherapy. Both detachments were successfully repaired with surgery. Control of intraocular inflammation appears to be the key factor for regression of NVD in pars planitis. If NVD does not regress or vitreous hemorrhage occur, photocoagulation and peripheral cryotherapy may be beneficial.

In a retrospective study, 50 (8.2%) of 610 patients with malignant melanoma of the ciliary body or choroid had extrascleral extension. Of 46 patients for whom follow-up data were available, 24 (52%) survived five years, 20 (42%) survived ten years, and 17 (37%) survived 15 years. Factors that seemed to affect survival significantly included intraocular tumor size and extraocular tumor size and location. Our observations did not support the role of primary exenteration. Five patients (11%) with extrascleral extension had orbital recurrences and all died within 31 months of surgery regardless of treatment.

From 1969 to 1985, 224 cases of choroidal or ciliary body malignant melanoma had metastatic evaluations at the Mayo Clinic, Rochester, Minn. Five cases (2.2%) were found to have evidence of metastasis during the pretreatment evaluation. In each case, metastatic melanoma was verified histologically. Prior to enucleation or radiation treatment, we recommend a general medical evaluation, liver enzyme studies, and chest roentgenogram. Computed tomography (CT) of the liver should be performed if liver involvement is suggested by either the general medical evaluation or liver enzyme studies. Although CT of the liver in the initial surveillance of patients with choroidal or ciliary body melanoma is routinely performed at our institution, CT is not likely to produce a high yield of detectable disease in the presence of normal liver enzyme levels.