Andreas G. Tzakis

Black

Friberg

Patricia B. Carroll

Ramsey

Thomas E. Starzl

Thomas R. Friberg

English

PubMed

Friberg, TR

Tzakis, AG

Carroll, PB

Starzl, TE

Name not available

Visual improvement after long-term success of pancreatic transplantation

Crossref

American Journal of Ophthalmology

Visual Improvement After Long-term Success of Pancreatic Transplantation

D-Scholarship@Pitt

-_._-_._------_ .... _---_ .... _ ... LETTERS TO THE JOURNAL Visual Improvement After Long-term Success of Pancreatic Transplantation Thomas R. Friberg, M.D., Andreas G. Tzakis, M.D., Patricia B. Carroll, M.D., and Thomas E. Starzl, M.D. Department of Ophthalmology, University of Pitts-burgh School of Medicine. Inquiries to Thomas R. Friber8, M.D., Department of Ophthalmology, University 01 Pittsburgh Schoo! of Medicine, Eye and Ear Institute, 203 Lothrop St., PItts-burgh, PA 15213. Several investigators have reported that pan-creatic transplantation does not appear to have a favorable effect on diabetic retinopathy .1.2 In a series of 22 patients who were followed up an average of 24 months, Ramsey and associates2 reported that the functional success of the transplantation did not prevent progression of diabetic retinopathy and that visual loss secon-dary to diabetic maculopathy occurred in some patients. Fourteen patients received cadaveric pancre-atic transplants at our institution between March 1983 and November 1985 after or in conjunction with renal transplantation. Pa-tients were immunosuppressed with oral cyclo-sporine and prednisone to which antilym-phocytic globulin, the monoclonal antibody OKT3, and azathioprine were added as needed. Patients were examined at least every six months with visual acuity measurements, oph-thalmoscopy, and fundus photography. Photo-graphs were evaluated and graded by using conventional criteria.3 Eight patients had functional pancreatic grafts and maintained euglycemia (mean total hemoglobin AI' 5.0 to 7.4 g/dl) for more than six months without diabetic medications. Of this group of 16 eyes, no eyes showed improve-ment in diabetic retinopathy scores during the period of graft survival, five worsened, and 11 remained stable. Four patients maintained functioning pancre-atic grafts for more than 48 months. These patients were 31, 33, 38, and 45 years of age, respectively (Cases 1 through 4). All patients had had combined kidney and pancreatic trans-plants except the patient in Case 2, who had a kidney transplant performed before pancreatic transplantation. All four patients had been treated previously with panretinallaser photo-coagulation in each eye. In Case I, the patient also had had a vitrectomy in the right eye and macular grid treatment in the left eye. At study entry, one patient (Case 1) had visual acuity of R.E.: light perception and L.E.: 20/50. Macular edema was noted in the left eye as determined by clinical examination and as seen on stereoscopic fundus photog.raphs. Four years later, the macular edema had resolved and visual acuity in the left eye improved to 20/25. The patient in Case 2 had visual acuity of 20/60 in both eyes with bilateral macular ede-THE JOURNAL welcomes letters that describe unusual clinical or pathologic findings, experimental results, and new instruments or techniques. The title and the names of all authors appear in the Table of Contents and are retrievable through the Index Medicus and other standard indexing services. Letters must not duplicate data previously published or submitted for publication. Each letter must be accompanied by a signed disclosure statement and copyright transfer agreement published in each issue of THE JOURNAL. Letters must be typewritten, double-spaced, on 8112 x II-inch bond paper with I112-inch margins on all four sides. (See Instructions to Authors.) An original and two copies of the typescript and figures must be sent. The letters should not exceed 500 words of text .. A maximum of two black-and-white figures may be used; they should be cropped to a width of 3 inches (one column). Color figures cannot be used. References should be limited to five. Letters may be referred to outside editorial referees for evaluation or may be reviewed by members of the Editorial Board. All letters are published promptly after acceptance. Authors do not receive galley proofs but if the editorial changes are extensive, the corrected typescript is submitted to them for approval. These instructions markedly limit the opportunity for an extended discussion or review. Therefore, THE JOURNAL does not publish correspondence concerning previously published letters. Vol. 110, No.5 Letters to the Journal 565 rna at entry. Over the four-year period, a ~~trec­tomy was required in each eye and addltlOnal panretinal photocoagulation was needed in the right eye. The macular edema resolved and visual acuity improved to 20/40 in each eye at 48 months. In Case 3, the patient had visual acuity of R.E.: no light perception and L.E.: 20/20 before pancreatic and kidney transplantation. Visual acuity remained unchanged throughout the fol-low-up period and the preViously treated pro-liferative diabetic retinopathy remained stable. The patient in Case 4 had visual acuity of R.E.: 20/40 and L.E. 20/100 with diabetic mac-ular edema in both eyes before transplantation. Additional panretinal photocoagulation was added during the course of follow-up. Visual acuity improved to R.E.: 20/30 and L.E.: 20/60 at 48 months, and the macular edema in each eye resolved. Although no patient had a significant lens opacity before pancreatic transplantation, the left eye of one patient (Case 1) and both eyes of another patient (Case 2) developed posterior su bcapsular cataracts associated with long-term prednisone treatment. Uneventful cataract removal and intraocular lens implantation were performed during the course of follow-up. The findings in these patients confirm the previous finding that pancreatic transplanta-tion in patients with preexisting proliferative diabetic retinopathy does not prevent progres-sion of the retinopathy despite euglycemia. Our cases, however, suggest that long-term excel-lent visual function can be attained if the prolif-erative disease is treated appropriately. Four of six seeing eyes ultimately improved two lines of visual acuity or better, whereas the remaining seeing eyes maintained stable vision. Improve-ment of vision was not inconsequential, as it allowed two patients to drive their automobiles and return to work. It is difficult to ascertain precisely how the functioning pancreatic grafts in these patients affected visual outcome. We find it noteworthy, however, that the macular edema noted initial-ly in these patients eventually subsided with-out subsequent macular grid therapy. Although this improvement could be partially attributed to kidney transplantation and restoration of renal function, neither vision nor the maculo-pathy improved during the .first 18 months after transplantation. These patu=.nts also had addi-tional panretinal photocoagulation, but this type of laser treatment generally. exacerbates diabetic maculopathy rather than lmproves it. References 1. Black, P. D.: Visual status of diabetic patients after pancreatic and other organ transplantation. Trans. Ophthalmol. Soc. U.K. 101:100,1981. 2. Ramsey, R. c., Goetz, F. c., Sutherland, D. E., Mauer, S. M., Robison, L. L., CantriIl, H. L., Knob-loch, W. H., and Najarian, J. S.: Progression of dia-betic retinopathy after pancreas transplantation for insulin-dependent diabetes mellitus. N. Eng!. J. Med. 318:208, 1988. 3. Friberg, T. R., Rosenstock, J., Sanborn, G., Vag-heft, A.,.and Raskin, P.: The effect of long-term near normal glycemic control on mild diabetic retinopa-thy. Ophthalmology 92:1051, 1985. Duane's Retraction Syndrome in the Fetal Alcohol Syndrome Andrew E. Holzman, M.D., Georgia A. Chrousos, M.D., Chahira Kozma, M.D., and Elias I. Traboulsi, M.D. Department of Ophthalmology, George Washington University Medical Center (A.E.H.); and Depart-ments of Ophthalmology (G.A.C., E.I.T.) and Pediat-rics (C.K.), Georgetown University Medical Center. Inquiries to Elias 1. Traboulsi, M.D., Wilmer Ophthal-mological Institute, 600 N. Wolfe St., Baltimore, MD 21205. The fetal alcohoi syndrome is characterized by prenatal and postnatal growth retardation, mild to severe mental retardation, central nerv-ous system, cardiovascular, and skeletal anom-alies, and characteristic facial features includ-ing a narrow forehead, short and upturned nose, a long upper lip with indistinct or absent philtrum, and low nasal bridge.! A number of ocular malformations have been reported in the fetal alcohol syndrome including bilater~l mild to moderate blepharoptosis (which usually be-comes more noticeable in adolescence), hori-zontally shortened palpebral fissures, epican-thus, strabismus, retinal vessel tortuosity, optic nerve hypoplasia, myopia, cataract, Peters' anomaly, and microphthalmia.! We treated a patient with bilateral Duane's retraction syn-drome type III (limited abduction and adduc-tion of involved eye~ and the fetal alcohol syndrome. An i I-year-old girl with fetal alcohol syn-drome had characteristic facial features, growth retardation, and central nervous system dys-

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Visual improvement after long-term success of pancreatic transplantation

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