- Email: [email protected]
Tuberculous Uveitis: Reply
126
AMERICAN JOURNAL OF OPHTHALMOLOGY
ed that the alkyl-2-cyanoacrylates have antimicrobial action in vitro but that this action varies with the individual mono mers used. It has been suggested that this antimicrobial action results partly from their degradation into formaldehyde and their cyanoacetate derivative. Refojo, Dohlman, and Koliopoulos 3 added to this theory when they found that the monomers with the longer radical R groups had less ocular toxicity and slower degradation time. Yet, we noted a wide spectrum of antimicrobial effect for isobutyl-2-cyanoacrylate, which has a degradation time very similar to that of methyl-2-cyanoacrylate. 4 The experiment by Lehman, West, and Leonard 5 further muddied the waters when they found that formaldehyde and the cyanoacetate de rivative drops each produced their own zones of inhibition. In vivo testing is needed to prove our clinical impression that isobutyl-2cyanoacrylate has an inherent antimicro bial effect. Further research is also indi cated to isolate what property of the alkyl-2-cyanoacrylates imparts this anti microbial action. THOMAS C. F E N Z L ,
Milwaukee,
M.D.
Wisconsin
ROBERT E. F E N Z L , M.D. LYNN HARRIS
Garden Grove,
California
REFERENCES 1. Boruchoff, S. A., Refojo, M., Slansky, H. H., Webster, R. G., Jr., Freeman, N. I., and Dohlman, C. H.: Clinical applications of adhesives in corneal surgery. Trans. Am. Acad. Ophthalmol. Otolaryngol. 73:499, 1969. 2. Webster, R. G., Jr., Slansky, H. H., Refojo, M. F., Boruchoff, S. A., and Dohlman, C. H.: The use of adhesives for the closure of corneal perfora tions. Report of two cases. Arch. Ophthalmol. 80:705, 1968. 3. Refojo, M. F., Dohlman, C. H., and Koliopou los, J. : Adhesives in ophthalmology. A review. Surv. Ophthalmol. 15:217, 1971. 4. Leonard, F.: The N-alkyl-alpha cyanoacrylate tissue adhesives. Ann. N.Y. Acad. Sci. 146:203, 1966.
JANUARY, 1983
5. Lehman, A. W., West, R. L., and Leonard, F. : Toxicity of aIkyl-2-cyanoacryIates. II. Bacterial growth. Arch. Surg. 93:447, 1966.
Tuberculous Uveitis I recently had a case that presented the same issues discussed in the article, "The role of the isoniazid therapeutic test in tuberculous uveitis" (Am. J. Ophthalmol. 94:511, October 1982), by J. Abrams and T. F. Schlaegel, Jr. I have two important questions that this article failed to ad dress and I hope that Mr. Abrams and Dr. Schlaegel can answer them. First, they did not mention concurrent conven tional antiuveitis therapy during the time of the I N H testing (that is, whether the patients were receiving corticosteroids and cycloplegics). Second, what did they use as an endpoint to state that the pa tients responded positively to the I N H stimulation test? If they were receiving concurrent medications, how did they know what the patients were responding to? Were the results based on the rapidity of resolution in the positively responding cases or on the decreased incidence of recurrent cases in the positively respond ing group? If concurrent conventional therapy was not used, were these cases allowed to go without corticosteroid treatment for a few weeks to see if they would respond to the INH? C H A R L E S J. ABBOTT,
Los Angeles,
M.D.
California
Reply When our patients are referred they are usually taking cycloplegics and corti costeroids. Ordinarily they continue to do so unless the uveitis is so mild that a response to isoniazid could not be identi fied unless the corticosteroids were dis continued. The endpoint for a positive response to isoniazid is a dramatic im-
VOL. 95, NO. 1
BOOK REVIEWS
provement. However, in some cases we still diagnose "tuberculosis" because of other factors. Recently we examined a 16-year-old girl with phlebitis and chorioretinitis who developed a typical tubercu lous keratitis confirmed by our external disease service. Her response to isoniazid was slow but we still labeled her condi tion as "tuberculous." However, we did not label the isoniazid therapeutic test as positive. The ophthalmologist has to be thoroughly conversant with the condition of the eye before beginning the isoniazid therapeutic test, and sure that the proc ess is relatively stable or getting worse before an improvement can be ascribed to isoniazid. If the disease recurs after the patient has had a complete year of treat ment with isoniazid, vitamin Ββ, and an other agent such as rifampin, we consider the diagnosis of tuberculosis to be wrong and we change it. J O H N ABRAMS,
A.B.
T. F. SCHLAEGEL, JR., M.D. Indianapolis, Indiana BOOK REVIEWS International Histological Classification of Tumours of the Eye and Its Adnexa. By L. E. Zimmerman in collaboration with L. H. Sobin. Geneva, World Health Organization, 1980. Hardcover, 82 pages, index, 150 color figures. Sw. F. 210 (approx. $98) with color figures and Sw. F. 60 (approx. $28) without color figures This is the 24th installment of an exten sive World Health Organization project in which tumors of all the organ systems of the body are briefly described in a text organized around high-quality color pho tomicrographs. Dr. Zimmerman headed an international team that included S. R. Andersen from Denmark, N. Ashton from England, F. Contreras from Peru,
127
P. Dhermy from France, the late H. Greer from Australia, O. Litriτin from Yugoslavia, G. G. Ziangirova from the U.S.S.R., and L. H. Sobin, who coordi nated the entire project from Switzer land. The purpose of involving such a geographically separated group of ex perts was to produce a useful and mutual ly intelligible classification scheme to promote an exchange of knowledge and research on ocular neoplasms. When I was an ophthalmic pathology fellow at the Armed Forces Institute of Pathology in the early 1970s, Dr. Zim merman was exchanging glass slides of representative entities, which he then circulated among the fellows for our edu cational enrichment. From this experi ence, I discovered the enormous care and energy expended on developing a pragmatic and clear nosology for the use of ocular clinicians and pathologists. After the establishment of the World Health Organization Collaborating Center for the histologie classification of tumors of the eye and its adnexa in 1972 at the Armed Forces Institute of Pathology, it took seven more years of painstaking work to assemble the material contained in the present volume and to reach agree ments in controversial areas. Ophthal mologists throughout the world should be grateful for this remarkable accomplish ment. The color illustrations are beautiful, and they may be purchased separately as a set of 150 Kodachrome slides for teach ing purposes. Ophthalmic clinicians, on cologists, ophthalmic pathologists, and general pathologists will all profit im measurably from the long hours of collab oration, compromise, and artistic effort that culminated in this new standardized nomenclature for ocular neoplasms. When combined with earlier World Health Organization publications dealing with soft-tissue tumors and skin tumors,
AMERICAN JOURNAL OF OPHTHALMOLOGY
ed that the alkyl-2-cyanoacrylates have antimicrobial action in vitro but that this action varies with the individual mono mers used. It has been suggested that this antimicrobial action results partly from their degradation into formaldehyde and their cyanoacetate derivative. Refojo, Dohlman, and Koliopoulos 3 added to this theory when they found that the monomers with the longer radical R groups had less ocular toxicity and slower degradation time. Yet, we noted a wide spectrum of antimicrobial effect for isobutyl-2-cyanoacrylate, which has a degradation time very similar to that of methyl-2-cyanoacrylate. 4 The experiment by Lehman, West, and Leonard 5 further muddied the waters when they found that formaldehyde and the cyanoacetate de rivative drops each produced their own zones of inhibition. In vivo testing is needed to prove our clinical impression that isobutyl-2cyanoacrylate has an inherent antimicro bial effect. Further research is also indi cated to isolate what property of the alkyl-2-cyanoacrylates imparts this anti microbial action. THOMAS C. F E N Z L ,
Milwaukee,
M.D.
Wisconsin
ROBERT E. F E N Z L , M.D. LYNN HARRIS
Garden Grove,
California
REFERENCES 1. Boruchoff, S. A., Refojo, M., Slansky, H. H., Webster, R. G., Jr., Freeman, N. I., and Dohlman, C. H.: Clinical applications of adhesives in corneal surgery. Trans. Am. Acad. Ophthalmol. Otolaryngol. 73:499, 1969. 2. Webster, R. G., Jr., Slansky, H. H., Refojo, M. F., Boruchoff, S. A., and Dohlman, C. H.: The use of adhesives for the closure of corneal perfora tions. Report of two cases. Arch. Ophthalmol. 80:705, 1968. 3. Refojo, M. F., Dohlman, C. H., and Koliopou los, J. : Adhesives in ophthalmology. A review. Surv. Ophthalmol. 15:217, 1971. 4. Leonard, F.: The N-alkyl-alpha cyanoacrylate tissue adhesives. Ann. N.Y. Acad. Sci. 146:203, 1966.
JANUARY, 1983
5. Lehman, A. W., West, R. L., and Leonard, F. : Toxicity of aIkyl-2-cyanoacryIates. II. Bacterial growth. Arch. Surg. 93:447, 1966.
Tuberculous Uveitis I recently had a case that presented the same issues discussed in the article, "The role of the isoniazid therapeutic test in tuberculous uveitis" (Am. J. Ophthalmol. 94:511, October 1982), by J. Abrams and T. F. Schlaegel, Jr. I have two important questions that this article failed to ad dress and I hope that Mr. Abrams and Dr. Schlaegel can answer them. First, they did not mention concurrent conven tional antiuveitis therapy during the time of the I N H testing (that is, whether the patients were receiving corticosteroids and cycloplegics). Second, what did they use as an endpoint to state that the pa tients responded positively to the I N H stimulation test? If they were receiving concurrent medications, how did they know what the patients were responding to? Were the results based on the rapidity of resolution in the positively responding cases or on the decreased incidence of recurrent cases in the positively respond ing group? If concurrent conventional therapy was not used, were these cases allowed to go without corticosteroid treatment for a few weeks to see if they would respond to the INH? C H A R L E S J. ABBOTT,
Los Angeles,
M.D.
California
Reply When our patients are referred they are usually taking cycloplegics and corti costeroids. Ordinarily they continue to do so unless the uveitis is so mild that a response to isoniazid could not be identi fied unless the corticosteroids were dis continued. The endpoint for a positive response to isoniazid is a dramatic im-
VOL. 95, NO. 1
BOOK REVIEWS
provement. However, in some cases we still diagnose "tuberculosis" because of other factors. Recently we examined a 16-year-old girl with phlebitis and chorioretinitis who developed a typical tubercu lous keratitis confirmed by our external disease service. Her response to isoniazid was slow but we still labeled her condi tion as "tuberculous." However, we did not label the isoniazid therapeutic test as positive. The ophthalmologist has to be thoroughly conversant with the condition of the eye before beginning the isoniazid therapeutic test, and sure that the proc ess is relatively stable or getting worse before an improvement can be ascribed to isoniazid. If the disease recurs after the patient has had a complete year of treat ment with isoniazid, vitamin Ββ, and an other agent such as rifampin, we consider the diagnosis of tuberculosis to be wrong and we change it. J O H N ABRAMS,
A.B.
T. F. SCHLAEGEL, JR., M.D. Indianapolis, Indiana BOOK REVIEWS International Histological Classification of Tumours of the Eye and Its Adnexa. By L. E. Zimmerman in collaboration with L. H. Sobin. Geneva, World Health Organization, 1980. Hardcover, 82 pages, index, 150 color figures. Sw. F. 210 (approx. $98) with color figures and Sw. F. 60 (approx. $28) without color figures This is the 24th installment of an exten sive World Health Organization project in which tumors of all the organ systems of the body are briefly described in a text organized around high-quality color pho tomicrographs. Dr. Zimmerman headed an international team that included S. R. Andersen from Denmark, N. Ashton from England, F. Contreras from Peru,
127
P. Dhermy from France, the late H. Greer from Australia, O. Litriτin from Yugoslavia, G. G. Ziangirova from the U.S.S.R., and L. H. Sobin, who coordi nated the entire project from Switzer land. The purpose of involving such a geographically separated group of ex perts was to produce a useful and mutual ly intelligible classification scheme to promote an exchange of knowledge and research on ocular neoplasms. When I was an ophthalmic pathology fellow at the Armed Forces Institute of Pathology in the early 1970s, Dr. Zim merman was exchanging glass slides of representative entities, which he then circulated among the fellows for our edu cational enrichment. From this experi ence, I discovered the enormous care and energy expended on developing a pragmatic and clear nosology for the use of ocular clinicians and pathologists. After the establishment of the World Health Organization Collaborating Center for the histologie classification of tumors of the eye and its adnexa in 1972 at the Armed Forces Institute of Pathology, it took seven more years of painstaking work to assemble the material contained in the present volume and to reach agree ments in controversial areas. Ophthal mologists throughout the world should be grateful for this remarkable accomplish ment. The color illustrations are beautiful, and they may be purchased separately as a set of 150 Kodachrome slides for teach ing purposes. Ophthalmic clinicians, on cologists, ophthalmic pathologists, and general pathologists will all profit im measurably from the long hours of collab oration, compromise, and artistic effort that culminated in this new standardized nomenclature for ocular neoplasms. When combined with earlier World Health Organization publications dealing with soft-tissue tumors and skin tumors,