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Autofluorescence of the Human Diabetic Lens in VIVO
AUTOFLUORESCENCE O F T H E 13 U M A N DIABETIC L E N S IN VIVO J. HELVE,
M.D., AND H . NlEMINEN
Oulu, Finland The aging lens contains a progressively normal subjects. The mean age of the dia increasing amount of fluorescent material. betics was 15 years (maximum 30 years, Vannas and Wilska 1 noted exceptionally minimum 6 years), and the mean duration strong fluorescence in vivo in diabetic pa of diabetes was six years (maximum 20 tients with clear lenses, although Klang 2 did years, minimum one year). Of 25 young not find any difference when comparing the healthy control subjects, the mean age was fluorescence in the lenses of normal patients 16 years (maximum 23 years, minimum 4 with the fluorescence in clear diabetic lenses. years). All patients with lens opacities lead Brolin and Krakau 3 found changes in fluo ing to a reduction in visual acuity or the rescence early in the course of cataract for visibility of the ocular fundus were excluded. mation in lactase-fed rats. Hammar 4 ob Examinations were made during the winter seasonal variations served that the fluorescence of the lens in in the hope of avoiding 2 in lens fluorescence. Fluorescein angiogalloxan diabetic rats increased before the ap raphy and applanation tonometry had not pearance of the cataract. been performed within four months before Several substances contribute to the fluo rescence of the lens. Lerman 5 studied the the measurements. Since we soon noted that fluorescent material of the aging human lens, the autofluorescence was symmetrical, only obtaining a maximum of 444 nm for the the data for the right eye were presented. emission peak. Van Heyningen 6 isolated yel The autofluorescence measurements were made by using the routine photographic low, highly fluorescent glucosides from aging apparatus used in fluorescein angiography. human lenses. Their quantities in the cortex All density measurement photographs were and nucleus of the lens were similar and there taken in the direction of the optic axis. The were no great changes with age. Bando 7 Zeiss fundus camera was adjusted so the found that alt the yellow fractions emit blue distance from the camera to the eye was al fluorescence at a wavelength between 420 and ways the same. A Zeiss power supply (480 470 nm. Little is known about the fluorescent W ) was used as a light source. A Baird material in human cataracts, and there seems Atomic B 4 filter was used as the exciting to be no information on the nature of this filter and a Kodak Wratten 15 filter as the material in the human diabetic lens without barrier filter. The film (Kodak Tri X ) was cataract. developed by using a developing machine We compared the autofluorescence of the (Kodak 5-N) controlled by control strips. human lens in vivo in two groups, normal Density measurements were made directly young subjects and young diabetic patients through the negatives by using a densitomwith clear lenses. eter (Macbeth TD-102). The density of MATERIAL AND METHODS
We report autofluorescence values for the lenses of 80 young diabetics and 25 young
From the Department of Ophthalmology, Uni versity of Oulu, Oulu, Finland. Reprint requests to J. Helve, M.D., Department of Ophthalmology, University of Oulu, Kajaanintie SO, 90220 Oulu 22, Finland.
the film base was also measured in each case. The density value is the difference between the density of the lens and the density of the film base. RESULTS
The pathologic autofluorescence of the lens in young diabetics is a symmetrical phenome non. The difference in the density of the eyes
491
492
AMERICAN JOURNAL OF OPHTHALMOLOGY
of the same subject never exceeded 1 density unit. In the control material the density value of the autofluorescence was never more than 1 density unit ( Fig. 1 ). On the other hand, only 18 of the 80 diabetics had density values less than 2 units and in 16 of these patients, the duration of diabetes was a maxi mum of five years (mean, two years). The density value was never less than 2 units in subjects who had diabetes for seven years or more. The autofluorescence of the lens increased with increasing age and duration of diabetes. Most patients with diabetic retinopathy ( Fig. 1 ) had high density values. The mean density values for subjects with and without retinopathy was 11 units (maxi mum 21, minimum 4) and 3 units (maximum 10, minimum 0), respectively. Both retinop athy and intense autofluorescence of the lens reflected long-standing diabetes. The
APRIL, 1976
slit-lamp photograph of an autofluorescing diabetic lens (Fig. 2, right) was clearly nar rower than the ordinary black and white slit image of the same lens (Fig. 2, left). The missing autofluorescence of the anterior lay er of the lens was demonstrated by biomicroscopy with a cobalt filter. No autofluorescence was seen in a normal juvenile lens. The actual measurements were taken in the direction of the optic axis, while the slit-lamp photographs only demonstrated the autofluorescence in the different layers of the lens. DISCUSSION
Autofluorescence emitted by the lens was well demonstrated in some cases of juvenile diabetic cataract where no autofluorescence could be measured after the cataract opera tion. The difference between the autofluo-
A G E (years) 30
S*
sy 20
9Γ
·— R R
9
•—R
a rR
<6» • 9 o» o • o» Φ Λ ax a» a o oo o a a
10
0
& x O duration 0-5 years φ . 6-10 » • « >10 « R diabetic retinopathy
L
10
i
i
15
20
.normal -diabetes
25 DENSITY
Fig. 1 (Helve and Nieminen). Scattergram demonstrating the correlation between the density of the autofluorescence of the lens (abscissa) with the age (ordinate) in 80 young diabetics and 25 normal subjects. The duration of the diabetes and the cases with retinopathy are shown with separate symbols.
VOL. 81, NO. 4
DIABETIC LENS FLUORESCENCE
493
Fig. 2 (Helve and Nieminen). The autofluorescence of a juvenile diabetic lens. Left, Ordinary slit image of a juvenile diabetic lens. Right, Slit image of the autofluorescence of the same diabetic lens. rescence of normal and diabetic lenses is ob vious here. Klang 2 did not find any differ ence because he used a different barrier filter. The barrier filter we used excludes all wave lengths below 500 nm, so that the fluorescent material responsible for the yellow, normal aging lenses that emit blue fluorescence (420 to 470 nm, according to Lerman 5 and Bando7) is excluded. We noted no yellow or yellow-brownish tinge in the diabetic lenses. The missing autofluorescence of at least the anterior layer of the diabetic lens (Fig. 2) might have some correlation with the "band of disjunction" of the lens in diabetes mellitus described by Huggert. 8 This band of disjunction is a pathologically broadened clear interval between the slit image of the capsule of the lens and the second visible zone that is markedly broadened in juvenile diabetics. Both the abnormal broadening of the band of disjunction and the pathologic
autofluorescence of the diabetic lens seem to have a positive correlation with duration of diabetes. However, our own experience of the relationship between these two phe nomena is limited. Since most juvenile dia betics who have had the disease for seven years or more show pathologic autofluo rescence of the lens, while a diabetic juvenile cataract is an uncommon complication, these two phenomena may have little to do with each other, although possibly they have a common biochemical basis. SUMMARY
We studied the in vivo measurements of the autofluorescence of the clear lens in 80 juvenile diabetics and 25 young healthy sub jects. When the diabetes was of seven years' duration or more, no overlap with the con trol subjects was found. The pathologic autofluorescence of the diabetic lens showed a
494
AMERICAN JOURNAL O F OPHTHALMOLOGY
positive correlation with age and the dura tion of diabetes. REFERENCES
1. Vannas, M., and Wilska, A. : Eine Methode zur Messung der Fluoreszenz der lebenden mensch lichen Augenlinse und eine Untersuchung über ihre Abhängigkeit vom Alter. Klin. Monatsbl. Augenheilkd. 95:53, 1935. 2. Klang, G. : Measurements and studies of the fluorescence of the human lens in vivo. Acta Ophthalmol. 31(Suppl.) :132, 1948. 3. Brolin, S., and Krakau, T. : Spectrophotometric investigations on the fluorescence of the ocular lens with changed metabolism in rats with
OPHTHALMIC
APRIL, 1976
galactose. Acta Ophthalmol. 27:291, 1949. 4. Hammar, H. : The influence of different fat diets on the fluorescence of the eye lens and of serum in alloxan diabetic rats. Acta Ophthalmol. 43:61, 1965. 5. Lerman, S. : Lens proteins and fluorescence. Isr. J. Med. Sei. 8:1583, 1972. 6. Van Heyningen, R. : Assay of fluorescent glucosides in the human lens. Exp. Eye Res. 15 : 121, 1973. 7. Bando, M. : The relationship between colora tion and fluorescence in human lens. Acta Soc. Ophthalmol. Jap. 77:873, 1973. 8. Huggert, A. : The appearance of the band of disjunction of the lens in diabetes mellitus. Acta Ophthalmol. 31:227, 1953.
MINIATURE
" T h i s is w h e r e w e k e e p t h e i n s t r u m e n t s . " F a r n o n s h o w e d m e into a n o t h e r little r o o m . T h e s m a l l a n i m a l e q u i p m e n t lay o n green b a i z e s h e l v e s , very n e a t a n d i m p r e s s i v e l y c l e a n . H y p o d e r m i c s y r i n g e s , w h e l p i n g f o r c e p s , t o o t h sealers, p r o b e s , s e a r c h e r s , a n d , in a p l a c e of prominence, an ophthalmoscope. F a r n o n lifted it l o v i n g l y from its b l a c k b o x . " M y latest p u r c h a s e , " h e m u r m u r e d , s t r o k i n g its s m o o t h shaft. " W o n d e r f u l t h i n g . H e r e , h a v e a p e e p at m y r e t i n a . " I s w i t c h e d o n t h e b u l b a n d g a z e d w i t h i n t e r e s t at t h e g l i s t e n i n g , c o l o u r e d t a p e s t r y in t h e d e p t h s of h i s e y e . " V e r y p r e t t y . I c o u l d w r i t e y o u a certificate of s o u n d n e s s . " J a m e s H e r r i o t , / / Only They Could Talk M i c h a e l J o s e p h , Ltd., 1970
M.D., AND H . NlEMINEN
Oulu, Finland The aging lens contains a progressively normal subjects. The mean age of the dia increasing amount of fluorescent material. betics was 15 years (maximum 30 years, Vannas and Wilska 1 noted exceptionally minimum 6 years), and the mean duration strong fluorescence in vivo in diabetic pa of diabetes was six years (maximum 20 tients with clear lenses, although Klang 2 did years, minimum one year). Of 25 young not find any difference when comparing the healthy control subjects, the mean age was fluorescence in the lenses of normal patients 16 years (maximum 23 years, minimum 4 with the fluorescence in clear diabetic lenses. years). All patients with lens opacities lead Brolin and Krakau 3 found changes in fluo ing to a reduction in visual acuity or the rescence early in the course of cataract for visibility of the ocular fundus were excluded. mation in lactase-fed rats. Hammar 4 ob Examinations were made during the winter seasonal variations served that the fluorescence of the lens in in the hope of avoiding 2 in lens fluorescence. Fluorescein angiogalloxan diabetic rats increased before the ap raphy and applanation tonometry had not pearance of the cataract. been performed within four months before Several substances contribute to the fluo rescence of the lens. Lerman 5 studied the the measurements. Since we soon noted that fluorescent material of the aging human lens, the autofluorescence was symmetrical, only obtaining a maximum of 444 nm for the the data for the right eye were presented. emission peak. Van Heyningen 6 isolated yel The autofluorescence measurements were made by using the routine photographic low, highly fluorescent glucosides from aging apparatus used in fluorescein angiography. human lenses. Their quantities in the cortex All density measurement photographs were and nucleus of the lens were similar and there taken in the direction of the optic axis. The were no great changes with age. Bando 7 Zeiss fundus camera was adjusted so the found that alt the yellow fractions emit blue distance from the camera to the eye was al fluorescence at a wavelength between 420 and ways the same. A Zeiss power supply (480 470 nm. Little is known about the fluorescent W ) was used as a light source. A Baird material in human cataracts, and there seems Atomic B 4 filter was used as the exciting to be no information on the nature of this filter and a Kodak Wratten 15 filter as the material in the human diabetic lens without barrier filter. The film (Kodak Tri X ) was cataract. developed by using a developing machine We compared the autofluorescence of the (Kodak 5-N) controlled by control strips. human lens in vivo in two groups, normal Density measurements were made directly young subjects and young diabetic patients through the negatives by using a densitomwith clear lenses. eter (Macbeth TD-102). The density of MATERIAL AND METHODS
We report autofluorescence values for the lenses of 80 young diabetics and 25 young
From the Department of Ophthalmology, Uni versity of Oulu, Oulu, Finland. Reprint requests to J. Helve, M.D., Department of Ophthalmology, University of Oulu, Kajaanintie SO, 90220 Oulu 22, Finland.
the film base was also measured in each case. The density value is the difference between the density of the lens and the density of the film base. RESULTS
The pathologic autofluorescence of the lens in young diabetics is a symmetrical phenome non. The difference in the density of the eyes
491
492
AMERICAN JOURNAL OF OPHTHALMOLOGY
of the same subject never exceeded 1 density unit. In the control material the density value of the autofluorescence was never more than 1 density unit ( Fig. 1 ). On the other hand, only 18 of the 80 diabetics had density values less than 2 units and in 16 of these patients, the duration of diabetes was a maxi mum of five years (mean, two years). The density value was never less than 2 units in subjects who had diabetes for seven years or more. The autofluorescence of the lens increased with increasing age and duration of diabetes. Most patients with diabetic retinopathy ( Fig. 1 ) had high density values. The mean density values for subjects with and without retinopathy was 11 units (maxi mum 21, minimum 4) and 3 units (maximum 10, minimum 0), respectively. Both retinop athy and intense autofluorescence of the lens reflected long-standing diabetes. The
APRIL, 1976
slit-lamp photograph of an autofluorescing diabetic lens (Fig. 2, right) was clearly nar rower than the ordinary black and white slit image of the same lens (Fig. 2, left). The missing autofluorescence of the anterior lay er of the lens was demonstrated by biomicroscopy with a cobalt filter. No autofluorescence was seen in a normal juvenile lens. The actual measurements were taken in the direction of the optic axis, while the slit-lamp photographs only demonstrated the autofluorescence in the different layers of the lens. DISCUSSION
Autofluorescence emitted by the lens was well demonstrated in some cases of juvenile diabetic cataract where no autofluorescence could be measured after the cataract opera tion. The difference between the autofluo-
A G E (years) 30
S*
sy 20
9Γ
·— R R
9
•—R
a rR
<6» • 9 o» o • o» Φ Λ ax a» a o oo o a a
10
0
& x O duration 0-5 years φ . 6-10 » • « >10 « R diabetic retinopathy
L
10
i
i
15
20
.normal -diabetes
25 DENSITY
Fig. 1 (Helve and Nieminen). Scattergram demonstrating the correlation between the density of the autofluorescence of the lens (abscissa) with the age (ordinate) in 80 young diabetics and 25 normal subjects. The duration of the diabetes and the cases with retinopathy are shown with separate symbols.
VOL. 81, NO. 4
DIABETIC LENS FLUORESCENCE
493
Fig. 2 (Helve and Nieminen). The autofluorescence of a juvenile diabetic lens. Left, Ordinary slit image of a juvenile diabetic lens. Right, Slit image of the autofluorescence of the same diabetic lens. rescence of normal and diabetic lenses is ob vious here. Klang 2 did not find any differ ence because he used a different barrier filter. The barrier filter we used excludes all wave lengths below 500 nm, so that the fluorescent material responsible for the yellow, normal aging lenses that emit blue fluorescence (420 to 470 nm, according to Lerman 5 and Bando7) is excluded. We noted no yellow or yellow-brownish tinge in the diabetic lenses. The missing autofluorescence of at least the anterior layer of the diabetic lens (Fig. 2) might have some correlation with the "band of disjunction" of the lens in diabetes mellitus described by Huggert. 8 This band of disjunction is a pathologically broadened clear interval between the slit image of the capsule of the lens and the second visible zone that is markedly broadened in juvenile diabetics. Both the abnormal broadening of the band of disjunction and the pathologic
autofluorescence of the diabetic lens seem to have a positive correlation with duration of diabetes. However, our own experience of the relationship between these two phe nomena is limited. Since most juvenile dia betics who have had the disease for seven years or more show pathologic autofluo rescence of the lens, while a diabetic juvenile cataract is an uncommon complication, these two phenomena may have little to do with each other, although possibly they have a common biochemical basis. SUMMARY
We studied the in vivo measurements of the autofluorescence of the clear lens in 80 juvenile diabetics and 25 young healthy sub jects. When the diabetes was of seven years' duration or more, no overlap with the con trol subjects was found. The pathologic autofluorescence of the diabetic lens showed a
494
AMERICAN JOURNAL O F OPHTHALMOLOGY
positive correlation with age and the dura tion of diabetes. REFERENCES
1. Vannas, M., and Wilska, A. : Eine Methode zur Messung der Fluoreszenz der lebenden mensch lichen Augenlinse und eine Untersuchung über ihre Abhängigkeit vom Alter. Klin. Monatsbl. Augenheilkd. 95:53, 1935. 2. Klang, G. : Measurements and studies of the fluorescence of the human lens in vivo. Acta Ophthalmol. 31(Suppl.) :132, 1948. 3. Brolin, S., and Krakau, T. : Spectrophotometric investigations on the fluorescence of the ocular lens with changed metabolism in rats with
OPHTHALMIC
APRIL, 1976
galactose. Acta Ophthalmol. 27:291, 1949. 4. Hammar, H. : The influence of different fat diets on the fluorescence of the eye lens and of serum in alloxan diabetic rats. Acta Ophthalmol. 43:61, 1965. 5. Lerman, S. : Lens proteins and fluorescence. Isr. J. Med. Sei. 8:1583, 1972. 6. Van Heyningen, R. : Assay of fluorescent glucosides in the human lens. Exp. Eye Res. 15 : 121, 1973. 7. Bando, M. : The relationship between colora tion and fluorescence in human lens. Acta Soc. Ophthalmol. Jap. 77:873, 1973. 8. Huggert, A. : The appearance of the band of disjunction of the lens in diabetes mellitus. Acta Ophthalmol. 31:227, 1953.
MINIATURE
" T h i s is w h e r e w e k e e p t h e i n s t r u m e n t s . " F a r n o n s h o w e d m e into a n o t h e r little r o o m . T h e s m a l l a n i m a l e q u i p m e n t lay o n green b a i z e s h e l v e s , very n e a t a n d i m p r e s s i v e l y c l e a n . H y p o d e r m i c s y r i n g e s , w h e l p i n g f o r c e p s , t o o t h sealers, p r o b e s , s e a r c h e r s , a n d , in a p l a c e of prominence, an ophthalmoscope. F a r n o n lifted it l o v i n g l y from its b l a c k b o x . " M y latest p u r c h a s e , " h e m u r m u r e d , s t r o k i n g its s m o o t h shaft. " W o n d e r f u l t h i n g . H e r e , h a v e a p e e p at m y r e t i n a . " I s w i t c h e d o n t h e b u l b a n d g a z e d w i t h i n t e r e s t at t h e g l i s t e n i n g , c o l o u r e d t a p e s t r y in t h e d e p t h s of h i s e y e . " V e r y p r e t t y . I c o u l d w r i t e y o u a certificate of s o u n d n e s s . " J a m e s H e r r i o t , / / Only They Could Talk M i c h a e l J o s e p h , Ltd., 1970