Abstract: BACKGROUND: Therapy delay in neovascular age-related macular degeneration (NV-AMD) is associated with risk of visual deterioration. METHODS: Retrospective cross section analysis including patients with NV-AMD who received fluorescein angiography (FA). The time elapsed from symptom onset to assessment was analysed in relation to different factors. Inclusion criteria were: age >50 years, symptom onset within 6 months before assessment, no previous AMD therapy, indication for vascular endothelial growth factor inhibitor treatment. RESULTS: Mean duration of symptoms was 2.272 +/- 1.683 months (n = 220); percentiles 25, 50, 75 and 90 corresponded to 1, 2, 3 and 5.383 months. A significant increase (p = 0.033) in mean symptom duration was found between age groups 65-74, 75-84 and over 84 years. Privately insured persons (assessment 1.242 +/- 1.060 months after symptom onset; n = 14) received FA 1.083 months earlier (p = 0.0089) than patients with a statutory health insurance (assessment 2.325 +/- 1.661 months after symptom onset; n = 194). CONCLUSION: In order to avoid progressive visual deterioration in patients with NV-AMD earlier assessment of these individuals should be aimed for.
Abstract: PURPOSE: The purpose was to study preinjection optical coherence tomography-related factors in age-related macular degeneration eyes with retinal pigment epithelial detachment (PED) that may predispose retinal pigment epithelial (RPE) tears associated with intravitreal bevacizumab injections. METHODS: This multicenter retrospective case series involving 9 retina specialists and 7 centers investigated Stratus optical coherence tomography (Carl Zeiss Meditec, Dublin, CA) parameters in eyes with vascularized PED (vPED) from February 2006 to February 2007. Of the 1,280 eyes in 1,255 patients receiving 2,890 intravitreal injections, there were 125 eyes with vPED. For every vPED eye that developed an RPE tear (Group 1), 3 or more vPED eyes without RPE tears (Group 2) were randomly selected in each study center during the same time period for comparison. The primary outcome measure was PED height (microm), and the secondary measures included volume index (vPED height x surface area), total macular volume, subretinal fluid, cystoid macular edema, center-point thickness, central 1 mm, and pre- and postinjection best-corrected Snellen visual acuities. RESULTS: Twenty-one vPED eyes in 21 patients among 125 vPED eyes (16.8% of all vPED eyes) developed RPE tears. The 21 Group 1 eyes were compared with the 78 randomly selected Group 2 eyes. The vPED height was significantly higher for Group 1 eyes in comparison to Group 2 eyes (mean: 648.9 +/- 245.0 vs. 338.1 +/- 201.6 microm, P < 0.001). The same was true for the following: volume index (P = 0.001), subretinal fluid (P = 0.002), and total macular volume (P = 0.04). The mean preinjection and post-RPE tear best-corrected visual acuity were 0.92 logMAR (20/166) and 0.84 logMAR (20/137), respectively (P = 0.25). Multivariate analysis showed PED height to be the only significant risk factor associated with RPE tears in Group 1 eyes [odds ratio = 0.995 (95% confidence interval: 0.992-0.997), P < 0.001]. CONCLUSION: Elevated preinjection vPED height is the single most significant predictor for RPE tears after bevacizumab injections for vPED eyes. A vPED height >400 microm is associated with a significant risk for such a complication.
Abstract: PURPOSE: To evaluate the ability of novel dyes to stain lens capsule (LC), internal limiting membrane (ILM), epiretinal membrane (ERM), and vitreous. DESIGN: Experimental study in animal and human donor eyes. METHODS: Thirteen dyes, methyl violet, crystal violet, eosin Y, sudan black B, methylene blue, toluidine blue, light green, indigo carmine, fast green, congo red, evans blue, brilliant blue, and bromophenol blue, were injected onto the LC and ILM of enucleated porcine eyes. The vitreous was stained with 2 mL of dyes for 1 minute. Six dyes (indigo carmine, evans blue, fast green, light green, bromophenol blue, and brilliant blue) were selected for experiments in human donor eyes and freshly removed ERM. RESULTS: In the porcine eyes, ILM staining with methylene blue, toluidine blue, indigo carmine, evans blue, bromophenol blue, and fast green was moderate, and methyl violet, crystal violet, brilliant blue, or sudan black resulted in strong staining. Methyl violet, crystal violet, sudan black, toluidine blue, and methylene blue caused histologic damage in porcine retinas. Vitreous examination revealed moderate staining with congo red, crystal violet, fast green, eosin Y, methylene blue, toluidine blue, brilliant blue, bromophenol blue, and methyl violet and strong staining with light green and evans blue. ERMs showed strong staining with 0.5% evans blue and moderate staining with 0.5% light green, fast green, brilliant blue, and bromophenol blue. Evaluation of donor eyes disclosed moderate staining with evans blue, light green, and bromophenol blue and strong staining with 0.5% brilliant blue. Moderate or strong staining of the vitreous occurred with most dyes. LC evaluation showed moderate staining with 0.5% evans blue, fast green, and brilliant blue, whereas 0.5% light green produced strong LC staining. CONCLUSIONS: Brilliant blue shows the best ILM staining, whereas bromophenol blue, evans blue, and light green also stain ILM. Most dyes bind well to LC, vitreous, and ERM.
Abstract: Abstract. Purpose: To determine the concentration of unbound bevacizumab in untreated fellow eyes after contralateral intravitreal injection of bevacizumab. Methods: A total of 18 eyes received intravitreal injections of 1.5 mg bevacizumab. Nine probes were obtained in the injected eye and nine in the fellow eye. Each group contained three individual eyes. Aqueous humour samples were obtained during uneventful phacoemulsification at three intervals 1-7 days (group a), 8-12 days (group b) or 13-28 days (group c). Results: In untreated fellow eyes, the concentration of unbound bevacizumab was below the detectable limit of the ELISA (5 ng/ml in all samples). The mean concentration of unbound bevacizumab in the injected eye declined from 28.6 mug/ml (group a), 16.5 mug/ml (group b) to 7.4 mug/ml (group c). Conclusions: There are no pharmacological indications for a significant concentration of unbound bevacizumab in the anterior chamber of contralateral eyes in humans.
Abstract: Abstract. Objective: Retinal capillary haemangioma complications are characterized by progressive exudation with consecutive intraretinal and subretinal leakage. A successful therapy without side-effects has not been found. We report a case of retinal juxtapapillary capillary haemangioma causing consecutive leakage with macular involvement. The tumour was treated with a combination of anti-vascular endothelial growth factor (VEGF) and photodynamic therapy (PDT) and was followed for 1 year. Methods: A 44-year-old woman with retinal juxtapapillary capillary haemangioma in the right eye experienced a decrease of visual acuity from 20/20 to 20/60 because of a severe leakage from the tumour involving the macula with lipid depositions. Two sessions of PDT (sparing the part of the haemangioma located within the optic disc) and five injections of bevacizumab were applied in a period of 5 months. Visual acuity, visual field testing, retinal thickness measurements, fundus photography and fluorescein angiography were performed to evaluate the treatment effect. Results: One year after the last injection, visual acuity increased to 20/40. All lipid exudates at the posterior pole resolved. Retinal thickness decreased from 490 to 150 mum with the restoration of normal central macular architecture. Leakage in fluorescence angiography reduced significantly, but hyperfluorescence of the tumour was still evident. Visual field testing and angiography did not show any treatment-related vaso-occlusive side-effects. Conclusion: In this single case, the combination of anti-VEGF and PDT appeared to be an effective strategy for the treatment of retinal juxtapapillary capillary haemangioma without side-effects. Further studies with a greater number of eyes and adequate follow-up are necessary to support these first clinical results.
Abstract: Abstract. Purpose: To evaluate the clinical relevance of a new diagnostic modality, simultaneous confocal scanning laser ophthalmoscopy (cSLO) and high-speed, high-resolution, spectral-domain optical coherence tomography (OCT), for the visualization of macular pathologies. Methods: OCT images and simultaneous recording of fluorescein angiography, indocyanine green (ICG) angiography, infrared, and blue reflectance ('red-free') or fundus autofluorecence (FAF) images were obtained with a novel imaging device (Spectralis HRA + OCT; Heidelberg Engineering, Heidelberg, Germany). An optically pumped solid-state laser generated the excitation wavelength (488 nm) required for blue reflectance, FAF and fluorescein angiography images. For ICG angiography and infrared imaging, diode laser sources at 790 and 815 nm were used. For OCT, 40 000 A-scans per second were acquired with 7 mum axial and 14 mum lateral optical resolution. The B-scans covering a transversal range of 30 degrees had a scan width up to 1.536 A-scans with a digital lateral resolution of 5 mum/pixel, a scan depth of 1.8 mm with 3.5 mum/pixel digital axial resolution and a scan rate of up to 48 B-scans/second. In addition, volume scans could be obtained at 15, 20 and 30 degrees fields of view. An integrated eye tracking allowed for live averaging of cSLO images as well as OCT B-scans. Results: Early, neovascular and atrophic age-related macular degeneration, macular telangiectasia, retinal arterial, branch vein occlusion and other pathologies were imaged, and cSLO and OCT frames correlated. Fluorescein and ICG angiographic phenomena recorded in cSLO images could be analysed accurately in corresponding OCT cross-sections. Abnormal FAF signals were correlated to alterations at the outer retinal/retinal pigment epithelial cell layer in high-resolution OCT scans. Three-dimensional OCT enabled comprehensive retinal coverage. The imaging software tracked eye movements accurately. Averaging of live B-scans enhanced image quality considerably. Conclusion: The combined cSLO/OCT system allowed for simultaneous recordings of topographic and tomographic images with accurate correlation between the confocal angiograms, FAF images as well as other imaging modes with the OCT scans. The instrument thus provides simultaneous multi-modal imaging of retinal pathologies and disease.
Abstract: BACKGROUND: Quality evaluation of web-based health information in ophthalmology requires valid standards and reproducible assessment procedures. The objective was to evaluate the interrater-reliability of quality assessment of ophthalmic websites and a possible correlation between the results of the evaluation categories reliability/trustworthiness, quality of medical content and accessibility/usability. MATERIALS AND METHOD: After selection with the search engine "Google" 20 ophthalmic websites had been analysed by two independent evaluators using criteria checklists (modified Afgis transparency criteria, modified BITV test, medical content related to AMD) related to the aforementioned 3 categories. RESULTS: The interrater-reliability was almost perfectly estimated with Kappa-values of 0.91 for reliability/trustworthiness plus 0.89 for accessibility/usability and 0.79 for content. On average 62.5 % (+/- 17.43 %), 27.36 % (+/- 16.5 %) and 59.54 % (+/- 15.73 %) of the quality requirements were fulfilled for reliability/trustworthiness, content and accessibility/usability, respectively. No significant correlation was found between reliability and content (r = -0.039, p = 0.8709), reliability and accessibility/usability (r = -0.284; p = 0.228) plus content and accessibility/usability (r = 0.199; p = 0.4047). CONCLUSION: Sufficiently operationalised criteria are prerequisites for reproducible results of quality assessment of ophthalmic websites between different observers. The assessment within a single category, such as reliability/trustworthiness, does not allow one to draw conclusions on other categories such as content or accessibility/usability or the overall quality of a website. Therefore, simplified tools for quality assessment of health information by laymen and patients may have a limited validity.
Abstract: Vital dyes have advanced diagnosis and surgical technique in various specialties, including oncology, gastroenterology, and ophthalmology. In ocular surgery vital dyes are widely used in cataract and vitreoretinal surgery. Worldwide, intra-operative use of trypan blue during cataract surgery has enhanced visualization of the anterior capsule during capsulorrhexis, and patent blue has been recently licensed in Europe for cataract surgery. For chromovitrectomy, the vital dyes indocyanine green, infracyanine green, and brilliant blue stain the internal limiting membrane, and trypan blue and triamcinolone acetonide help visualize epiretinal membranes and vitreous, respectively. Intra-operative vital dyes are finding uses in corneal, glaucoma, orbit, strabismus, and conjunctival surgery. We provide a summary of current knowledge of the use of vital dyes in ocular surgery. We review the properties of dyes, techniques of application, indications, and complications in ocular surgery. Vital dyes represent an expanding area of research, and novel dyes deserve further investigation.
Abstract: BACKGROUND: Photodynamic therapy (PDT) in eye disease was approved 10 years ago for age-related macular degeneration (AMD). Thereafter it was approved for choroidal neovascularisation (CNV) in pathological myopia. The treatment regimen is based on two prospective, multicentre trials (TAP and VIP studies). MATERIAL AND METHODS: In the meantime PDT has been successfully used also in several other ocular diseases. PDT is minimally invasive and has an excellent side effect profile. Different diseases and their treatment with PDT are discussed. RESULTS: The treatments of idiopathic CNV, secondary CNV in inflammatory diseases of the retina and choroid, choroidal haemangioma, vasoproliferative tumours, malignant melanoma of the choroid, and central serous chorioretinopathy with PDT are described. In most patients the disease progression can be stopped and in some the PDT treatment results in visual improvement. The prognosis is better in patients with early disease detection and small lesions. CONCLUSION: Several retinal and choroidal diseases can be treated successfully with PDT. Except for AMD and pathological myopia, PDT is an off label treatment.
Abstract: BACKGROUND/AIMS: To analyze the long-term changes in retinal perfusion and functional improvement induced by radial optic neurotomy (RON) in central retinal vein occlusion (CRVO). METHODS: Sixty-three eyes of 63 consecutive patients with CRVO were included. Twenty-eight (44.5%) patients underwent RON and 35 (55.5%) were followed as a control group. Time of arteriovenous transit and visual acuity were determined at baseline and after 1-year follow-up. RESULTS: After 1 year, retinal perfusion status improved in 63.1% of operated eyes and 14.3% of controls (p = 0.048). The improvement in arteriovenous retinal transit was statistically significant (p = 0.023) only in the RON group. The visual improvement in the RON group was significantly better (p = 0.043) than in the control group. Moreover, the development of chorioretinal anastomosis was significantly higher (p = 0.036) after RON than in controls and correlated with better functional results. In operated eyes there was a lower incidence of CRVO-related complications. CONCLUSION: RON improved retinal perfusion and achieved a better functional outcome. The measurement of perfusion changes as presented here may be useful for monitoring CRVO and assessing other treatment modalities.
Abstract: Diabetic retinopathy (DR) is one of the leading causes of blindness worldwide. Breakdown of the blood-retinal barrier in DR promotes accumulation of a high concentration of pre-retinal serum-derived chemoattractants, thereby stimulating cellular migration on the attached posterior hyaloid. This review assesses the role of intravitreal application of vascular endothelial growth factor (VEGF)inhibitors in combination with surgical removal of the vitreous. Vitrectomy with removal of the posterior hyaloids wash out the pocket of preretinal growth factors and enhance the diffusion of macro-molecules, including VEGF, insulin-like growth factor 1 or histamines, from the retinal into the vitreous cavity for further absorption through the anterior segment outflow pathways. The release of tractional forces induced by the vitreomacular traction or epiretinal membranes demonstrated a strong correlation to the reduction of retinal thickness in DME. Three techniques are described to remove the pre-retinal thickened and adherent vitreous: (1) delamination, (2) segmentation, and (3)en block dissection. A better visualization of remaining cortex vitreous or adjacent epiretinal membrane and safer removal may be achieved by a better intraoperative visualization using a variety of vital dyes to satin retinal tissue (chromovitrectomy). Anti-VEGF treatments may represent an alternative adjunctive treatment for DR.
Abstract: PURPOSE: To determine the efficacy of a novel technique for a 'transconjunctival 20-gauge vitrectomy' (T20V). METHODS: In total, 12 eyes of 12 consecutive patients were included in a prospective study. The mean age was 58 years (range: 38-74 years); 4 patients were male and 8 were female. The T20V was indicated when short-duration vitrectomy was envisioned: macular surgery for macular hole and epiretinal membrane therapy, moderate vitreous hemorrhage due to retina vein occlusions or diabetic retinopathy, or neurotomy for central retinal vein occlusion. RESULTS: The average time for each procedure was 35 +/- 30 min (SD). The preoperative visual acuity ranged from 20/200 to hand motions, while postoperative vision was between 20/30 and counting fingers. The average intraocular pressure changed from 16.1 +/- 5.6 mm Hg preoperatively to 15.8 +/- 8.1 mm Hg in the first postoperative day, and 17.8 +/- 9.4 mm Hg 1 week after surgery - these differences were not statistically significant (p > 0.05). Subjective postoperative pain and foreign body sensation at postoperative day 1 and week 1 were mild to moderate. The chemosis observed 1 h after surgery was minimal, and disappeared quickly during the 1-week follow-up. CONCLUSION: The T20V is suitable to perform short-duration vitrectomy surgery, and has a low rate of ocular complications, similar to 25- or 23-gauge sutureless vitrectomy systems.
Abstract: Fluorescein angiography (FA) was discovered by Nowotny and Alvis in the 1960s of the 20th century and has evolved to become the 'Gold standard' for macular diagnostics. Scanning laser imaging technology achieved enhancement of contrast and resolution. The combined Heidelberg retina angiograph (HRA2) adds novel innovative features to established fundus cameras. The principle of confocal scanning laser imaging provides a high resolution of retinal and choroidal vasculature with low light exposure providing comfort and safety for the patient. Enhanced contrast, details and image sharpness image are generated using confocality. For the visualization of the choroid an indocyanine green angiography (ICGA) is the most suitable application. The main indications for ICGA are age-related macular degeneration, choroidal polypoidal vasculopathy and choroidal haemangiomas. Simultaneous digital FA and ICGA images with three-dimensional resolution offer improved diagnosis of retinal and choroidal pathologies. High-speed ICGA dynamic imaging can identify feeder vessels and retinal choroidal anastomoses, ensuring safer treatment of choroidal neovascularization. Autofluorescence imaging and fundus reflectance imaging with blue and infrared light offer new follow-up parameters for retinal diseases. Finally, the real-time optical coherence tomography provides a new level of accuracy for assessment of the angiographic and morphological correlation. The combination of various macular diagnostic tools, such as infrared, blue reflectance, fundus autofluorescence, FA, ICGA and also spectral domain optical coherence tomography, lead to a better understanding and improved knowledge of macular diseases.
Abstract: BACKGROUND: Congenital hypertrophy of the retinal pigment epithelium (CHRPE) are rare hyperpigmented fundus lesions of the peripheral retina. METHODS: We evaluated CHRPE with the Optomap wide-field fundus camera. RESULTS: The pattern, location, and extension of the pigmented lesion were compared between the wide-field and composed digital fundus camera. The wide-field image had the same angle of the fundus image, magnification as well homogenious illumination of the entire fundus. Superimposed pattern of the lesions extended from the margin of the optic disk and radiated in sectors to the fundus periphery. Smaller lesion clusters were mainly located near the optic disk, whereas larger lesions were found in the periphery. CONCLUSION: The sectorial pigmentations on the ocular fundus may reflect the stream, outgrowth and migration of RPE-cells during embryogenesis.
Abstract: The aim of this article is to present the current data with regard to the application of vital dyes during vitreoretinal surgery, 'chromovitrectomy', as well as to overview the current literature regarding the properties of dyes, techniques of application, indications and complications in chromovitrectomy. A large body of published research has recently addressed the toxicity profile of indocyanine green for chromovitrectomy. Experimental data demonstrate dose-dependent toxicity of indocyanine green to various retinal cells. Newer generation vital dyes for chromovitrectomy include trypan blue, patent blue, triamcinolone acetonide, infracyanine green, sodium fluorescein, bromophenol blue, fluorometholone acetate and brilliant blue. Novel instruments may enable a selective painting of preretinal tissues during chromovitrectomy. This review suggests that the field of chromovitrectomy represents an expanding area of research. The first line agents for internal limiting membrane staining in chromovitrectomy are indocyanine green, infracyanine green, and brilliant blue. Patent blue, bromophenol blue and trypan blue arose as outstanding biostains for visualization of epiretinal membranes. Novel dyes available for chromovitrectomy deserve further investigation.
Abstract: INTRODUCTION: Monthly controls are necessary after injections of vascular endothelial growth factor (VEGF) to enable timely recognition of a renewed decrease in vision. However, these monthly control intervals are not realistic for many older patients with age-related macular degeneration (AMD), and outpatient clinics often reach their logistical limits because of inadequate funding for the additional medical work. Against this background, we conceived the ACTO self-test as a novel screening method for patients to discover unnoticed visual changes outside the routinely scheduled ophthalmic examination. MATERIAL AND METHODS: The paper version of the ACTO self-test consists of a reading chart gradated in decimal steps as well as six questions regarding the quality of the Amsler grid. The patient uses a self-screening test to examine each eye separately and then transfers the results to a table. Along with the self-examination, the Action Eyesight Service Center is available to the patient by phone to motivate the patient and schedule a new appointment if improved test results occur. If decreased values or suspected decreased visual function occur, these are verified immediately by the referring physician. RESULTS: There is a good correlation between the steps of the ACTO self-test and standard visual acuity at 4 m (r(2)=0.9). Altogether, 1,444 patients were followed by phone and 745 participated in repeated regular audits, for a total of 3,003 phone contacts. The treating physician was informed about decreased visual acuity or increased Amsler distortion in the ACTO test in 137 cases, and immediate verification was done. We had 699 dropouts; the reasons were decreased visual acuity below the limits of the ACTO test in 39%, additional monthly examinations by the local ophthalmologist in 29%, and a desire for no more telephone follow-up (despite initial written consent) in 32%. Decreased vision when reading or an increased score on the Amsler test within the ACTO screening test was observed in 18% of AMD patients during the maintenance phase. CONCLUSION: Monthly screening by the ACTO screening test in combination with phone audits offers a new way to test visual acuity, with the Amsler score helping to detect changes in visual function. For patients with visual changes, confirmation by the ophthalmic physician can be achieved in time. Self-assessment cannot replace qualified ophthalmologic examination, but monthly self-controls enhance safety, reduce the number of physician contacts, and improve the detection of visual changes, with the option of immediate ophthalmic retreatment.
Abstract: PURPOSE: To investigate the retinal biocompatibility of six novel vital dyes for chromovitrectomy. METHODS: An amount of 0.05 mL of 0.5% and 0.05% light green (LG), fast green (FG), Evans blue (EB), brilliant blue (BriB), bromophenol blue (BroB), or indigo carmine (IC) was injected intravitreally in the right eye, whereas in the left eye balanced salt solution was applied for control in rabbits' eyes. Clinical examination, fluorescein angiography, histology with light microscopy, and transmission electron microscopy were performed after 1 and 7 days. Retinal cell layers were evaluated for morphologic alterations and number of cells. The electroretinographic changes were assessed at baseline, 24 hours and 7 days. RESULTS: Fluorescein angiography disclosed hypofluorescent spots only in the 0.5% EB group. Light microscopy and transmission electron microscopy disclosed slight focal morphologic changes in eyes exposed to 0.05% IC, FG, BriB, similar to the control at 1 and 7 days. In the lower dose groups, EB, LG, and BroB caused substantial retinal alterations by light microscopy. At the higher dose, BroB and EB produced diffuse cellular edema and vacuolization within the ganglion cells, bipolar cells, and photoreceptors. FG and IC at 0.5% caused slight retinal alterations similar to balanced salt solution injection. LG at 0.5% caused diffuse vacuolization of bipolar cells after 1 and 7 days. Injection of 0.5% EB caused a significant decrease in neuroretinal cell counts in comparison to control eyes in the 7-day examination (P < 0.05). Electroretinography revealed intermittent prolonged latency and decreased amplitude in eyes injected with 0.5% EB, LG, BriB, and BroB, while at the lower dose, only LG and EB induced few functional changes. CONCLUSION: The progressive order of retinal biocompatibility, from safest to most toxic, was IC, FG, BriB, BroB, LG, EB.
Abstract: Purpose. To demonstrate keratoconus-like hydrops after laser in situ keratomileusis (LASIK) by optical coherence tomography (OCT). Patient and Methods. A 21-year-old man received uneventful bilateral LASIK. On slit lamp examination or corneal topography there were no signs of fruste keratoconus. The preoperative corneal thickness was 587-mum OD and the calculated ablation for two treatments was 114-mum. Uneventful LASIK with an optical zone of 7 mm and an ablation of 89-mum OD, and an ablation of 73-mum OS was performed. Three years postoperatively, he complained about progressive myopia and impaired vision OD. His VA was hand motion OD and 20/20 OS. Results. OCT and light microscopy revealed an anterior corneal steepening and acute keratoconus-like excessive edematous swelling. Conclusion. The cornea is mechanically weakened after LASIK by the lamellar cut and tissue subtraction. Although the advocated minimal residual stromal bed thickness is 250-mum, it may not be adequate to prevent progressive keratoconus-like hydrops in the selected cases.
Abstract: PURPOSE: To describe the clinical features, retinal architecture and tomographic configuration of a pigmented epiretinal membrane on optical coherence tomography (OCT). METHODS: A 52-year-old man presented during a routine examination with an asymptomatic, darkly pigmented, pre-retinal epiretinal membrane in his right eye. His best corrected visual acuity (BCVA) on Snellen charts was 20/25 in the right eye and 20/20 in the left. The patient complained of no visual symptoms or metamorphopsia. RESULTS: In the fundus periphery there was a small, old, well pigmented retinal hole with pigmentation in its immediate vicinity, without signs of vitreal traction, which required no treatment. The foveal indentation was not apparent on OCT and a well demarcated hyperreflective band defined the pigmented epiretinal membranes (ERMs). Sequential fundus examination over a 2-year period demonstrated no functional or anatomical deterioration attributable to the disease. CONCLUSIONS: Pigmented ERM may have different cellular origins depending on the underlying pathology. Patients with pigmented ERM and full VA should be followed by sequential OCT.
Abstract: BACKGROUND: The number of visually impaired people who use the internet for obtaining health information around the eye, is rising continuously. For this reason the accessibility for visually impaired persons to such websites is an important factor. Our investigation deals with the question: How good is the accessibility for the visually impaired to gather information on eye diseases on the Internet and how could this be improved? MATERIALS AND METHOD: After identification using the the search engine "Google", 20 websites of German university eye hospitals have been checked for their accessibility using the modified BITV test which is based upon 52 test criteria. RESULTS: On average 70.75 % (+/- 6.19 % min. 56.6 %, max; 86.79 %) of the required accessibility criteria have been fulfilled. This corresponds to an average accessibility value of 70.58 % (+/- 6.69 % min. 56.31 %, max. 89.32 %). According to the BITV test, this means that the average of the analysed websites is not accessible. The improper use of mark-up languages, unclear document or web page titles or missing alternative texts for pictures, graphics and navigation elements and misleading navigational architecture are frequent findings. This builds up the greatest accessibility barriers, although these barriers could be eliminated even with a relatively low expense. CONCLUSION: Good accessibility allows not only a barrier-free access to information for visually impaired users but is also a most important feature related to search engine optimisation.
Abstract: A 68-year-old man with solar retinopathy had a lamellar foveal lesion on ophthalmoscopy and optical coherence tomography in one eye while the fellow eye appeared unremarkable. However, macular imaging by means of confocal scanning laser ophthalmoscopy (reflectance imaging and autofluorescence) revealed alterations in both eyes. Visual deterioration due to solar retinopathy may be a diagnostic challenge and the patient's history may be incomplete. The authors recommend including noninvasive confocal scanning laser ophthalmoscopy imaging in the work-up of unexplained visual disturbances because it may add important information beyond ophthalmoscopy and other imaging techniques.
Abstract: Intravitreal injection is generally regarded as safe. Many of the potential complications caused by this procedure are extremely rare and can be avoided by careful inspection beforehand and proper performance of the injection. In rare cases, however, the administered drugs may cause various pharmacological side effects. This article summarizes the safety profiles of Macugen and Lucentis from the drug approval studies and describes initial findings on possible or observed side effects after intravitreal administration of Avastin. In addition, important points to observe in order to avoid intra- and postoperative complications are provided.
Abstract: Trypan blue (TB) is a blue vital dye with fine color properties to stain the anterior lens capsule and thereby may facilitate capsulorrhexis during cataract surgery. In addition, the blue stain may assist in the visualization of various preretinal membranes and tissues during vitreoretinal surgery in a procedure also called chromovitrectomy. TB has demonstrated great binding affinity for the glial epiretinal membranes, although it remains yet to be determined in which circumstances the dye may color the vitreous and internal limiting membrane. Most studies suggest that 0.06% TB does not pose harm to the retina, but at higher concentrations further investigation is necessary. In this paper, various aspects of the application of TB for chromovitrectomy are discussed including laboratory investigations, surgical technique and clinical outcomes.
Abstract: The use of vital dyes during vitrectomy allows easier removal of less recognizable structures like epiretinal membranes or the internal limiting membrane (ILM). In recent years, numerous studies have investigated the use of indocyanine green (ICG), trypan blue (Membrane Blue), triamcinolone, autologous blood and presently trityl dyes such as patent blue V (PBV, Blueron), crystal violet and brilliant blue G (BBG, Brilliant Peel) in chromovitrectomy. Reports on potential risks of these dyes, especially ICG, such as reduced visual acuity, possible visual field defects or alterations of the retinal pigment epithelium (RPE) limited their application. A systematic review of the literature up to July 2007 was performed using Medline (http://www.ncbi.nlm.nih.gov/ PubMed/) where we specifically searched for relevant information regarding the laboratory as well as clinical use of PB and BBG. To evaluate the effect of PB and BBG on the RPE, PB and BBG have been added to an in vitro model of the outer blood-retinal barrier to assess dye-associated barrier properties. Two concentrations of PB (2.4 and 1.2 mg/ml) and BBG (0.25 and 2.4 mg/ml) were investigated. To simulate in vivo conditions of a fluid-filled eye and an air-filled eye the dyes were added either to the culture medium or directly to the RPE cells where they remained for 2.5 min. To determine barrier properties, transepithelial resistance (TER) was measured at 3 days of follow-up. Ultrastructural integrity of RPE cells was evaluated by transmission electron microscopy. Following application of PB, barrier properties in the fluid- as well as in the air-filled eye showed only mild, transient and no significant decrease in TER. BBG did not cause a breakdown of the outer bloodretinal barrier at the concentration of 0.25 mg/ml in the model of the fluid-filled eye. The concentration of 2.4 mg/ml in the model of the fluid-filled eye as well as both concentrations in the model of the air-filled eye showed a minor decrease after 1.5 h, which was no longer observed after 24 h. Transmission electron microscopy did not show any dye-associated ultrastructural alterations to the RPE cells. In clinical use, PB showed only mild staining of epiretinal membranes and moderate staining of the ILM. Although BBG did not stain epiretinal membranes, it represents an appropriate candidate for the future, as BBG has a high affinity for the ILM. The use of trityl dyes in the posterior eye segment seems to be safe concerning damage to the RPE and its barrier function, especially when the dye is applied to the fluid-filled eye.
Abstract: PURPOSE: To investigate intraocular concentrations and pharmacokinetics of bevacizumab after a single intravitreal injection in humans. DESIGN: Prospective, noncomparative, interventional case series. METHODS: We included 30 nonvitrectomized eyes of 30 patients (age range, 43 to 93 years) diagnosed with clinically significant cataract and concurrent macular edema secondary to neovascular age-related macular degeneration, diabetic retinopathy, or retinal venous occlusion in the same eye. All patients received an intravitreal injection of 1.5 mg bevacizumab. Between one and 53 days after injection, an aqueous humor sample was obtained during elective cataract surgery. Concentrations of unbound bevacizumab in these samples were quantified by enzyme-linked immunosorbent assay. RESULTS: Concentration of bevacizumab in aqueous humor peaked on the first day after injection with a mean concentration (c(max)) of 33.3 microg/ml (range, 16.6 to 42.5 microg/ml) and subsequently declined in a monoexponential fashion. Nonlinear regression analysis determined an elimination half-time (t(1/2)) of 9.82 days (R(2) = 0.81). No significant differences between diagnosis subgroups were noted. CONCLUSIONS: In human nonvitrectomized eyes, the aqueous half-life of 1.5 mg intravitreally injected bevacizumab is 9.82 days.
Abstract: BACKGROUND: Initial historical considerations to perform a pars plana vitrectomy were made for opaque vitreous cortex due to dense asteroid hyalosis or vitreous hemorrhages. However, current indications for vitreoretinal surgery include mainly vitrectomies in the presence of a clear vitreous, for example retinal detachments, epiretinal membranes or macular holes, thus visualization of the transparent vitreous gel facilitates proper vitreous removal. MATERIALS AND METHODS: The transparent structure of the vitreous cortex as well as the thin epiretinal membrane may become visible during surgery by mild vitreous hemorrhages or intravitreous application of 0.05 ml crystalline triamcinolone acetonide. Eyes with a significant breakdown of the blood-retinal barrier accumulate intravenously applied vital dyes, for example fluorescein, in the vitreous cavity. RESULTS: Mild accidental intraoperative bleedings or intended injection of 0.05 ml autologous blood may help to stain transparent vitreous structures and visualize the remaining vitreous. Intravitreous triamcinolone crystals attach to the surface of the vitreous cortex, bursa premacularis or retina itself allowing better visualization of a controlled vitreous removal. A preoperative diagnostic fluorescein angiography in eyes with active uveitis or diabetic retinopathy may lead to a moderate accumulation of the dye in the vitreous cavity and greenish staining of the vitreous cortex at the vitreoretinal interface. DISCUSSION: A safe and complete removal of clear vitreous or transparent membranes may be achieved by the intraoperative application of autologous blood or triamcinolone. The preoperative systemic application of fluorescein greatly enhances the visualization of previously clear structures.
Abstract: For an efficient documentation during Anti-VEGF-therapy we designed a novel record form, to summarize all relevant parameters such as visual acuity, optical coherence tomography (OCT), fluorescence angiography (FAG) as well as edema, haemorrhages or RPE-tears on biomicroscopy.
Abstract: PURPOSE: To evaluate the visual acuity (VA) of patients following intravitreal (IVT) injections. METHODS: 15 patients received 3 anti-vascular-endothelial-growth-factor (VEGF) injections on a monthly basis. Prior to each injection as well as 2 months after, the patients received a standardized examination including Snellen VA and optical coherence tomography (OCT). During this time the patients were trained to evaluate their central VA by 3 computer-based tests: (a) VA was examined by the patient on a computer-based vision chart and (b) subjectively categorized as 'same', 'worse' or 'better'; (c) the edge of metamorphopsia was outlined on a digital Amsler grid. RESULTS: VA improved during the 3 injections by >or=2 lines (13/15). The assessment demonstrated subjective improvement (13/15), i.e. a gain of 2 or more lines or decreased central metamorphopsia (12/15). Reevaluation 2 months later demonstrated a decline of >or=1 Snellen line or increased retinal thickness on OCT (8/15), and a decline of >or=1 line or an enlarged metamorphopsia in the computer-based tests (6/15). CONCLUSION: Our pilot study demonstrated a good correlation between the professional examination and the computer-based assessment. Selected patients can define their visual impairment. A web-based VA evaluation may help to screen patients after IVT injections on a regular basis at home.
Abstract: PURPOSE: To assess the effectiveness of consecutive intravitreal injections of recombined tissue plasminogen activator (rtPA), expansile gas and bevacizumab in eyes with acute subretinal haemorrhage (SRH). METHODS: A retrospective, non-randomized consecutive case series included 19 eyes in 19 patients with SRH related to exudative age-related macular degeneration (AMD). The initial size of the subfoveal SRH was 1-3 disc diameters. Each patient received a triple procedure using 0.05 ml rtPA (50 microg), 0.3 ml of sulphur hexafluoride (SF6) gas and 0.05 ml bevacizumab (1.25 mg). Lesion size, location of the SRH and early treatment in diabetic retinopathy study (ETDRS) visual acuity were evaluated pretreatment as well as 1 and 3 months after the procedure. RESULTS: At the initial presentation, the patients' mean age was 77 years (range 63-88 years) and the mean duration of symptoms was 9.3 days (range 4-12 days). The mean visual acuity pretreatment (20/133) improved significantly to 20/86 at 1 month and to 20/74 at 3 months. The mean ETDRS visual acuity improved from baseline by 2.1 lines at 1 month (Wilcoxon ranks test; P < 0.005) and 3.7 lines at 3 months after treatment (Wilcoxon ranks test; P < 0.005). None of our patients had reading visual acuity prior to treatment, with visual acuity below 0.3. One month after the triple procedure, 25% of our patients had reading visual acuity (> or = 0.4); at 3 months, the figure was 35%. A successful inferior displacement of the SRH was achieved in 17/19 eyes. Eyes with elevated intraocular pressure were treated immediately by a corneal paracentesis. CONCLUSION: The intravitreal application of rtPA, gas and bevacizumab appears to be beneficial and well tolerated in the treatment of SRH in the short term. The triple approach seems a logical alternative to the current combined dual approach in limiting the progression of the underlying disease and achieving better visual outcome. Further randomized evaluations are warranted.
Abstract: Lobeck and coworkers performed the first intravitreal application of vital dyes to visualize preretinal structures in 1932. Since then numerous investigators in the 20th century examined the use of biological stains through the endovenous, subretinal and intravitreal delivery route in order to identify vitreoretinal tissues and breaks. However, in the year 2000, a new surgical approach, recently coined chromovitrectomy, has arisen, which consists in the intraoperative application of vital dyes during vitrectomy. Initially fluorescein, and more recently indocyanine green, trypan blue, bromophenol blue, triamcinolone acetonide and patent blue have been used for the staining of preretinal membranes and tissues. Currently, many vital stains are under evaluation in animals for future clinical application during chromovitrectomy such as indigo carmine or light green. In this paper, several historical considerations in regard to the application of vital dyes in chromovitrectomy are discussed.
Abstract: Age-related macular degeneration (AMD) is one of the most common causes of blindness in western industrialised nations. Most AMD patients suffer from the dry early form of AMD; however, wet AMD with choroidal neovascularization (CNV) is the main cause of blindness in all AMD patients. New prospects have been developed in AMD treatment using pharmacological methods available for treating all subtypes of exudative AMD. A number of inhibiting and inducing growth factors, such as vascular endothelial growth factor (VEGF), are particularly important in the pathophysiology of wet AMD. The secreted VEGF appears to play a crucial role in the pathogenesis of CNV and macular edemas as a result of its angiogenetic and permeability-enhancing effect. This recognition led to the treatment approach now used, i.e., competitive VEGF blocking through intravitreal adminsitration of anti-VEGF drugs. The anti-VEGF durgs lead to a rapid decrease in retinal thickness. Optical coherence tomography (OCT) is a valuable monitoring tool, but may only be used to assist in decision-making. Clinical follow-up of patients and further treatment recommendations must always be guided by the overall clinical picture. Visual acuity is regarded as the decisive criterion for repeat treatment.
Abstract: BACKGROUND: In a retrospective study we examined the anatomical and functional effects of a combined macular hole surgery with and without the application of indocyanin green (ICG) as well as phacoemulsification. METHODS AND PATIENTS: Out of 91 patients (91 eyes) with idiopatic macular holes 82 eyes were phacic. 25 cases received during the first surgery a combined pars plana vitrectomy with phacoemulsification. In 46 eyes the vitrectomy and consecutive peeling of the inner limiting membrane (ILM) was performed without ICG (Group A), in 45 eyes with ICG-assisted staining of the ILM (Group B). The average follow-up time was 19 months (12 - 24 months). RESULTS: The primary closure rate was 82.4 % and 94.5 % after reoperation. In Group A there were primarily 76 % and at the end 89.1 % closed results compared with 88.9 % and 100 % in group 2 (p = 0.172). Five persisting holes had a preoperative diameter above 600 microm (p = 0.014). Visual acuity improved in Group A preoperatively from 0.17 to postoperatively 0.33 and in Group B from 0.22 to postoperatively 0.38. The difference between both groups was not significant (p = 0.106). From 82 phacic eyes 25 were treated by a combined vitrectomy with phacoemulsification, 23 eyes received later a phacoemulsification while 34 remained phacic. DISCUSSION: Peeling of the ILM was complete after staining with ICG resulting in an increased closure rate. The functional results between both groups did not differ significantly. Phacic eyes may keep their clear lens even after multiple surgeries.
Abstract: PURPOSE: To report a meta-analysis of the literature comparing internal limiting membrane (ILM) peeling with and without indocyanine green (ICG) staining in macular hole (MH) treatment. METHODS: A Pubmed search was conducted from January 1999 to June 2004. Manuscripts describing the anatomical and functional outcomes of vitrectomy plus ILM peeling with and without ICG application in MH surgery were reviewed. A statistical meta-analysis was performed including studies which defined anatomical outcomes as closure of the MH and disappearance of the fluid cuff and functional outcomes as improvement of 2 or more Snellen lines. A secondary outcome was to investigate the incidence of retinal pigment epithelium (RPE) alterations with and without ICG staining in MH surgery. RESULTS: Results including all types of MHs in 837 eyes indicated the same anatomical success but worse functional outcomes in the group with ICG application (p = 0.0008; odds ratio = 0.587, 95% confidence interval = 0.427-0.808). A higher incidence of RPE alterations in the ICG injection group was observed. The incidence of RPE alterations was found to be 1.98%, whereas RPE changes were noted in 13.83% of 201 patients with ICG application (odds ratio = 7.998). CONCLUSION: This meta-analysis of previous reports comparing ILM peeling with and without intravitreal ICG application in the treatment of MHs demonstrated statistically worse functional outcomes when ICG was applied (p = 0.0008). A higher number of RPE alterations were observed in the ICG-stained group.
Abstract: PURPOSE: To describe transient structured visual hallucinations in a patient with vascular age-related macular degeneration (AMD), following an intravitreal Avastin-injection. DESIGN: Interventional case reports. METHODS: A fully alert 83-year-old woman with disciform scar right eye (OD) and occult choroidal neovascularization (CNV) left eye (OS) experienced a progressive visual loss to 20/800 OD and 20/400 OS. A coherent 84-year-old woman with occult CNV both eyes (OU) experienced decreased vision of 20/800 OU. After both patients gave informed consent, an uneventful intravitreal injection of 1.25 mg Avastin was performed in the left eyes. RESULTS: One day and three days after an uneventful intravitreal injection both patients experienced structured hallucinations including trees, faces, and water for approximately 15 to 30 minutes. CONCLUSIONS: We report a typical symptoms of Charles-Bonnet syndrome (CBS) in patients with severe AMD after intravitreal Avastin-injections. The reduced retinal edema and realignment of the photoreceptors may promote the release phenomenon and trigger hallucinatory episodes.
Abstract: PURPOSE: To investigate the efficacy of tunneled scleral incision compared with standard straight scleral incision to prevent vitreal reflux after intravitreal (IVT) injection. DESIGN: Prospective comparative controlled nonrandomized clinical study. METHODS: Eighty-eight eyes undergoing IVT-injection were allocated into four groups to compare the vitreal reflux after injection of 0.1 ml of triamcinolone acetonide (TA) and Avastin using a tunneled vs straight injection technique. The amount of intraoperative drug reflux was estimated by measuring the width of the subconjunctival bleb. RESULTS: The mean measured reflux of volume was statistically less with the tunneled scleral incision (1.13 mm standard deviation [SD] +/- 1.16 for TA; 1.13 mm SD +/- 1.39 for Avastin) than in eyes undergoing the straight scleral injection (3.00 mm SD +/- 1.77 for TA; 3.18 mm SD +/- 1.68 for Avastin) for both Avastin and TA IVT-injections groups (P < .001). CONCLUSIONS: The tunneled scleral incision promotes statistically significant less vitreal reflux for IVT drug injection.
Abstract: PURPOSE: To study retinal pigment epithelium (RPE) tears after off-label intravitreal bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA) injection for neovascular age-related macular degeneration. Eyes with a vascularized pigment epithelial detachment (PED) that developed an RPE tear were compared with eyes with a vascularized PED but without an RPE tear. METHODS: Nine retina specialists across the United States and in Europe participated in this retrospective case series. All eyes that received intravitreal bevacizumab injection for choroidal neovascularization (CNV) over 12 months (October 2005 to September 2006) were included. Eyes without all three confirmed tests (fluorescein angiography, fundus photography, and optical coherence tomography) were excluded from analysis. Statistical analyses were performed on multiple characteristics of eyes with a vascularized PED that did and did not develop an RPE tear. RESULTS: Among 2,785 intravitreal bevacizumab injections for 1,064 eyes, RPE tears were found in 22 eyes in 22 patients (2.2%). A vascularized PED was present in 21 of 22 eyes that developed an RPE tear (17.1% of PED eyes; 15, 100% occult CNV; 6, predominantly occult CNV). Mean interval from bevacizumab injections to RPE tears was 37.3 days. Mean follow-up time was 124.9 days. Mean subfoveal PED size was larger for eyes with tears than for those without tears (13.97 mm vs 9.9 mm, respectively; P = 0.01; odds ratio, 1.09). There was substantially smaller mean ratio of CNV size to PED size for eyes with tears than for those without tears (27.9% vs 67.6%, respectively; P = 0.005). Mean pre-bevacizumab injection best-corrected Snellen visual acuity was 20/162, and mean post-RPE tear best-corrected visual acuity was 20/160 (P = 0.48). CONCLUSION: Large PED size is a predictor for RPE tears, and a small ratio of CNV size to PED size (<50%) is more common in eyes with RPE tears. Vision may be preserved despite RPE tears.
Abstract: Ocular photodynamic therapy (PDT) was introduced as a novel treatment for neovascular forms of age-related macular degeneration and choroidal neovascularization (CNV) secondary to pathologic myopia in the mid/end 1990s. The current treatment recommendations are based on the results of two large, prospective, multicenter, randomized clinical trials (Treatment of Age-Related Macular Degeneration with Photodynamic Therapy and Verteporfin in Photodynamic Therapy Studies) and thousands of patients have been treated worldwide over the last years. Meanwhile, PDT has been performed in several other ocular pathologies with some remarkable results, however, with most reports being case reports and small case series without statistical significance. These extended applications include CNV secondary to choroiditis and retinochoroiditis, angioid streaks, central serous chorioretinopathy, retinal angiomatous proliferation, parafoveal telangiectasia or CNV associated with macular dystrophy and idiopathic CNV, as well as diseases without CNV, such as choroidal hemangioma, retinal hamartoma, choroidal melanoma, chronic central serous chorioretinopathy, angiomatous lesions secondary to systemic diseases, rubeosis iridis or neovascular glaucoma. To date, with the introduction of anti-VEGF therapy, the role of PDT will certainly change. However, it is reasonable to believe that it will maintain an important role in combination therapy due to its unique properties of selective vascular targeting. Therefore, it is essential for the ophthalmologist to be familiar with the extended applications and their modifications of treatment parameters. This review will summarize the standard and experimental applications of PDT based on our own results and the literature.
Abstract: PURPOSE: To investigate the histologic and clinical effects of subretinal injection of patent blue (PB) and trypan blue (TB) in rabbits. METHODS: Dutch-belted rabbits (n=8) were vitrectomized followed by subretinal injection of 2.4 mg/ml PB (285 mOsm) and 1.5 mg/ml TB (312 mOsm); balanced salt solution (BSS) (300 mOsm) served as the control. Animals were examined 6, 12, and 24 hr and 14 days after the procedure by fluorescein angiography (FA) and indirect ophthalmoscopy; for retinal toxicity, histologic evaluation studies were performed by light and transmission electron microscopy. RESULTS: FA examination demonstrated window defects suggestive of retinal pigment epithelium (RPE) atrophy in positions of subretinal TB injection, but this was not observed after subretinal injection of PB or BSS. Histologic evaluation disclosed only minimal abnormalities on the photoreceptor outer segment (POS) after subretinal injection of BSS during all follow-up. Subretinal injection of PB caused POS and photoreceptor inner segment (PIS) abnormalities 12 and 24 hr after surgery as well as outer nuclear layer (ONL) damage 14 days after surgery. Subretinal TB injection resulted in POS and PIS damage at 12 hr follow-up. The ONL damage was observed 24 hr after surgery; additionally, POS, PIS, ONL, and RPE abnormalities were observed 14 days after surgery after TB injection. CONCLUSIONS: Subretinal injection of TB induced more significant clinical and histologic damage of neurosensory retina/RPE than did PB or BSS. Future human studies are necessary to access the clinical relevance of these in vivo experiments.
Abstract: PURPOSE: To review current treatment approaches in diabetic macular edema (DME). METHODS: The underlying pathopathology, classifications and diagnostic examination techniques including fluorescein angiography, optical coherence tomography and stereoscopic biomicroscopy. Treatment modalities with focal or grid argon laser photocoagulation, pars plana vitrectomy with and without peeling of the inner limiting membrane (ILM), as well as intravitreal injections using triamcinolone acetonide or novel vascular endothelial growth factor (VEGF) inhibitors are described. RESULTS: DME results from a series of biochemical and cellular changes, causing progressive leakage and exudation. Focal and grid photocoagulation remains the standard care for diabetic maculopathy. However, the availability of new agents raises the possibility of improvements if significant benefits can be validated in randomized clinical trials. Posterior vitreous attachments play a critical role through several mechanical or physiological mechanisms. Vitrectomy without ILM removal seems to be effective in reducing the retinal thickness and improving visual acuity. CONCLUSION: A proper evaluation of the vitreous and retina is fundamental to select the most appropriate treatment approach in DME. While small microaneurysms with focal DME may be treated by conventional focal photocoagulation, diffuse DME which do not respond to grid photocoagulation may benefit from intravitreal injections using triamcinolone acetonide or novel VEGF inhibitors. Eyes with DME and additional vitreous traction may benefit from pars plana vitrectomy without ILM peeling. A combination of laser, pharmacological and surgical treatment modalities may be necessary to maintain central vision in eyes with DME.
Abstract: PURPOSE: Idiopathic thrombocytopenic purpura (ITP) is characterized by refractory thrombocytopenia, production of autoantibodies, and persistent predisposition to bleeding affecting virtually all mucocutaneous tissues and various organs. METHODS: A 50-year-old man with chronic ITP and diabetic maculopathy developed massive preretinal, intraretinal, and numerous subretinal hemorrhages accompanied by impaired vision to 20/400. His platelet count was 1100/microL, hemoglobin concentration was 4.6 mg/dL, however his blood clotting and activated partial thromboplastin time (APTT) maintained a normal 26 sec. RESULTS: After a splenectomy the patient was placed on high-dose oral corticosteroids (40 mg/day), immunoglobulin, and CellCept. The platelet count was restored to 25,000/microL within months. Four months later the unaffected retina received a panretinal photocoagulation and intravitreal triamcinolone injection (25 mg). Two years after the thrombolytic event the hemorrhages resolved completely and the patient's vision recovered to 20/100. CONCLUSIONS: Repetitive treatments with immunoglobulins and high-dose corticosteroids may increase the platelet count, inducing a complete resorption of the retinal hemorrhages and visual recovery during a long-term follow-up.
Abstract: BACKGROUND: Intravitreal injection of vascular endothelial growth factor inhibitors is safe as a standardized procedure. In a retrospective study, we examined the incidence of intraocular inflammation and endophthalmitis when intravitreal Avastin was given on both an outpatient and an inpatient basis. METHODS AND PATIENTS: Two centers treated a total of 1844 patients with intravitreal Avastin injection (IVA), 1.25 mg/0.05 ml. The medication was given under aseptic conditions with a sterile drape and lid speculum and after an incubation of 5% povidone-iodine for 60 s in the conjunctival fornix. Center A performed all applications as an outpatient procedure with no postoperative topical antibiotics. Center B performed all IVAs prior to a 1-day hospital admission and gave topical antibiotics for 3 days. In both centers the patients were told to return to the hospital immediately if visual disturbance, pain, or redness of the eyes was noticed. RESULTS: Center A did 984 IVAs. Postoperatively no patients had endophthalmitis. On the 2nd postoperative day, two patients developed a mild intraocular uveitis, which was treated with local steroid ointments. Center B did 860 IVAs. Five days after discharge from the hospital, two patients presented with endophthalmitis and underwent vitrectomy when their vision dropped to counting fingers. There was no positive microbiological result of either vitreous probe. CONCLUSIONS: Although equal treatment guidelines were established, the perioperative hospital admission and postoperative application of topical antibiotic ointment could not reduce the occurrence of mild to severe intraocular endophthalmitis.
Abstract: Diabetic macular edema (DME) is the most frequent cause of severe vision impairment in patients with non-proliferative diabetic retinopathy. Even though patients should achieve optimal glycemic control, normalization of blood pressure and serum lipids, as well as improvement of cardiac and renal status, these measures alone will not prevent every patient from developing visual loss caused by DME. The goal of local treatment for DME is vision improvement, usually achieved after reducing leakage on fluorescein angiography (FA) and retinal thickness on optical coherence tomography (OCT). Laser photocoagulation is still the standard treatment for clinically significant DME. However, laser photocoagulation rarely provides major visual improvement, especially in patients with diffuse DME. Thus, a therapeutic intervention that restores visual acuity impaired by DME more often remains a significant unmet medical need. This review aims to present the most important emerging drug technologies for therapy of DME at present, including corticosteroids, vascular endothelial growth factor inhibitors, protein kinase C inhibitors, small interfering RNA, hydroxy-3-methyl-glutaryl coenzyme A reductase inhibitors and non-hormonal anti-inflammatory agents. Recent progress in this field suggests that local management of DME may change rapidly in the near future. Novel emerging drugs should enable better anatomical and functional outcomes for therapy of this sight-threatening disease.
Abstract: PURPOSE: To determine the vascular morphology of racemose haemangioma and related functional alterations in arteriovenous (AV) malformation type 3. METHODS: A 17-year-old patient with unilateral racemose haemangioma received a full ophthalmic examination including Snellen visual acuity (VA) and Goldmann visual field. The central vision was investigated by scanning laser ophthalmoscope (SLO) and multifocal electroretinogram (mfERG). The ocular haemodynamics were examined by fluorescence angiography and Doppler ultrasound. The tomographic contour of the vascular architecture was visualized using B-scan ultrasound, Stratus optical coherence tomography (OCT) and three-dimensional Heidelberg retina tomograph (3D-HRT II). RESULTS: The VA of the patient's right eye was reduced to 20/400 and her visual field was constricted concentrically. Microperimetry revealed a small central field with good central fixation. The mfERG demonstrated reduced amplitudes of the central retina. On fluorescein angiography, there was a fast filling of the retinal branches related to the racemose vessels. Doppler ultrasound confirmed a significantly changed haemodynamic flow in the racemose vessels. Ultrasound, OCT and HRT demonstrated a prominent optic nerve head. CONCLUSION: The racemose haemangioma led to a marked visual field defect. Racemose haemangiomas are associated with severe changes in the haemodynamics of the retinal vasculature.
Abstract: BACKGROUND: The treatment of therapy-resistant secondary glaucoma with cyclodestructive approaches may give rise to unsatisfactory intraocular pressure results, leading to phthisis. A final option may be the implantation of an external glaucoma drainage system (GDS). A consecutive positioning of the drainage system under the conjunctiva and implantation of the drainage tube into the anterior chamber, may result in an uncontrolled reduced of intraocular pressure leading to intraocular haemorrhages into the anterior chamber or vitreous cavity. In particular, expulsive haemorrhages are feared as deleterious complication. PATIENTS AND METHODS: 15 patients (15 eyes) with secondary glaucoma received a GDS. All patients were previously unsuccessfully treated by numerous approaches (mean 2.7 times). The mean preoperative intraocular pressure was 37 mmHg (range: 22 to 55 mmHg). We performed a sequential approach: during the first operation we implanted and fixed the resorption site of a Molteno GDS onto the sclera close to the equator in the superotemporal quadrant. After an inflammation-free interval of 2 - 3 weeks we placed the drainage tube into the anterior chamber. The average postoperative follow-up period was 20.5 months (range: 3 to 62 months). RESULTS: The implantation of the GDS using a sequential approach was well tolerated by all patients. While 14 out of 15 eyes achieved an IOP of 15 mmHg (range: 12 to 18 mmHg), 2 of them still required additional topical glaucoma treatment. An unsatisfactory IOP regulation was observed in only one eye although a revision surgery was performed postoperatively. Four eyes developed a light anterior chamber haemorrhage that resorbed without serious complications within 3 weeks. A choroidal effusion in one eye was treated by an anterior chamber injection of a viscoelastic gel. CONCLUSION: The potential disadvantage of the GDS can be almost completely avoided using a sequential approach. The implant heals well in the subtenon space during the first postoperative week, thus preventing an overfiltration of anterior chamber fluid. Our positive results show that the GDS is an important treatment option in selected patients.
Abstract: PURPOSE: Indocyanine green (ICG) dye was shown to improve the visualization of preretinal tissues during chromovitrectomy. However, controversy arose regarding the safety of intravitreal ICG application, because worse functional outcomes and a higher incidence of retinal pigment epithelium (RPE) changes and visual field defects were reported. The mechanisms of ICG-related toxicity and their relevance for chromovitrectomy are reviewed. METHODS: A literature search was performed from 1998 through 2005 for relevant information related to the mechanisms of intravitreal ICG toxicity. Animal and clinical data on intravitreal ICG-related toxicity were collected to clarify the mechanisms of the risk of intravitreal ICG injection. RESULTS: Over 80 controversial in vitro, ex vivo, and in vivo animal investigations as well as clinical reports on intravitreal ICG staining were found in the literature. The main postulated mechanisms of intravitreal ICG-related toxicity were as follows: biochemical direct injury to the ganglion cells/neuroretinal cells, RPE cells, and superficial retinal vessels; apoptosis and gene expression alterations to either RPE cells or neuroretinal cells; osmolarity effect of ICG solution on the vitreoretinal interface; light-induced injury; and mechanical cleavage effect to the internal limiting membrane/inner retina. Whereas the exact mechanism of intravitreal ICG-related damage remains yet to be determined, most animal experiments proposed that ICG dye has a dose-dependent toxic effect on retinal tissue. This hypothesis was supported by clinical data, because better functional outcomes were obtained when low dye concentrations and short incubation times were reported. CONCLUSIONS: Much evidence supports that ICG dye has a dose-dependent toxic effect on the retina. Therefore, the following recommendations to minimize toxic effects on the retina are proposed: dye injection in concentrations as low as possible; avoidance of repeated ICG injections onto bare retina; dye injection far from the macular hole to prevent direct dye contact with the RPE; short incubation time of ICG in the vitreous cavity to diminish the concentration in contact with the retinal tissue; and the light pipe kept far from the retina throughout the whole surgical procedure.
Abstract: Photodynamic therapy (PDT) has become a well-established treatment for vascular forms of age-related macular degeneration (AMD). The implementation of evidence-based medicine principles into the treatment regimen of AMD seems to be immensly important, since AMD continues to be the most frequent cause of blindness among patients older than 65 years in industrialized countries. Numerous randomized prospective studies demonstrated high levels of evidence for the efficacy of various treatment approaches such as laser photocoagulation, PDT, subretinal surgery or novel anti-angiogenic drugs [Arch Ophthalmol 2006;124:597-599]. The high evidence shown by these studies supported the rationale to use PDT also in additional, less frequent, vasoproliferative diseases. Although these 'case series' and 'individual case control studies' have a low level of evidence, they give us important information for treatment decisions in these rare conditions. The goal of this survey is to review the current literature regarding PDT in vasoproliferative and exudative ocular diseases outside AMD. Many studies modified the treatment parameters of PDT to address the specific pathology of the underlying disease. Table 1 summarizes the diseases and treatment parameters that are described in this part 2, the entire table of this review is included in part 1 (www.karger.com/doi/10.1159/ 000101922).
Abstract: BACKGROUND: More than 50% of vitrectomies are performed in pseudophakic eyes. There is free communication between the anterior segment of the eye and the vitreous cavity through the zonular fibres of the lens. This means it is possible to use a primary anterior chamber infusion for pars-plana vitrectomy. METHODS: For some years, therefore, we have used an anterior chamber approach for the infusion cannula when carrying out such simple vitreo-retinal procedures as silicone oil removal or macular pucker peeling in pseudophakic eyes. RESULTS: In all eyes the anterior chamber access was placed via a corneal paracenthesis and during all vitrectomies it was held in place by corneal tissue tone with no need for suturing. Secure wound closure was also achieved without suturing by simply swelling the paracentesis. Conventional sclerotomies were closed with absorbable sutures. During vitrectomy the infusional flow was sufficient to ensure adequate intraocular pressure regardless of intraocular lens type and diameter. CONCLUSIONS: In pseudophakic eyes the anterior chamber infusion approach by way of a paracentesis is a safe way of reducing surgical trauma during vitrectomy. It must, however, be borne in mind that when an endotamponade is applied it is necessary to switch the infusion to one of the sclerotomies.
Abstract: PURPOSE OF REVIEW: The aim of this article is to present the current state-of-the-art in regard to the application of vital dyes during vitreoretinal surgery, 'chromovitrectomy', as well as to overview the current literature regarding the properties of dyes, techniques of application, indications, and complications in chromovitrectomy. RECENT FINDINGS: A large body of published research has recently addressed the toxicity profile of indocyanine green for chromovitrectomy. Experimental data demonstrate dose-dependent toxicity of indocyanine green to various retinal cells. Newer generation vital dyes for chromovitrectomy include trypan blue, patent blue, triamcinolone acetonide, infracyanine green, sodium fluorescein, bromophenol blue, fluorometholone acetate and brilliant blue. Novel instruments may enable a selective painting of preretinal tissues during chromovitrectomy. SUMMARY: This review suggests that the field of chromovitrectomy represents an expanding area of research. The first line agents for internal limiting membrane staining in chromovitrectomy are indocyanine green, infracyanine green, and brilliant blue. Patent blue, bromophenol blue and trypan blue arose as outstanding biostains for visualization of epiretinal membranes. Novel dyes available for chromovitrectomy deserve further investigation.
Abstract: BACKGROUND: Retinal hamartoma is a common finding in tuberous sclerosis, but the symptomatic changes of this lesion have rarely been described. This evidence-based review evaluated the incidence of symptomatic retinal hamartoma and compared possible treatment modalities. METHODS: We carried out a review of the literature using MEDLINE. Older publications not listed in MEDLINE were obtained from the reference list of currently published papers. RESULTS: Three observational case series with a follow-up of up to 34 years included 93 patients and reported progression from a flat to a more elevated lesion without visual symptoms in nine patients (9.7%). Additional symptomatic changes were described in 11 case reports published over a period of three decades. The symptomatic alterations were caused by an enlarged tumour with leakage, macular oedema, accumulating lipoid exudates, serous retinal detachment (n = 8/11) and vitreous haemorrhage (n = 4/11). Most symptomatic cases involved a retinal hamartoma type 1 (n = 6/8). Spontaneous resolution of symptomatic exudative hamartomas occurred in three patients within 4 weeks, although a delayed resorption of subretinal fluid caused permanent visual impairment in one patient. Investigational reports described a slow resorption of subretinal fluid after argon laser photocoagulation (n = 2), although recurrent laser applications induced choroidal neovascularization and destruction of the neurosensory retina (n = 1). A vitrectomy was used to remove a vitreous haemorrhage in another reported patient. In one case, complete resorption of subretinal fluid and an increase in visual acuity was observed within 2 weeks after a single treatment with photodynamic therapy (PDT). No complications were noted during a follow-up of 4 years. CONCLUSIONS: Symptomatic changes are very rare in retinal hamartomas secondary to tuberous sclerosis. Spontaneous resolution of subretinal fluid may occur within 4 weeks. If a macular oedema with increasing lipoid exudates persists over a period of 6 weeks, treatment should be considered. Although previous reports demonstrated possible visual stabilization after argon laser photocoagulation, vision-threatening complications can occur. Current treatment strategies may include PDT based on favourable anatomical and functional results.
Abstract: BACKGROUND: The causes of recurrent choroidal neovascularisation (CNV) after photodynamic therapy (PDT) remain controversial. Subretinal surgery was carried out after unsuccessful PDT. AIMS: To determine intraoperatively the status of the posterior vitreous interface. DESIGN: Interventional case series. METHODS: Conventional three-port vitrectomy was carried out in 10 eyes with CNV that had undergone 1-4 PDT sessions. The vitreous cutter was held close to the edge of the optic nerve to evaluate the status of the posterior vitreous. RESULTS: Lesion size showed an increase from 1.5 (standard deviation (SD) 0.53) to 2.3 (SD 0.83) macular photocoagulation study disc diameters, between the first and the last PDT. Intraoperative findings during vitrectomy showed little liquefaction of the vitreous gel and an incomplete posterior-vitreous detachment, with remarkably firm attachments at the macula in all cases (10/10). CONCLUSION: We determined an abnormally high incidence of vitreous attachments in eyes with recurrent CNV. Vitreomacular attachments may trigger the progression or recurrence of CNV.
Abstract: INTRODUCTION: To determine the anatomical location and functional impairment in acute Purtscher's retinopathy (PR). MATERIAL AND METHODS: A 15-year-old boy with acute PR was examined with optical coherence tomography (OCT) and microperimetry (MP). RESULTS: His initial best corrected visual acuity was 20/30 OD and 20/80 OS, the MP demonstrated absolute scotomas in the central and peripapillary area of the cotton-wool spots. On the OCT, there was a hyporeflective area in the inner aspect of the retina, corresponding to white patches on funduscopy. After he had been treated with oral prednisolone 100 mg, his visual acuity improved to 20/20 OU within 4 weeks and there were no scotomas on the MP. The central retinal architecture returned to normal with no sub- or intraretinal fluid. DISCUSSION: Cotton-wool spots in PR represent infarctions of the retinal nerve fiber layer. Deeper layers of the retina may also be involved, causing a breakdown of the inner blood-retina barrier with temporary intra- and subretinal edema.
Abstract: Age-related macular degeneration (ARMD) remains a leading cause of blindness in the western world. Several clinical forms of the disease are recognized, whereas choroidal neovascularization (CNV) represents an important manifestation suitable for treatment. The treatment of CNV has been a major focus of research in the past decades, and the first evidence-based established therapy was laser photocoagulation, which reduces the risk of visual loss in extrafoveal lesions. In the late 90's photodynamic therapy has been established as an efficient method for the treatment of predominantly classic and occult CNV. Additional therapies such as macular translocation, submacular surgery, and indocyanine-mediated prothrombosis are currently under investigation in large-scale clinical trials. Molecular biology has recently provided a better comprehension of the pathogenesis of ARMD, and vascular endothelial growth factor (VEGF) was recognized as key mediator in the angiogenesis of CNV-formation. Therefore, the pharmacological approach rose as a key research area to treat CNV. The first FDA-approved agent for CNV-therapy is aptamer pegaptanib sodium (Macugen), which inactivates the key angiogenic isoform VEGF165. Additional VEGF-blockers such as ranibizumab RhuFab V2 (Lucentis) and bevacizumab (Avastin) are under evaluation in major clinical studies. Impressive results of intravitreal bevacizumab were released recently. Moreover, the steroid-derived anecortave acetate as well as the corticosteroid triamcinolone acetate have been proposed as methods for treatment of wet-ARMD. This paper presents the rationale and principles of the pharmacologic antiangiogenic therapy for CNV in ARMD.
Abstract: PURPOSE: To determine a novel vital dye (patent blue; Blueron) for vitreoretinal surgery in a prospective consecutive case series. METHODS: Five patients with either idiopathic epiretinal membrane (ERM; n = 2), proliferative vitreoretinopathy (n = 2), or a macular hole (n = 1) underwent a three-port pars plana vitrectomy. Patent blue assisted staining of the retinal surface followed by a consecutive peeling of the ERM (n = 4) or of the internal limiting membrane (ILM; n = 1) was performed. The main outcome measures were quality of intraoperative visualization of preretinal structures and postoperative visual acuity. RESULTS: The dye induced a moderate staining (++) of the ERM and a mild staining (+) of the ILM. Complete ERM and ILM removal was successfully achieved in all cases. A mean visual improvement of three Snellen lines was observed 6 months postoperatively. No visual field defects or visible retinal pigment epithelial changes were present 6 months postoperatively. CONCLUSION: Patent blue, a novel dye for intraocular applications, may be added as an alternative dye in chromovitrectomy.
Abstract: BACKGROUND: The use of vital dyes in "chromovitrectomy" allows the easier removal of less recognizable structures like epiretinal membranes (EM) or the inner limiting membrane (ILM). In recent years numerous studies demonstrated the use of indocyanine green (ICG), trypan blue (TB) and patent blue (PB) for this indication. Reports of the possible risk of these dyes, i. e. especially ICG, in respect of reduced visual acuity results, possible visual field defects or alterations of the retinal pigment epithelium (RPE) resulted in limitations in their application. MATERIAL AND METHODS: Human RPE cells and choroidal endothelial cells were cultured in monolayers on semipermeable membranes representing an in vitro model of the outer blood-retinal barrier. By measurement of the transepithelial electrical resistance (TER) the stable barrier function was determined. Two different models representing an air-filled and a fluid-filled eye were tested on the one hand by addition of the dye to the culture medium and, on the other, by direct application on the cell monolayer. In these two models ICG (5 mg/ml, 0.5 mg/ml, 0.125 mg/ml), TB (1.5 mg/ml, 0.15 mg/ml) and PB (2.4 mg/ml, 0.24 mg/ml) were applied for three minutes and the influence on the barrier function was determined. RPE cell growth was also tested in these two models after the application of ICG, TB and PB. Finally, monolayers of RPE cells were evaluated by transmission electron microscopy (TEM). RESULTS: After application of TB, PB and the lowest concentration of ICG of 0.125 mg/ml, the TER remained stable in both models. In contrast, ICG in a concentration of 5 mg/ml and 0.5 mg/ml caused a significant TER decrease in the model of the air-filled eye, whereas no influence on the function of the outer blood-retinal barrier was noted in the model of the fluid-filled eye. RPE cell growth rates were not influenced by the addition of the vital dyes, with the exception of ICG in a concentration of 5 mg/ml in the model of the air-filled eye, resulting in a temporary reduction of the cell count. In good correspondence to these results also in TEM intercellular blisters were noted after application of 5 mg/mL ICG for 3 minutes in the model of the air-filled eye. However, damage to the RPE cells themselves was not obvious. No pathological changes in the TEM were noted after application of TB and PB. CONCLUSIONS: The use of PB and TB at the posterior eye segment seems to be safe concerning damage to the PRE and its barrier function. In contrast, ICG in higher concentrations and with longer application times may cause a toxic effect on RPE morphology and function.
Abstract: BACKGROUND: Photodynamic therapy (PDT) is a well established clinical treatment for age-related macular degeneration (AMD), and comprises intravenous injection of verteporfin and subsequent application of a non-thermal laser beam to the area of AMD to induce selective vascular occlusion. Since there is evidence that PDT may cause outer blood-retinal barrier (BRB) breakdown and possibly RPE cell alteration, we investigated the effect of PDT on the BRB function of the RPE in an in vitro model. METHODS: Twenty-one monolayers of human RPE cells were cultured on semipermeable membranes until a stable barrier function was achieved as determined by transepithelial electrical resistance (TER) and sodium fluorescein permeability. To test the effect of PDT on the outer BRB function, non-thermal laser (692 nm), verteporfin or a combination of both were applied. TER assessment prior to and after PDT was utilized to identify changes in barrier function of the RPE in this in vitro model. Finally, monolayers of RPE cells were evaluated by transmission electron microscopy (TEM). RESULTS: No significant TER decrease was observed after application of non-thermal laser alone or after administration of verteporfin in therapeutic concentrations, but combination of these modalities resulted in significantly decreased TER within 4 h. Except for intercellular blisters, no damage to the RPE was evident in TEM. Verteporfin added at concentrations higher than therapeutic doses (2 mg/ml) resulted in an immediate decrease in TER and damage to the RPE cells. CONCLUSION: The combination of a therapeutic concentration of verteporfin and application of non-thermal laser resulted in a morphologically and functionally detectable breakdown of the outer BRB function of the RPE without any damage to the RPE cells themselves in vitro. However, increasing the concentration of verteporfin can result in RPE cell damage.
Abstract: PURPOSE: The primary goal of this study was to investigate the functional results after scleral buckling (SB) surgery in macula-off rhegmatogenous retinal detachment (RRD), with more or less than 7 days' duration of macular detachment (DMD). The secondary outcome measure was to determine the long-term functional results in these two groups 5 years after SB surgery. METHODS: The retrospective studies included 96 eyes of 96 patients with primary, uncomplicated, macula-off RRD. Two studies, one with a short-term follow-up and one with a long-term follow-up, were performed, and in both studies the eyes were divided into two groups according to the DMD. In study I, 96 patients were divided into DMD <or=7 days (n = 73) and prolonged DMD more than 7 days (n = 23) with a postoperative follow-up of at least 3 months (mean 43.5 months). In a subgroup analysis, patients were divided into acute DMD <or=3 days (n = 37) and subacute DMD >or=4 days and <or=7 days (n = 36). Study II included 47 patients with a follow-up of at least 5 years (mean 6 years). All patients were divided into(subacute) DMD <or=7 days (n = 36) and (prolonged) DMD of >7 days (n = 11). Additional preoperative predictive factors including DMD, preoperative visual acuity (VA) and patients' age at the time of the RRD were correlated with the postoperative VA. RESULTS: In study I, the mean final VA was significantly better (0.45) after a DMD of less than or equal to 7 days, compared to patients with a DMD of more than 7 days (0.22; Student's t test, p = 0.02). VA >or=0.4 was achieved in 68% with a subacute DMD compared to 52% in patients with prolonged DMD (chi(2) test, p < 0.001). However, the postoperative VA (0.48 +/- 0.09) in eyes with DMD of 1-3 days was similar (0.42 +/- 0.07) to eyes with DMD of 4-7 days (Student's t test, p = 0.455). We divided the 96 patients into 2 groups according to a preoperative VA. Eyes with a preoperative VA <or=0.1 (n = 62) had a significantly lower final VA compared to eyes with a preoperative VA >0.1 (n = 34; Student's t test, p < 0.001). Patients 75 years of age or younger were more likely to achieve a VA of 0.4 or better after SB surgery than older patients (more than 75 years; chi(2) test, p = 0.008). In study II, VA improved (by a mean of 1.60 +/- 0.02 lines) during the follow-up period from 0.32 +/- 0.08 at the 3-month follow-up to 0.46 +/- 0.10 at the 5-year follow-up. Eyes with a subacute DMD had a significantly better VA than eyes with a prolonged DMD (Student's t test, p = 0.004). Patients aged 75 years or less were more likely to achieve a VA of 0.4 or better than patients older than 75 (chi(2) test, p = 0.003). CONCLUSION: The time point of SB surgery has no statistical impact on the final visual recovery in patients with an acute primary macular-off RRD of less than or equal to 7 days. A delay of SB surgery within this time frame does not contribute to an impaired final visual outcome. There was no evidence, that primary macula-off RRDs are emergencies, which cannot wait for a systemic evaluation of the RRD and surgical treatment at the next available scheduled day. A preoperative VA of more than 0.1 and patients' age under 60 years at presentation had an additional prognostic value on the final outcome. Surgeons should be aware that visual function after reattachment may continue to improve over a long period. This study provides useful guidelines for the clinical management of macula-off RRD and the assessment of potential visual recovery in patients after successful SB surgery.
Abstract: OBJECTIVE: To investigate image preferences after photodynamic therapy (PDT). DESIGN: Prospective, cross-sectional study. METHODS: Seventeen patients with neovascular age-related macular degeneration were tested by color vision, contrast sensitivity, and near visual acuity (VA) with positive images and negative images before, 1 week after, and 3 months after PDT. RESULTS: Before PDT, 13 patients (76%) preferred positive images; the difference was not significant (P < .04). One week after PDT, 16 patients (94%) preferred negative images. The average near VA improved to 27 letters on positive images and to 32 letters on negative images (P < .00001). Three months after PDT, near VA declined to 19 letters on positive images and to 26 letters on negative images (P < .000001). Color vision and contrast sensitivity remained constant during all examinations. CONCLUSION: Although PDT may not alter the neurosensory retina, it may affect intraretinal function by changing image preference.
Abstract: PURPOSE: To describe photodynamic therapy (PDT) and additional indocyanine green (ICG) guided feeder vessel photocoagulation as a treatment of choroidal neovascularization (CNV) secondary to choroidal rupture in case of blunt head trauma. DESIGN: Interventional case report. METHODS: A 61-year-old woman developed subfoveal CNV originating from a choroid tear 8 years after blunt head trauma. Four sessions of PDT were applied and an additional two consecutive sessions of selective ICG-guided feeder vessel photocoagulation conducted. RESULTS: Transient reduction of leakage and closure of feeder vessels could not prevent further growth of the CNV. CONCLUSIONS: PDT reduced leakage temporarily and additional ICG-guided feeder vessel photocoagulation closed treated feeder vessel and CNV. New feeder vessel formation and growth of CNV in case of traumatic choroid rupture could not be treated effectively by these two laser treatment modalities to prevent severe deterioration of visual acuity.
Abstract: Age-related cataract (ARC) is the leading cause of blindness in the world, particularly in developing countries. In contrast, cataract surgery has become the most frequent surgical procedure in people aged 65 years or older in the Western world, causing a considerable financial burden to the health care system. The development of cataracts is mainly an age-related phenomenon, although socioeconomic and lifestyle factors appear to influence their development, e.g. smoking has been found to directly influence ARC. A key role in the pathomechanism of the crystalline lens alteration is played by glucose metabolism and associated effected redox potential, which may induce oxidative damages. Aldose reductase blockers were able to prevent the development of diabetic cataracts in experimental studies, however clinical trials were interrupted due to unclear side effects. Other drugs with radical scavenging properties were effective in in vitro and in vivo experiments, but could not be proven to be efficient and safe in preclinical human trials. A number of epidemiological studies showed an increased risk of nuclear or cortical cataract in people with low blood levels of vitamin E. It is also known that the measured levels of ascorbic acid decline with increasing age in the lens. Beta-Carotin and other non-polar carotenoids seem to be missing and may therefore only play a minor role. Polarized carotenoid lutein and zeaxanthin are available in low concentrations and may therefore have some direct effects. The results of the present interventional studies are still controversial. While the Linxian studies indicated that the prevalence for nuclear cataract was reduced by the supplementation with retinol/zinc or vitamin C/molybdenum, the AREDS trial showed no effect of the antioxidant formulation on the development or progression of ARC. Again, while the REACT study demonstrated a statistically significant positive treatment effect 2 years after treatment for the US patients and for both subgroups (US & UK) after 3 years, no effect was observed in UK patients alone. In another US study, the Physician Health Study, no positive or negative effect of Beta-carotin was observed. Taken together, these studies suggest that any effect of antioxidants on cataract development is likely to be very small and probably is of no clinical or public health significance, thus removing a major rationale for 'anticataract' vitamin supplementation among health-conscious individuals.
Abstract: BACKGROUND: After photodynamic therapy (PDT) some patients complain about a transient decrease of visual acuity during the first postoperative week. PATIENTS AND METHODS: Prior to and at 2 days and 1 week after PDT the following parameters were measured: (1) best corrected visual acuity (VA), (2) changes in refraction, and (3) A scan ultrasound biometry was carried out. Linear and 3-D optical coherence tomography was performed in three cases. A total of 53 PDT treatments were followed-up in 24 patients. RESULTS: Comparison of the pre- and postoperative refraction demonstrated a mean hyperopic shift of +0.35 diopters (dpt) in 43% of treatments (23/53) on the second postoperative day. The hyperopic shift reduced to +0.07 dpt after 1 week. The best corrected VA remained stable or was even better in 68% (36/53) on the second postoperative day. A decrease in VA could be noticed in 32% (17/53) at this time which declined to 23% (12/53) after 1 week. Measurement of the cornea-retina distance using A-scan ultrasound biometry disclosed a mean axial reduction of 0,13 mm at the second postoperative day. This correlates closely with an average hyperopic shift of 0,35 dpt. OCT examination disclosed a transient macular edema in the treated retinal areas. CONCLUSIONS: A transient hyperopic shift can be measured in 43% on the second postoperative day. The subjective decrease in visual acuity measured over the postoperative days was mainly due to a transient hyperopic shift in our patients. OCT findings disclosed a transient macular edema of the retina treated with PDT, which may relate to a hyperopic shift.
Abstract: The purpose of this study was to determine the shear compliance of human crystalline lenses as a function of age and frequency. Dynamic mechanical analysis was performed on 39 human lenses, ranging in age from 18 to 90 years, within the frequency range of 0.001-30 Hz. The lenses were stored at -70 degrees C before being measured. The influence of freezing on the mechanical properties was determined using pairs of porcine lenses, with one lens measured directly after enucleation and the other after freezing. The measurement method had a repeatability standard deviation of 4 and 6% for the storage and loss compliance, respectively. The reproducibility standard deviation was 31 and 33% for the storage and loss compliance respectively. On average, freezing increased the storage compliance by 8% and increased the loss compliance by 32%, both depending slightly on age and frequency. The human lenses exhibited a distinct viscoelastic behavior. The storage and loss compliance depended strongly on age and decreased a factor 1000 over a lifetime. Dynamic mechanical analysis has proven to be a successful technique for characterizing the mechanical properties of the human crystalline lens. The shear compliance decreases exponentially with age.
Abstract: CASE REPORT: A 68-year-old patient complained of decreased visual acuity (VA) two days after photodynamic therapy (PDT) had been performed. VA decreased from the pre-operative value of 0.4 to 0.1 on the second postoperative day. With additional + 1.75 diopters, VA was 0.32. Optical coherence tomography (OCT) disclosed a subneuroretinal fluid accumulation causing a serous retinal detachment 600 microm in height. One week postoperatively, neither decreased vision nor retinal elevation were noted. DISCUSSION: The temporary subjective decreased VA could be predominantly reduced by adequate refraction. OCT and VA measurements excluded ischemia of the neuroretina or the choroid as a causative factor.
Abstract: AIMS: To present patients with branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO) after application of rofecoxib (Vioxx), a cyclo-oxygenase (COX) 2 inhibitor. METHODS: Three patients with sudden decrease in their vision were referred for evaluation and possible treatment. RESULTS: A 72-year-old female with rheumatoid arthritis was treated with rofecoxib. When the dosage was doubled to 50 mg daily, she noticed a sudden painless decrease of vision in her right eye. Her visual acuity (VA) was 20/400 OD and 20/20 OS. Biomicroscopy OD demonstrated a CRVO with tortuous retinal veins and numerous flecked hemorrhages in the midperiphery. A 68-year-old female with severe osteoporosis developed a BRVO with flame-shaped hemorrhages in the superior hemisphere OS 1 day after taking rofecoxib (25 mg) daily. A 47-year-old American male took Vioxx for 1 week to relieve hip pain and noticed temporarily decreased vision OD. A month later, he resumed taking Vioxx and noticed a progressive decline in his VA with persistent cloudiness. Ophthalmic examination revealed a CRVO in his right eye. CONCLUSION: Although COX-2 inhibitors are safe in the majority of patients, under certain conditions they may induce prothrombotic effects. Few patients with predisposed thrombosis may be at risk for cardiovascular and ocular thrombotic events.
Abstract: Surgical management of macular holes consists of pars plana vitrectomy, removal of the posterior hyaloid facia, and peeling of the epiretinal membranes (ERM). Additionally, removal of the internal limiting membrane (ILM) may enable an increase in the anatomic and functional success rates. However, recognition of fine ILM is difficult thus increasing the time that the macula is exposed to intraoperative light. Staining the ILM with indocyanine green (ICG) dye during vitrectomy facilitates recognition of the ILM and assures that all adjacent ERM are removed. Therefore, ICG-assisted ILM peeling has gained worldwide popularity among vitreoretinal surgeons. However, there are some concerns about the intravitreal ICG application. Reports in the literature described a variety of application techniques using different concentrations. The postoperative outcomes were controversial reporting heterogeneous anatomical and functional outcomes after ICG application, as well as descriptions of adverse effects related to the dye. We discuss the indications, techniques, surgical results, and complications after intravitreal ICG injection for the treatment of macular holes.
Abstract: PURPOSE: To quantify transient serous retinal detachment in classic and occult choroidal neovascularization (CNV) after photodynamic therapy (PDT). DESIGN: Prospective consecutive case series. METHODS: Consecutive patients with classic and occult CNV were examined by optical coherence tomography before PDT and at 2 and 7 days after PDT. RESULTS: In classic CNV (n = 6), retinal elevations increased from 217 (SD 42) microm before PDT to 626 (SD 157) microm 2 days after PDT and decreased to 240 (SD 36) microm 7 days after treatment. In occult CNV (n = 4), the mean retinal elevation of 266 (SD 41) microm before PDT increased to 544 (SD 94) microm 2 days after PDT and decreased to 259 (SD 40) microm 7 days after treatment. CONCLUSION: Cross-sectional optical coherence tomography imaging revealed transient subretinal fluid accumulation in classic as well as in occult CNV after PDT. The subretinal location possibly relates to an outer blood-retinal barrier breakdown after PDT.
Abstract: PURPOSE: To determine whether sectorial-oriented grouped pigmentations of the retina follow developmental patterns of pigmentary mosaicism. DESIGN: Systematic literature review. PARTICIPANTS: Fundus images from patients with grouped congenital hypertrophy of the retinal pigment epithelium (CHRPE). METHODS: An extensive Internet and library search was performed to obtain articles dealing with grouped CHRPE. Each article was carefully screened for fundus images and inclusion criteria. Fundus images of sufficient quality were scanned, digitized, and matched in size using Adobe Photo Shop to compare the pattern location and extension of the pigmented lesion. These obtained patterns of grouped CHRPE were than mapped and superimposed. RESULTS: Forty-five images were retrieved from 32 articles with grouped CHRPE. The lesions extended from the margin of the optic disc and radiated in sectors to the fundus periphery. The stream of growth did not follow the pattern of the retinal nerve fiber layer, because the clusters of pigmented cells crossed the midline raphe not sparing the macular area. Smaller lesion clusters were mainly located near the optic disc, whereas larger lesions were found in the periphery. CONCLUSIONS: The growth pattern of grouped CHRPE is similar to cutaneous sectorial pigmentations. We speculate that pigmentary mosaicisms may be a modified wild-type allele in a somatic cell clone during early embryogenesis following developmental lines analogous to the cutaneous lines of Blaschko. The sectorial pigmentations on the ocular fundus may reflect the stream, outgrowth, and migration of retinal pigment epithelium cells during embryogenesis.
Abstract: PURPOSE: To evaluate benefits and side effects of bandage soft contact lens (BSCL) insertion after LASIK in relation to patients' characteristics. DESIGN: Prospective, randomized, bicenter comparative investigational trial. PARTICIPANTS: One hundred patients (200 eyes) with myopia and/or myopic astigmatism. METHODS: Each patient underwent consecutive (Marburg, Germany) or simultaneous (Mainz, Germany) bilateral LASIK. At the end of the procedure, the first treated eye received a drop of ofloxacin and dexamethasone, patch, and transparent protective shield for 2 to 4 hours. The fellow eye received in addition a BSCL, soaked in the same eyedrops for 20 to 24 hours. MAIN OUTCOME MEASURES: Schirmer II test results, first-day uncorrected visual acuity (UCVA), and tolerance of contact lens wear (poor, moderate, good) were recorded. Patients' subjective preference for the BSCL on the first postoperative day was graded as more comfortable than fellow eye, no difference, or less comfortable. Three months after surgery, the corneal flap was photographed in retroillumination for objective evaluation of microstriae. Statistical significance was determined using the Kruskal-Wallis 1-way analysis of variance on ranks test. RESULTS: Fifty-four percent of patients felt discomfort in the eye that had the BSCL (contra-BSCL subgroup), whereas 27% enjoyed having a BSCL (pro-BSCL subgroup). The remaining 19% felt no difference. The average Schirmer II value was 16.6 mm (+/-7.7) in the pro-BSCL subgroup, 14.9 mm (+/-6.4) in the no difference subgroup, and 12.3 mm (+/-7.7) in the contra-BSCL subgroup. There was a female preponderance in the contra-BSCL (39:15) and no difference (15:6) subgroups. A preoperative history of poor contact lens tolerance was recorded in 50% of the contra-BSCL subgroup patients; 41%, no difference; and 33%, pro-BSCL. Postoperative parameters such as first-day UCVA, number of eyes with microstriae, folds requiring stretching, or cases of diffuse lamellar keratitis did not differ significantly. Eyes with flap microstriae had a significantly deeper mean ablation (114.5 microm [range, 52-146 microm]) than eyes without any flap abnormalities (75.4 microm [39-120 microm]). No significant differences were found between the consecutive and simultaneous groups. CONCLUSION: The majority of patients did not experience better postoperative comfort from the application of a BSCL. Only 27% of patients reported more comfort from postoperative BSCL use. The latter have better tear film characteristics and a history of less difficulty with contact lenses preoperatively. A BSCL does not protect from the occurrence of microstriae.
Abstract: PURPOSE: To evaluate the long-term results and complications after bare sclera pterygium excision with local application of mitomycin C and consecutive smoothing of the wound area with an excimer laser (PTK). METHODS: This was an observational case series of 133 eyes of 101 patients who underwent pterygium surgery using the bare sclera technique. Thirty-one of these treated eyes (23%) were recurrences with a mean of 3 previous operations. After pterygium surgery, phototherapeutic keratectomy with an ArF:excimer laser was performed in the area of the excision. Additionally, all patients were treated with mitomycin C 0.02% twice daily for 4 days. Median follow-up was 53 months (minimum, 36). RESULTS: In the group with primary pterygia, 3 recurrences occurred after 6, 12, and 28 months (recurrence rate, 2.9%). In the group with previous pterygium operations, 2 recurrences (recurrence rate, 6.4%) were recorded. Uncorrected visual acuity of all treated patients improved from 0.61 preoperatively to 0.79 postoperatively (P < 0.0001), best corrected visual acuity increased from 0.82 to 0.91 (P = 0.0001) [LogMAR]. Mean astigmatism was significantly reduced from 1.54 D preoperatively to 0.61 D postoperatively (P < 0.0001). In 7 eyes, discrete granulomas developed postoperatively (5.3%); in 3 cases (2.3%), dellen formation occurred that persisted for a maximum of 4 months. No further complications were recorded during the follow-up. CONCLUSIONS: Pterygium excision using the bare sclera technique, phototherapeutic keratectomy, and local application of mitomycin C 0.02% eyedrops is a safe method with good functional results and a low recurrence rate.
Abstract: PURPOSE: To demonstrate a novel applicator, the so-called vitreoretinal-internal limiting membrane colour enhancer to achieve the selective painting of pre-retinal structures. METHODS: The VINCE is a modified backflush needle, containing an adjustable silicone tube, which is surrounded by a metal cannula. The tube is connected to a dye container in the handpiece of the applicator. RESULTS: The instrument was successful in painting the retinal surface sufficiently and was found to be particularly useful to avoid unintended staining of the peripheral or foveal retina. The newly developed customized cartridge-loading system contains the ready prepared dye, avoiding time-consuming dilution and preparation of the vital dye during surgery in the OR. The VINCE is effective in restricting the dye only to the area of surgical interest. CONCLUSION: The VINCE is a useful tool to limit intraocular dye to the required area to minimize possible side effects to intraocular retinal structures.
Abstract: To evaluate the causative factor for multifocal chorioretinitis, papillitis, and recurrent optic neuritis. A 41-year-old patient presenting multifocal choroiditis, papillitis, and recurrent optic neuritis was evaluated with funduscopy, angiography (FA), optical coherence tomography (OCT), visual evoked potentials (VEP), and numerous blood laboratory tests. FA and OCT showed multifocal pigment epithelial detachments. VEP showed typical changes for optic neuritis and papillitis. Indirect fluorescent antibody assay disclosed Bartonella henselae. Although cat-scratch disease frequently presents with optic neuritis or neuroretinitis, additional multifocal chorioretinal lesions associated with serous pigment epithelial detachments may occur. In case of recurrent episodes, a detailed laboratory work-up is mandatory to define the appropriate diagnosis and treatment.
Abstract: OBJECTIVE: To describe fundus autofluorescence (AF), fluorescein angiography (FA) and indocyanine green angiography (ICGA) in different types of retinal astrocytic hamartomas in tuberous sclerosis (Morbus Bourneville-Pringle). METHODS: Two eyes with 8 lesions, i.e. type 1 (n = 7) and type 3 (n = 1), were examined. AF pictures were taken prior to injection, FA and ICGA images were obtained in the early and the late phase. To achieve additional cases, a systematic literature review with exten- sive Internet and library search was performed. RESULTS: Strong AF was seen in type 2 and type 3 retinal astrocytic hamartomas, whereas type 1 lesions blocked the physiologic fundus AF. Fluorescence angiography of all types of lesions revealed hypofluorescence in early frames and hyperfluorescence originating from leakage in late frames. ICGA showed a subtle blockade in type 1, a total blockade in type 2 and in the central part and a partial blockade in the peripheral part in type 3 lesions. CONCLUSIONS: Retinal astrocytic hamartomas in tuberous sclerosis can be easily detected by angiography, especially type 1 lesions which are difficult to visualize by funduscopy. Early- and late-phase fluorescein angiography and ICGA are helpful to differentiate the three lesion types.
Abstract: BACKGROUND: Idiopathic epiretinal membranes (ERM) grow on the surface of the internal limiting membrane (ILM) and are a very uncommon condition in young subjects. METHODS: We report six young subjects with ERM and describe the spontaneous separation of the membranes. The functional and anatomical recovery was assessed by Snellen visual acuity, Amsler grid and funduscopy. Selected cases were additionally assessed by optical coherence tomography (OCT). RESULTS: All subjects initially claimed a sudden, unilateral, reduction in visual acuity (VA) with severe distortion at the age of 15-30 years. No ocular trauma or disease was ascertained in any case. Initial fundus examination demonstrated a gray-whitish ERM with translucent stress lines over the macula. Visual recovery occurred in all cases after resolution of the ERM. Sequential OCT demonstrated the successive peeling of an ERM accompanied by normalization of foveal thickness. CONCLUSIONS: Young subjects should be counseled about the favorable prognosis for maintaining good vision and possible spontaneous membrane separation. Conservative observation is advocated if the visual disturbance is located temporally, as functional recovery and spontaneous membrane separation may occur. When the contracting forces of the immature ERM are stronger than its adhesions to the retina, the membrane may separate spontaneously.
Abstract: PURPOSE: Peeling of the internal limiting membrane (ILM) has improved the outcomes in vitreoretinal surgery of macular diseases. Indocyanine green (ICG) is used to stain and improve the visualization of the ILM. This paper aims to describe a modified approach to stain and peel the ILM avoiding potential adverse side effects. METHODS: After a core vitrectomy, 0.05 ml of ICG in a concentration of 5 mg/ml is quickly injected under water around the macular region. The tip of the syringe is positioned about 5 mm from the macular tissue, in a way that about a 3-mm diameter area around the fovea is stained by the ICG. Additional ICG is immediately removed by aspiration. Peeling of the ILM is accomplished with a forceps. RESULTS: Neither residual ICG in the vitreous cavity nor any clinical signs of phototoxicity like retinal edema were detected in any patients operated by this technique. CONCLUSIONS: This modified technique to stain the ILM limits the amount and concentration of ICG. The locally limited contact of ICG with the retinal surface seems to be a safe procedure to stain the ILM.
Abstract: PURPOSE: To demonstrate the cross-sectional morphology in crystalline retinopathy. METHODS: A 24-year-old woman with Bietti's crystalline dystrophy (BCD) and bilaterally decreased vision and nyctalopia was examined by optical coherence tomography (OCT). RESULTS: Fundus examination demonstrated numerous reflective, yellow-white crystalline deposits scattered throughout the posterior pole and midperipheral retina. Optical coherence tomography disclosed an abnormally level of high reflectivity in red to orange colours throughout the entire neuroretina, retinal pigment epithelium (RPE) and choroid. The RPE-choriocapillaris complex was thickened and hyper-reflective, corresponding with dense crystalline deposits. CONCLUSION: The observed uncommon hyper-reflectivity in BCD relates to the deposition of numerous infiltrates. In vivo investigations by OCT confirmed histological studies that a crystalline retinopathy corresponds with numerous infiltrates in the retina, RPE and choroid. The RPE and choroid have intensive hyper-reflection and may be the primary location of the disease.
Abstract: OBJECTIVE: To determine the intrastromal layer of corneal deposits in granular corneal dystrophy (GCD). DESIGN: Investigative case report. METHODS: A 32-year-old woman with bilateral decreased vision because of corneal deposits was examined with cross-sectional scans using optical coherence tomography (OCT). RESULTS: Visual acuity was 20/100 OU. Multiple confluent gray-white patches with an irregular shape were seen in the corneal stroma, leading to a diffuse opacification. OCT disclosed multiple hyperreflective dots in the anterior and deeper stromal layers. CONCLUSION: When severe corneal opacities obscure the clinical differentiation between anterior and deep infiltrates, OCT may determine the layers of the accumulation and select an appropriate surgical procedure.
Abstract: BACKGROUND: In patients with advanced age-related macular degeneration (AMD), massive subretinal hemorrhage may sometimes be the reason for a loss of peripheral vision, leading to a significantly reduced quality of life. PATIENTS AND METHODS: During the years 1995-2001 we operated five eyes (five consecutive patients) with acute massive subretinal hemorrhage extending into all four quadrants and profoundly reduced vision in the fellow eye due to a Junius-Kuhnt macular scar. Within an interval of 1-2 weeks after the bleeding, pars plana vitrectomy with peripheral retinotomy was performed. After the retina was turned upside down and the partially liquified blood was removed, the underlying subfoveal CNV membrane was removed with a vitrectome. Three phakic eyes required additional cataract surgery and IOL implantation. The retina reattached under PFCL and a silicone oil tamponade applied for 3-6 months. RESULTS: The removal of the subretinal hemorrhage was without complications. The size of the subretinal membrane was between 4 and 6 PD with partially fibrovascular tissue. After the membrane was removed, a large central pigment epithelium defect made a macular rotation impossible. Visual acuity of hand motion improved from preoperatively 0.05 to postoperatively 1/35 to 0.1 after a follow-up of 3-6 months. CONCLUSION: In patients with such an extremely reduced visual acuity and visual field, subretinal surgery with removal of the subretinal blood may achieve sufficient vision for the patients' orientation.
Abstract: A 32-year-old Caucasian man had a mosaic hyperpigmentation on his left arm, arranged in a pattern following the lines of Blaschko. In addition, a mosaic hyperpigmentation was noted in his left eye, in the form of grouped congenital hypertrophy of the retinal pigment epithelium (CHRPE). Such "bear tracks" are segmentally oriented, well-demarcated, flat, hyperpigmented lesions originating with small dots at the optic disk and expanding towards the periphery. We hypothesize that these mosaic pigmentary lesions involving the skin and the eye on the same side of the body may have originated from an early postzygotic mutation and thus may be etiologically related.
Abstract: PURPOSE: To present a symptomatic optic pit 3 months after a blunt ocular trauma. METHODS: A 16-year-old male with unilateral decreased vision was examined with multiple cross-sectional scans using optical coherence tomography (OCT) and kinetic ultrasound at the optic disc and macula. RESULTS: Visual acuity was 20/30 OD and 20/20 OS. Fundus examination OD demonstrated an optic pit with a corresponding serous macular detachment. OCT disclosed a schisis-like separation of the inner retinal layer emanating from the optic disc and an outer layer detachment of the retina. B-scan ultrasound disclosed attached Choquet's canal at the optic pit. CONCLUSIONS: Patients with optic pit and firm adherent posterior vitreous may develop schisis-like retinal detachments after blunt ocular trauma.
Abstract: BACKGROUND: Age-related macular degeneration (AMD) is a frequent cause of an irreversible loss of the ability to read. The non-exudative form of AMD has not been therapeutically approached in the past in contrast to the exudative form with choroidal neovascularizations (CNVs). Parafoveal laser coagulation can be applied, and in cases of subfoveal location a pars plana vitrectomy with subretinal resection of the CNV is possible. MATERIAL AND METHODS: Since 1995, we have operated 46 eyes of 45 patients with CNV developing from AMD. Patient ages ranged from 63 to 85 years (mean 71.8 years). Pre- and postoperatively we performed vision tests, fluorescence angiographies with sodium fluorescein and indocyanine green. Follow-up times ranged from 3 to 28 months (mean 12.3 months). RESULTS: Pre-operative vision was 0.10 (range: hand movements to 0.4). Postoperative vision at the end of the follow-up period was 0.12 (range: hand movements to 0.4). Vision at the end of the follow-up was lower in 41%, unchanged in 20% and improved in 39%. In 43 eyes, a non-exudative form of AMD developed. Two eyes had a recurrent CNV, which was removed successfully with a second pars plana vitrectomy. Three patients developed a retinal detachment, which was successfully treated by pars plana vitrectomy, encircling buckle and gas tamponade. CONCLUSIONS: We still have to wait for the results of the photodynamic study trials and a randomized study of macular dislocation. Subretinal removal of the CNV by pars plana vitrectomy allows a stabilization of the visual function in most of our cases of AMD. This method inhibits the development of large pseudotumour-like scars. Postoperatively remaining pigment epithelial defects with choroidal atrophies however limit a visual rehabilitation so that reading vision can only be achieved in cases with good pre-operative vision. Long-term results of photodynamic therapy are still lacking and have to show its effectiveness over greater time spans.
Abstract: INTRODUCTION: In a few types of rhegmatogenous retinal detachment (RRD), scleral buckling (SB) has a lower success, and, here, pars plana vitrectomy (PPV) is a good alternative option. This survey reviews the indications and the surgical outcome of primary PPV with internal tamponade. PATIENTS AND METHODS: We reviewed 205 eyes operated by primary PPV for RRD at the Department of Ophthalmology of the Philipps University Marburg between the years 1990 and 1997. The indications of PPV were: holes greater than 90 degrees; holes posterior to the equator; proliferative vitreoretinopathy grade C; pseudophakic status. RESULTS: A complete reattachment of the retina after absorption of the gas or after silicone oil removal was achieved by 1 operation in 146 eyes (71.2%) and in 195 eyes (95.2%) by a second intervention. CONCLUSION: Although SB is the standard procedure for the treatment of RRD, complicated cases can be treated successfully with primary PPV.
Abstract: PURPOSE: To demonstrate the cross-sectional anatomy in acute commotio retinae. METHODS: A 27-year-old male with unilateral decreased vision after acute blunt ocular trauma, was examined by optical coherence tomography (OCT). RESULTS: Visual acuity was 20/20 OD and 20/50 OS. Fundus examination OS demonstrated a mild edema in the papillomacular and foveal area. OCT confirmed a separation of the neurosensory retina and the retinal pigment epithelium (RPE). The thickness of the retina was normal and the contour of the foveola intact. The uncommon hyperreflective band at the outer retina may present the traumatic disruption of photoreceptors. CONCLUSIONS: In vivo investigations by OCT confirmed previous histological studies, a commotio retinae consists a disruption and fragmentation at the level of the foveal photoreceptor segments and RPE.
Abstract: Many vitreoretinal disorders increase in incidence with age. The vitreous is known to liquefy and separate from the retina in aging patients. Liquefaction and partial vitreous separation alter the biomechanics of the vitreous and change the tractional forces exerted by the vitreous on the retina. These forces may play a role in the development of a variety of vitreoretinal pathologies including retinal tears, cystoid macular edema, and macular holes. The purpose of this study is to test the hypothesis that the biomechanical properties of the vitreous change with aging and can be quantified by analysis of kinetic B scan ultrasound recordings. Kinetic B scan ultrasound recordings were made of the vitreous gel of 38 subjects from ages 18 to 91 during standard eye motions. The recordings were graded for speckle density (hyperreflective areas on ultrasound) and were examined for the presence or absence of posterior vitreous detachment. Tracking of the speckles on a polar grid allowed for the calculation of the angle travelled by the speckle relative to the angle travelled by the eye. The recordings were also analysed for "overshoot time", or the amount of time that the speckles continued to travel after the cessation of eye movement. The vitreous of subjects of age less than 46 years demonstrated significantly less speckle density (P < 0.001), less overshoot time (P < 0.001), and less angle travelled by the speckle relative to the angle travelled by the eye when compared to older subjects (P = 0.006). The presence or absence of PVD as diagnosed by kinetic ultrasound was not a significant predictor for speckle density, overshoot time, or ratio of angular motions. The results indicate that aging affects the biomechanics of the vitreous in ways which can be quantified with kinetic ultrasound analysis using the grading system described above.
Abstract: PURPOSE: To document, in vivo, the foveal morphology and thickness in a patient with oculocutaneous albinism. METHODS: Observational case report. In a 10-year-old female with oculocutaneous albinism, multiple cross-sectional scans of the fovea were performed using optical coherence tomography. RESULTS: Optical coherence tomography scans were unable to detect the foveal pit. A widespread thickening of the retina occurred throughout the entire fovea with no difference from the surrounding macula. The foveal thickness was greater than 300 microm in the eyes of this patient with oculocutaneous albinism, compared with 150 microm in the normal eye. The inner retina had a highly reflective signal on optical coherence tomography. CONCLUSION: Optical coherence tomography demonstrated in the anatomical location of the fovea a highly reflective inner retinal signal, possibly consistent with multiple layers of ganglion cells, and it confirmed foveal hypoplasia in a patient with oculocutaneous albinism.
Abstract: OBJECTIVE: To determine the prevalence and visual significance of cystoid macular edema (CME) in eyes with subfoveal neovascular age-related macular degeneration using optical coherence tomography (OCT). MATERIALS AND METHODS: The medical records of 61 consecutive patients initially seen with nondisciform subfoveal neovascular age-related macular degeneration were retrospectively reviewed. All patients underwent fluorescein angiography and OCT imaging. Eyes with intraretinal hyporeflective spaces in the macula in the OCT images were considered to have CME. RESULTS: Twenty-eight (46%) of 61 eyes demonstrated CME on the OCT images. The presence of CME and increased foveal thickness correlated with decreased visual acuity, but not with the duration of symptoms. Twenty-six (93%) of 28 eyes with CME contained classic choroidal neovascularization, whereas 16 (48%) of 33 eyes without CME contained classic choroidal neovascularization. CONCLUSIONS: Cystoid macular edema is a common finding in patients with choroidal neovascularization associated with age-related macular degeneration. The presence of CME and foveal thickening is associated with worse visual acuity in these patients. Cystoid macular edema is more common with choroidal neovascularization containing classic component. The OCT is a useful test to detect the presence of CME in these patients since CME may be difficult to identify on fluorescein angiogram.
Abstract: OBJECTIVE: To evaluate visual outcomes following macular translocation with 360 degrees peripheral retinectomy in patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration. METHODS: In a prospective study, 15 consecutive patients with large subfoveal choroidal neovascularization underwent macular translocation with 360 degrees peripheral retinectomy and silicone oil tamponade. Preoperative and postoperative photographs and fluorescein angiograms were obtained to evaluate lesion size and characteristics and translocation results. Standardized near and distance visual acuity and reading speed were measured preoperatively and 6 and 12 months postoperatively. MAIN OUTCOME MEASURES: Changes in and final levels of near and distance visual acuity and reading speed. RESULTS: Median lesion size was 9 Macular Photocoagulation Study disc areas (range, 4-16 disc areas). In all patients, the fovea was successfully translocated off the subfoveal lesion. The median near visual acuity logMAR score (logarithm of the minimum angle of resolution) improved significantly from 0.54 units to 0.40 units (Snellen equivalent, 20/70 to 20/50; P =.02) at the 6-month follow-up and stabilized at 0.54 (12 months postoperatively; Snellen equivalent, 20/70). Seven (54%) of 13 patients and 7 (58%) of 12 patients achieved reading speeds of 70 words/min or greater at the 6-month and 12-month postoperative visits, respectively. Median preoperative distance visual acuity (20/100) was maintained at both the 6-month and 12-month examinations. No postoperative retinal detachments occurred in this series. CONCLUSION: Macular translocation with 360 degrees peripheral retinectomy and silicone oil tamponade stabilizes and can sometimes improve near and distance visual acuity and reading speed in patients with vision loss from subfoveal neovascular age-related macular degeneration.
Abstract: PURPOSE: To evaluate a new concept in pharmacological vitreolysis by studying the efficacy of intravitreal RGD peptide-assisted vitrectomy in facilitating the separation of the posterior cortical vitreous from the retinal surface in an animal model. METHODS: Eight rabbits (16 eyes) received an intravitreal injection of 1 or 5 mg of RGD peptide in one eye and either RGE peptide (inactive control) or phosphate buffered saline in the fellow eye. After 24 hours, a pars plana vitrectomy with low aspiration (< or =30 mmHg) was performed in an attempt to create a detachment of the posterior cortical vitreous. A masked observer performed pre- and postoperative indirect ophthalmoscopy and B-scan ultrasonography. Postoperative scanning electron microscopy evaluated the vitreoretinal surface in selected eyes. Two additional rabbits received intravitreal injections of RGD peptide in one eye (1 mg and 5 mg) and 1 mg of RGE peptide in the fellow eye to examine apoptosis of the retinal cells by TUNEL assay. RESULTS: Based on postoperative ultrasound findings, six of the eight rabbits had a greater degree of posterior vitreous detachment in the RGD eye compared to the fellow eye (p = 0.03). The total number and the average number of detached quadrants in the group of RGD peptide eyes was twenty-three and 2.85 respectively compared to seven and 0.85 for the control fellow eyes (p = 0.02). Scanning electron microscopy confirmed the presence of postoperative posterior vitreous detachment. There was no evidence of retinal cell apoptosis in RGD injected eyes. CONCLUSION: RGD peptide-assisted vitrectomy facilitated posterior vitreous detachment in rabbit eyes, suggesting that RGD-containing peptides may prove to be effective adjuncts in producing posterior vitreous separation during vitreous surgery.
Abstract: Congenital hypertrophy of the retinal pigment epithelium (CHRPE) can be associated with Gardner's syndrome (GS). During childhood multiple adenomatose polyps develop in the colon ascendens (familiar-autosomal Polyposis coli [FAP]), and always become malignant until the age of 35. The tumour-suppressive FAP-gen was identified at the long arm of chromosome 5 (5q21). Ophthalmic funduscopy is very important. Patients with more than 3 CHRPE in one eye or a bilateral CHRPE, as well as patients with a positive family history and one unilateral solid CHRPE require further gastroenterological evaluation.
Abstract: PURPOSE: To evaluate the effects of subretinal and intravitreal delivery of INS37217, a P2Y(2) receptor agonist, on subretinal fluid reabsorption in experimentally induced retinal detachments in rabbits, and to characterize the effects of INS37217 on electroretinograms (ERG) in rabbits. METHODS: A single retinal detachment was produced in New Zealand White rabbits by injecting approximately 50 micro L of modified phosphate-buffered saline (MPBS) solution into the subretinal space (SRS). In all experiments, one eye served as the INS37217-treated eye and the contralateral eye served as the vehicle control. In the first series of experiments, each rabbit received a SRS injection of MPBS solution, with or without INS37217 (1 mM). In the second series of experiments, each eye received an SRS injection of MPBS solution, followed by an intravitreal injection of MPBS solution, with or without INS37217 (12, 1.4, and 0.15 mM). A masked observer determined the size of blebs by indirect ophthalmoscopy at 30-minute intervals for up to 3 hours after SRS injections. Optical coherence tomography (OCT) was conducted to provide cross-sectional images of the blebs. Cellular expression of P2Y(2) receptor mRNA was localized by nonradioisotopic in situ hybridization in fresh rabbit retina-RPE tissue sections. Bilateral, full-field scotopic and photopic ERGs were made at 1, 7, and 14 days after a single intravitreal injection of 24 mM INS37217. RESULTS: SRS administration of 1 mM INS37217 significantly enhanced subretinal fluid reabsorption when compared with vehicle controls (P < 0.05; repeated measures ANOVA). Intravitreal administration of INS37217 at 12 and 1.4 mM, but not at 0.15 mM, also significantly enhanced subretinal fluid reabsorption (P < 0.05). P2Y(2) receptor mRNA was observed throughout the RPE and in discrete layers of the retina. INS37217 had no adverse effects on scotopic and photopic ERG amplitude and latency parameters at any of the postadministration time points evaluated. CONCLUSIONS: These results demonstrate that INS37217 enhances subretinal fluid reabsorption in experimental retinal detachment in rabbits and support the development of INS37217 for stimulating subretinal fluid reabsorption in conditions that result in retinal detachment or retinal edema.
Abstract: PURPOSE: Different techniques have been proposed for translocating the macula in patients with subfoveal neovascularization secondary to age-related macular degeneration. A new approach utilizing radial outfolding of the sclera was investigated. MATERIALS AND METHODS: Surgical techniques and retinal displacement were evaluated in animal trials using metal scleral clips. Successful translocation and reattachment of the retina was achieved in eight rabbits (eight eyes). We conducted a retrospective review of macular translocation surgery, performed with radial scleral outfolding, in a series of five consecutive human patients (five eyes) using full-thickness transscleral mattress sutures. RESULTS: After surgery, vision improved in two of five patients, with one patient achieving a visual acuity of 20/50. The mean angle of rotation was 11.5 deg (range 8.6 -15.1). The mean amount of foveal displacement was 1,276 pm (range 852-1,620). Complications included one case of retinal detachment, one of diplopia, and one of subretinal hemorrhage. CONCLUSIONS: Limited macular translocation by radial scleral outfolding can improve vision in selected patients. Radial evagination appears to be as effective as circumferential infolding.
Abstract: OBJECTIVE: To document the corneal astigmatism that occurs with macular translocation after scleral infolding surgery. DESIGN: Retrospective case series of a nonrandomized clinical trial. PARTICIPANTS: Eight consecutive age-related macular degeneration patients (eight eyes) with choroidal neovascularization who underwent macular translocation with scleral infolding at the Duke University Eye Center from December 1998 through October 1999. METHODS: We retrospectively reviewed the charts of eight consecutive patients who underwent macular translocation surgery involving scleral infolding in the superotemporal quadrant. Two patients subsequently underwent release of scleral infolding. MAIN OUTCOME MEASURES: After surgery, these eyes were evaluated for corneal astigmatism with manifest refraction, keratometry, and computerized corneal topography. RESULTS: All eight eyes of eight patients revealed marked degrees of corneal astigmatism. Measurement of astigmatism via manifest refraction, keratometry, and corneal topography confirmed postoperative astigmatism corresponding to the axis of the scleral infolding. The amount of corneal astigmatism ranged from 1.75 to 7.37 diopters (D; mean, 4.60 D), with steepening along the axis of scleral infolding in the superotemporal quadrant of each eye (mean, 42.50 degrees from vertical; range, 24 degrees -66 degrees from vertical). Release of scleral infolding in two patients resulted in significant reduction of corneal astigmatism. CONCLUSIONS: Scleral shortening procedures used in macular translocation surgery may induce large amounts of corneal astigmatism. These patients should be assessed with keratometry and corneal topography to determine the accurate amount and axis. Thereafter, contact lens fitting or scleral infolding release may be considered as therapeutic options for large amounts of astigmatism persisting after surgery.
Abstract: BACKGROUND: The development of tears of the retinal pigment epithelium (RPE) has classically been described with or without choroidal neovascularization (CNV) or after laser treatment. Tangential shear forces within the RPE or CNV are usually considered to cause the dehiscence. METHODS: Three patients with CNV and spontaneous RPE tear and additional vitreomacular traction were examined by fluorescein angiography (FA), optical coherence tomography (OCT) and kinetic ultrasound. RESULTS: From the pre-tear to the tear stage a sudden decrease in vision was observed. Fluorescein angiographic images demonstrated RPE-tear formation with blocked filling in the area of the contracted RPE and a well-demarcated hyperfluorescence in the bed of the torn RPE. OCT-scans demonstrated vitreomacular traction at the foveal area in all three cases. Kinetic ultrasound revealed vitreous attachments at the optic disc and fovea. CONCLUSION: Magnitude, variation of mechanical forces, and the continuous shear stress of the aged vitreous gel transmitted across vitreoretinal attachments may cause a chronic stimulus to retina and RPE. Vitreomacular traction may contribute to the subsequent formation of RPE tears via mechanical or cell mediator pathways.
Abstract: PURPOSE: To describe successful macular translocation with temporary scleral infolding in a series of patients with small subfoveal choroidal neovascularization due to age-related macular degeneration or ocular histoplasmosis syndrome. METHODS: Ten eyes of 10 consecutive patients were studied in a prospective, nonrandomized clinical trial. Macular translocation with scleral infolding (MTSI) was performed. Absorbable polyglactin suture was used to create temporary scleral infolding. Distance and stability of retinal translocation, corneal topography, visual acuity, and rates of complications were measured. RESULTS: The median distance of translocation in the early postoperative period was 1,700 microm (range, 680-3,200) and did not regress after resolution of the scleral infolding. Induced postoperative oblique corneal astigmatism resolved, coinciding with the disappearance of peripheral retinal elevation due to scleral infolding. Three patients gained more than two lines of vision, two patients were within two lines of preoperative vision, and five patients lost more than two lines of vision. Complications were similar to previously published reports. CONCLUSION: Temporary scleral infolding is an effective technique in MTSI. The distance of translocation is comparable to that achieved with nonabsorbable suture or scleral resection, and does not regress after resolution of the scleral infolding. Induced postoperative corneal astigmatism appears to resolve.
Abstract: PURPOSE: To characterize ultrastrructual changes in atrophic disease of the retina, RPE and choroid as seen with gyrate atrophy using two new diagnostic modalities, optical coherence tomography (OCT) and topographic angiography. PATIENT AND METHOD: OCT images were taken in a patient with pericentral choroidal atrophy using a slit-lamp-adapted OCT system. Ophthalmoscopy, conventional and topographic angiographic findings were correlated to the reflectivity changes as seen on OCT. RESULTS: Areas of chorioretinal atrophy correlated with a loss of reflectivity in the RPE-choriocapillaris complex on OCT. Additionally OCT identified a thinning of the nerve fiber layer. Topographic angiography demonstrated an extensive defect, seen as an area of depression, consistent with a loss of choriocapillaris and larger-sized choroidal vessels. In contrast to conventional angiography, central islands were not found to demonstrate structural intensity, while the midperipheral surrounding area was clearly elevated to physiological levels. CONCLUSION: OCT and topographic angiography provide in vivo insight into morphologic changes within neurosensory retina and choroid caused by pericentral choroidal atrophy.
Abstract: Landmark explorations by Hubel and Wiesel investigating the importance of visual impressions in postnatal development of the visual system demonstrated that neural connections and eye growth can be affected by the absence of a clear retinal image during a critical period of postnatal development. Fundamental theories on neural plasticity and deprivation have recently been established that presume that a reduced quality of the retinal image during infancy and early childhood triggers an elongation of the posterior chamber of the eye, a so-called form deprivation myopia (FDM). In a retrospective multicenter study of 187 patients who suffered from phlyctenular keratitis with corneal opacification since early childhood, we reviewed data on gender, year and age at onset of the disease, refraction, and ultrasound biometry. Compared with the average refraction of +0.5 diopter (D) found in the general population, the mean refraction of -4.43 D that we found in our study demonstrated a marked shift toward myopia of almost 5 D. Patients with an early onset of phlyctenular keratitis had considerably higher myopia (-6.68 D) than those with a late onset (-1.67 D). Additionally, an axial elongation was confirmed by ultrasound biometry. Our average, axial length was 26.53 mm, compared with the epidemiologic mean of 24.00 mm. This myopic shift of 2.53 mm was caused mainly by an enlarged vitreous cavity. These results support the finding that blur can affect eye growth and lead to FDM not only in animal experiments but also in human beings.
Abstract: Ophthalmologist Maximilian Linde (1862-1940) had a passion for contemporary art and owned one of the most important private collections in Europe. He first met little known Norwegian expressionist Edvard Munch in 1903, recognized special talent, and welcomed him into his family. With Linde's encouragement, patronage, and friendship, Munich became one of the most important artists of his time. Many of Munch's works were commissioned by Linde and many featured Linde and his family as subjects.
Abstract: BACKGROUND: In spite of clear transplants the results of keratoplasty are often disappointing. We looked for possible reasons for these failures. PATIENTS AND METHODS: We analyzed in 204 eyes of 115 patients the factors influencing the prognosis. Our results are based on medical records and on demanded reports of the treating ophthalmologists. Patients were divided after different aspects (method of operation, beginning of the disease, operation of the first or second eye). RESULTS: A frequently associated cataract and the method of surgery (aphakia, one- or two-step, triple procedure) has no influence on the prognosis. However, age of onset and density of corneal scars are crucial. This is especially evident in eyes first operated on. In case of early onset (before the age of five) visual acuity only reached 0.21 average postoperatively, whereas patients with late onset gained visual acuity of 0.59. The fellow eye (n = 89) had postoperative visual acuity of 0.48. In patients with poor postoperative visual improvement (< or = two lines) high myopia was apparent in 50%. CONCLUSION: For estimating the prognosis besides early childhood amblyopia we must take into account high myopia induced by formdeprivation (FDM). Exact evaluation of patients' history and preoperative ultrasound biometry are recommended.
Abstract: INTRODUCTION: The conservative treatment of the most severe cases of keratoconjunctivitis sicca (KCS) can be sometimes frustrating. Especially with an underlying autoimmunologic disorder, even the application of artificial tears as often as every 5 min may not prevent further damage to the ocular surface. A microvascular transplantation of the autologous submandibular gland (SG) can be performed by a maxillo-facial surgeon as an alternative approach for those cases. We report 2 years of ophthalmological experience with the results of this procedure. MATERIAL AND METHODS: To date 27 operations have been performed in 23 patients. The SG was moved from its natural site into the temporal fossa. The secretory duct was implanted into the conjunctival fornix and the gland's vessels connected to the temporal artery and vein. A complete ophthalmological examination has been performed in 25 eyes of 21 patients up to 1 year and in 11 eyes of 9 patients 2 years after surgery. RESULTS: Three months and 1 year postoperatively 19 of 25, and 2 years postoperatively 8 of 11 transplants remained vital. The baseline secretion increased in patients with a vital transplant from an average of 1.6 +/- 1.3 mm before the operation to 16.2 +/- 11.3 mm after 3 months and 20.6 +/- 10.6 mm after 1 year. Ten of 19 vital grafts were reduced 1 year after transplantation in a minor second procedure to control an increasing epiphora. Subsequently baseline secretion was reduced to 13.6 +/- 8.2 mm 2 years after transplantation. Patients with a vital graft reported in 84% of cases (16 of 19) at 3 months, and 79% at 1 year (15 of 19) and 2 years (7 of 8), a strong relief of dry eye symptoms. In 58% (3 months), 79% (1 year) and 63% (2 years) of the eyes with a vital transplant all artificial tear substitution could be stopped. Break-up time increased significantly, resulting in reduced bengal rose staining. CONCLUSION: The transfer of the autologous SG into the temporal fossa can be used to provide patients with very severe KCS with a continuous, endogenous source of ocular lubrication. Despite surgical denervation the graft maintains a sufficient baseline secretion over a period of years. Subjective symptoms and the application of pharmaceutical lubricating substances are reduced to a large extent. If epiphora occurs, it can be controlled by surgically reducing the transplant. The influence of SG saliva on the ocular surface is the object of ongoing studies.
Abstract: PURPOSE: The retinal pigment epithelium (RPE) regulates the lipid metabolism of the photoreceptors by catalysis of membrane outer segments and via choriocapillary perfusion is also exposed to the regulation of blood lipid levels. Since the uptake the metabolism of cholesterol are mediated by specific low-density lipoprotein (LDL) receptors, expression and regulation of this receptor-type were studied in RPE cultures. METHODS: In vitro experiments were carried out in transformed (SV40) human RPE cells. Human fibroblasts were used as a comparative cell line with known receptor expression. LDL was coupled to a fluorescent marker (Dil); receptor binding was quantified by flow cytometry. Expression and saturation characteristics were determined. LDL metabolism was examined by variation of the temperature (4 and 37 degrees C). LDL and Dil-LDL showed competition at the receptor. RESULTS: RPE cells demonstrated a higher uptake of Dil-LDL than fibroblasts. Expression could be further stimulated by culture conditions. Uptake kinetics were saturable with complete saturation at 50 micrograms/ml Dil-LDL. LDL uptake was shown to be temperature-dependent, indicating an energy-dependent pathway. CONCLUSIONS: RPE cells exhibit significant expression of receptors for native LDL, possibly mediating the lipid metabolism of the RPE-photoreceptor complex, as well as the uptake of blood lipids. Lack of regulation of the receptor for LDL may lead to intracellular accumulation of lipids, which may play a role in the pathogenesis of AMD.
Abstract: Penetrating keratoplasties in pseudophakia were added to a group with limited prognosis. This was especially valuable, if iris-supported and anterior chamber intraocular lenses were implanted. Since today mainly posterior chamber lenses are implanted, the question of the long-term prognosis in this type of lens is important. PATIENTS AND METHOD: From 1985 to 1994, 62 penetrating keratoplasties in pseudophakic eyes with posterior chamber IOL were performed: group I: decompensated Fuchs dystrophy (26 patients), group II: secondary surgery-related bullous keratopathy (36 patients) exclusively. Minimal follow-up was 18 months, mean age was 73.7 years. RESULTS: The mean follow-up period was 32 months. The mean visual acuity on delivery was 0.11. After 6 months it was 0.23, after 1 year 0.3, after 2 years 0.35 and after 3 years 0.41 without significant differences in either group. Two years after transplantation 52.8% gained a visual acuity (VA) of > or = 0.3, after 3 years 58.6% of which 41.1% had a VA of > or = 0.5. There was a visual improvement in 83.4%; the mean spherical equivalent was -0.29 D. Refractive errors within 2 D of emmetropia were found in 56.7%; 95.1% of the grafts remained clear. Five patients had a reversible graft rejection. Extracorneal factors of impaired vision were observed in 25 patients. CONCLUSION: Despite a different VA before surgery, the visual outcome in the two groups was identical. Penetrating keratoplasty in Fuchs dystrophy and secondary bullous keratopathy with posterior chamber IOL have a much better long-term prognosis than those with iris-supported and anterior chamber IOL. Postoperative complications and graft rejections are rare.
Abstract: Zrenner and Schaeffel reported that translucent occluders may induce axial eye elongation in animals. This axial growth is also called form deprivation myopia (FDM). Searching for a clinical correlate we examined in a retrospective study 115 patients with keratitis scrophulosa peracta, mainly corneal transplant patients. These patients had an average refraction of -4.27 dpt. In epidemiologic studies Stenström found +0.5 dpt as the mean refraction in the general population. When the onset of the corneal disease was before the age of 5 years, the myopia was found to be higher than in patients with later age of onset. In 43 patients we determined axial length by ultrasound biometry and found an average axial length of 26.89 mm, whereas the general average is 24.00 mm. In conclusion, these results confirm that not only in animal experiments but also in clinical cases FDM is responsible for the axial growth of eyes.
