[Alcohol Injection in a Patient with Chronic Orbital Pain after Enucleation - a Case Report and Review of the Literature]. / Alkoholinjektion bei chronischem orbitalem Schmerz nach Enukleation ­ Falldarstellung und Literaturübersicht.

A case is presented of a 54-year old patient who had been treated 10 months previously with enucleation for a painful blind eye. This led to severe and chronic pain in the orbital region that did not respond to conventional pain management. However, a single 1.5 ml injection of 96 % ethanol led to almost complete resolution of pain for the follow-up period of 6 months. Orbital pain after enucleation or evisceration may originate from the implant itself, the prosthesis, the socket or the sinuses. Taking a careful medical history and an examination, including orbital scans, are necessary to decide on the correct differential diagnosis. If any pathology is excluded, one should keep in mind that phantom pain in the orbit seems common after removing an eye, more often when pain originating from the ball and/or headache was present before removal. The management of chronic pain in the orbital region has received little attention. Retrobulbar alcohol injection still has a place in modern ophthalmology, because it delivers effective pain relief in certain chronic conditions.

[Development of oculoplastic surgery in Kinshasa (capital of Democratic Republic of Congo)]. / Entwicklung der okuloplastischen Chirurgie in Kinshasa (Hauptstadt der Demokratischen Republik Kongo).

The partnership between Saint Joseph Hospital in Kinshasa (Capital city of DRC) and University Eye Clinic Rostock, Germany exists since 2000. The ophthalmologists from Rostock University performed 12 visits of St. Josef Hospital with the aim to perform oculoplastic surgery in complicated cases as well as to teach the local ophthalmologists. There they performed about 150 surgeries (entropion, ectropion, ptosis, repair of lid injuries, eye lid reconstruction and tumour management, lacrimal surgery) in joint teams. The programme of on-site training was established during this time. Meanwhile, the Kinshasa colleagues are able to perform the basic techniques by themselves. Two colleagues have obtained advanced training in oculoplastics in Rostock. The fruitful cooperation enabled the development of oculoplastic surgery in St. Josef Hospital in Kinshasa. The further education and training proccesses will support the continuous advancement in ophthalmological health care in DRC.

[Hermansky-Pudlak syndrome]. / Hermansky-Pudlak-Syndrom.

A 1-year-old female child suffering from nystagmus and abnormal head posture (AHP) was presented by the parents in our clinic. The family history revealed the presence of von Willebrand's disease in both parents. General examination showed a female child with light blond colored skin accompanied by black-haired parents. Physical and ophthalmic examination revealed nystagmus, AHP and oculocutaneous albinism. The molecular genetic analysis showed a mutation in the HPS-1 gene which confirmed the suspected diagnosis of Hermansky-Pudlak syndrome (HPS). Of clinical significance, patients with HPS commonly have hemorrhagic diathesis, granulomatous colitis or restrictive lung fibrosis. A detailed full medical history, ophthalmic examination as well as genetic analyses are essential in establishing the diagnosis of HPS. Treatment includes correcting refraction anomalies with spectacles or contact lenses, prescription of tinted glasses or surgical correction of the AHP. An internal medical consultation is also necessary for the management of other associated symptoms, such as hemorrhagic diathesis.

[Orbital neoplasia. Part II: mesenchymal, leukemic, lymphoproliferative and bony tumors, metastasis]. / Orbitale Neoplasien. Teil II: Mesenchymale, leukämische, lymphoproliferative und Knochentumoren, Metastasen.

With reference to the first article on the topic orbital neoplasias this second part focuses on the main characteristics of mesenchymal, leukemic, lymphoproliferative, osseous as well as secondary neoplasias of the orbit. For each entity the therapeutic approaches are presented. A large number of case report examples underline once more the importance of an efficient diagnostic procedure to ensure sufficient treatment of the lesion itself as well as the relatively common underlying systemic disease.

[Therapy options for blind microphthalmos and clinical anophthalmos]. / Therapiemöglichkeiten bei funktionslosem Mikrophthalmus und klinischem Anophthalmus.

Children suffering from congenital anophthalmos (absence of eyes) or blind microphthalmos (eyes too small without light perception) show significant smaller eyelids, conjunctival sacs and orbital volume due to the lack of intrauterine growth stimulus. Highly hydrophilic osmotic expanders allow prostheses to be fitted in the first year of life to compensate for the volume deficit and the substantial aesthetic disadvantages and to stimulate lid development.

[Orbital neoplasia. Part I: Introduction, vascular and neurogenic tumors]. / Orbitale Neoplasien. Teil I: Einführung, vaskuläre und neurogene Neoplasien.

Tumors of the orbit are rare but the huge variability of clinical symptoms and findings are challenging for the ophthalmologist who is frequently contacted as the first resort. If the patient history and clinical findings are suspicious for an orbital mass the result of the initial examination should allow a rough estimation of localization (intra/extraconal), type of growth (expansive/infiltrative), dignity (vascular/solid etc.) and threat to visual functions. An adequate initial diagnostic pathway enables a precise question to the radiologist to be formulated and selection of the disciplines required for an interdisciplinary workup and therefore for early treatment.

[Ophthalmological findings in paediatric and adolescent multiple sclerosis]. / Augenärztliche Aspekte Multipler Sklerose im Kindes- und Jugendalter.

BACKGROUND: Multiple sclerosis (MS) is a chronic demyelinating disorder of the central nervous system of unknown aetiology. The onset of MS in childhood poses diagnostic and therapeutic challenges. Differential diagnoses include acute disseminated encephalomyelitis and neurometabolic leukoencephalopathies. In this article the ophthalmological findings of paediatric and adolescent MS patients are described and discussed in the light of earlier studies. METHODS: In a retrospective study we evaluated the ophthalmological and neuro-ophthalmological findings of 44 paediatric/adolescent MS patients (aged 8-18 years). RESULTS: In 18/44 patients optic neuritis was found. Abnormalities of ocular motility were seen in 9/44 patients, 5/44 had abduction limitation, 3/44 internuclear ophthalmoplegia and 1/44 horizontal gaze palsy. Furthermore, 13/44 children showed nystagmus, mostly gaze-induced nystagmus. Uveitis was present in 4/44 patients. CONCLUSIONS: The ophthalmological and neuroophthalmological findings may lead to the diagnosis of MS. Children presenting with these symptoms should be examined by a paediatric neurologist.

[Faden operations - indications beyond esotropia and surgical results]. / Fadenoperationen außerhalb des Innenschielens - Indikationen und operative Ergebnisse.

BACKGROUND: Faden operations is a well-known surgical option for the treatment of esotropia. To the best of our knowledge there are only a few reports available dealing with this particular topic. PATIENTS AND METHOD: Retrospective series of patients in whom between 2000 and 2011 a faden operation was performed under all indications except esotropia. 23 patients (9 Graves' disease, 9 third nerve palsy, 3 sixth nerve palsy, 1 muscle dystrophy, 2 orbital trauma) were included. RESULTS: 5 out of 7 horizontally disturbed patients were operated unilaterally and the remaining 2 bilaterally. The field of binocular single vision increased from 15-70° preoperatively by 10-25° (unilateral) and 20-35° (bilateral) to 30-80° postoperatively. Out of the 16 vertically disturbed patients only one was operated on superior and inferior rectus simultaneously and all the other on only one muscle. The field of binocular single vision increased from 5-55° preoperatively by 5-45° to 10-80° postoperatively. There were no complications so far and none of the patients worsened with the surgery. CONCLUSION: A faden operation might help to increase the field of binocular single vision in cases of restrictive squint like Graves' disease or in paralytic strabismus.

Orbital decompression in thyroid eye disease.

Though enlargement of the bony orbit by orbital decompression surgery has been known for about a century, surgical techniques vary all around the world mostly depending on the patient's clinical presentation but also on the institutional habits or the surgeon's skills. Ideally every surgical intervention should be tailored to the patient's specific needs. Therefore the aim of this paper is to review outcomes, hints, trends, and perspectives in orbital decompression surgery in thyroid eye disease regarding different surgical techniques.

[Hydrogelexpander as drug delivery system for antibiotics]. / Hydrogelexpander als Medikamentenabgabe-System für Antibiotika.

PURPOSE: The suitability of a high-hydrophilic osmotic self-inflating hydrogel expander consisting of a co-polymer of N-vinylpyrolidone and methyl methacrylate as a drug delivery system for antibiotics to prevent a postoperative infection was investigated in a laboratory setting. METHODS: The dry expanders were incubated in a 0.3 % solution of Ofloxacin or Tobramycin for 24 hours. The completely swollen expander had increased in volume from 0.3 mL to almost 3 mL (adsorbing 2.7 mL of the 0.3 % solution, i. e.,8.1 mg of Ofloxacin or Tobramycin, respectively). Addressing the elimination of both antibiotics, the concentrations in 15 mL elution medium (simulating the volume of the orbit in a newborn baby) were measured after 0.25, 1, 2, 6, 24, 48 and 72 hours of elution. 0.9 % sodium chloride (B. Braun Melsungen, Germany) was used as elution medium. To imitate fluid exchange due to blood perfusion in the surrounding tissue the medium was renewed after every sampling. For each substance 10 expanders were tested. Concentrations of antibiotic were determined by HPLC/UV for Ofloxacin and by using a specific fluorescence-polarisation immunoassay (Abbott TDx) for Tobramycin. RESULTS: Mean concentrations of Ofloxacin at 0.25, 1, 2, 6, 24, 48 and 72 hours after beginning of the elution were 50.2, 46.8, 41.2, 75.4, 88.2, 46.2 and 19.1 µg/mL, respectively. The cumulative amount of Ofloxacin eluted after 72 hours reached 68 % of the loading dose. The corresponding mean concentrations of Tobramycin were 38.8, 48.5, 40.5, 69.8, 88.7, 119.3 and 71.6 µg/mL. The cumulative eluted amount was 88 %. CONCLUSIONS: The investigated hydrogel expanders soaked in 0.3 % antibiotic solution can store and later on release sufficient amounts of Ofloxacin or Tobramycin to produce antimicrobial effective concentrations in vitro in the surrounding environment. This principle, when used in a clinical setting, might help to eliminate post-implantation infection which is one of the major complications in clinical use.

[Recurrent canaliculitis in a 22-year-old patient]. / Rezidivierende Canaliculitis bei einem 22-Jährigen.

A 22-year-old patient presented with persistent epiphora over a period of about 7 months. The clinical examination revealed a canalicular swelling in both lacrimal ducts, which postoperatively transpired to be an exophytic tumor. The histopathology result of the excised tumor showed an epithelial lesion, a partially inverted papilloma without malignancy. For tumors arising from lachrimal ducts the first-line therapy is complete tumor resection.

In vitro kinetics of delivery of tobramycin and ofloxacin from osmotic hydro gel expanders.

OBJECTIVE: High-hydrophilic osmotic self-inflating hydro gel expanders are well-accepted for implantation to achieve tissue expansion in defined parts of the body like skin, breast and orbital soft tissue. To prevent post-implantation infections effective antibiotic prophylaxis might be helpful. The suitability of this hydro gel consisting of a co-polymer of N-vinyl-pyrolidone and methyl-methacrylate as a drug delivery system for antibiotics was investigated in a laboratory setting simulating the orbit in a newborn. METHODS: In a first setting the dry expanders were incubated in a 0.3% solution (5 ml) of tobramycin and ofloxacin for 24 h (n = 10 for each substance, adsorbing 2.4 ml of the 0.3% solution, i.e. 7,200 µg antibiotic). Addressing the release of both antibiotics, the concentrations in 15 ml elution medium (0.9% sodium chloride, renewed after every sampling) were measured after 0.25, 1, 2, 6, 24, 48 and 72 h of elution. To simulate the clinical use in a second setting the expanders were dried after incubation in a 0.3% and 0.03% solution of tobramycin (n = 5 for each concentration) before measuring the release. RESULTS: The cumulative amount of tobramycin released after 72 h reached 7,157 µg, i.e. 99% of the initially loaded antibiotic. The cumulatively released amount of ofloxacin was 5,505 µg (76% of loading dose). Main fraction of release (about two thirds) was detected for both antibiotics for a elution period 0 - 24 h. In the periods 24 - 48 and 48 - 72 h the released amount of tobramycin was significantly higher than for ofloxacin. The release from expander dried after loading tobramycin was comparable: The cumulatively released amount of 0.3% and 0.03% incubation solution was 99% and 79% of loading dose, respectively. CONCLUSIONS: The investigated hydro gel expanders soaked in antibiotic solution can store and further on release sufficient amounts of tobramycin or ofloxacin to produce antimicrobial effective concentrations in vitro in the surrounding environment according to the breakpoints reported by EUCAST [14]. This principle, when used in a clinical setting, might help to eliminate post-implantation infection, which is one of the major complications in clinical use.

[Amyloidosis--a rare differential diagnosis of an orbital tumour]. / Amyloidose--ein seltene Differenzialdiagnose orbitaler Raumforderungen.

BACKGROUND: Amyloidosis is a disorder caused by a misfoulding of proteins. The deposition of these proteins in tissues and organs can affect the normal function of those tissues and organs. MATERIALS AND METHODS: Two patients are presented and an overview over the so far published cases with a localised orbital amyloidosis is given. RESULTS: The first case is a 50-year-old woman with progressive ptosis since half a year, progressive proptosis since three months and deterioration of motility and deviation of the left globe. The second case is a 68-year-old man with progressive ptosis since four years and with affection of the subtarsal conjunctiva of the right eye. Macroscopically a yellow-brown, gelatinous, easily crumbled material was seen during operation. CONCLUSION: the histological proof of amyloidosis can be made visually in intense unidirectional polarised light after congo red staining. This should be done in suspected cases every time. The orbita can also be involved in systemic forms of amyloidosis, so a systemic form should be excluded. The localised amyloidosis has no effect on the survival time in contrast to the systemic forms does have an effect. An untreated systemic form may be associuated with a prognosis of only 9 to 13 months.

[Erdheim-Chester disease of the orbit with compressive optic neuropathy]. / Erdheim-Chester-Erkrankung der Orbita mit Kompressionsneuropathie.

A 60-year-old man presented with left exophthalmos and deterioration in visual acuity of slow evolution. Bilateral orbital Erdheim-Chester disease was diagnosed. Systemic evaluation revealed a retroperitoneal fibrosis. Treatment with interferon-alpha followed, but bilateral compressive optic neuropathy with visual acuity deterioration and visual field defects evolved. Bilateral orbital decompression was performed.

Systemic and ophthalmological anomalies in congenital anophthalmic or microphthalmic patients.

INTRODUCTION: Congenital anophthalmos and microphthalmos are reported to occur in 1-20/100 000 newborn infants. The conditions may be characterised by associated pathology in the fellow eye when unilateral disease is present and/or by complex systemic anomalies. METHODS: We conducted a review of 75 patients with congenital anophthalmos or blind microphthalmos who were examined in our department from 1997 to 2008. Data on pregnancy, birth and family history were collected. Patients were screened for any pathology in the fellow eye in unilateral disease and for any systemic anomaly. RESULTS: Sixteen patients had blind unilateral microphthalmos. To date there has been only one case of bilateral microphthalmos. Congenital anophthalmos was unilateral in 38 and bilateral in 20 patients. Only one of the children had a positive family history for anophthalmos. None of the mothers had had problems in pregnancy or during delivery. There were more associated systemic findings in anophthalmic (50%) than in microphthalmic (17.6%) patients. Typically, the pathology was characterised by Goldenhar's syndrome, facial clefts and developmental cerebral anomalies. Four out of 16 patients with unilateral microphthalmos (25%) and 18 out of 38 patients with unilateral anophthalmos (47.4%) had anomalies in the fellow eye, predominantly coloboma, dermoid, sclerocornea and glaucoma. On account of this pathology in a single eye, two (12.5%) of the patients with unilateral microphthalmos and 13 (34.2%) of the patients with unilateral anophthalmos, as well as all 20 patients with bilateral anophthalmos, were classified as legally blind. Therefore the overall blindness rate was 17.6% in microphthalmos and 3.4 times higher (56.9%) in anophthalmos. CONCLUSIONS: All children born with congenital anophthalmos or microphthalmos require a thorough clinical examination by an experienced ophthalmologist to rule out pathology in the fellow eye in unilateral disease and by a paediatrician to screen for any associated systemic anomalies.

[Comparing specific disc findings of a European and a Bantu population]. / Vergleich papillenspezifischer Parameter einer europäischen und einer Bantu-Population.

BACKGROUND: Glaucoma is the main cause of irreversible blindness in the world. Because of the increasing mean age, glaucoma is expected to become more common in the developing countries. Besides tonometry and perimetry the appearance of the optic nerve head is a main part of glaucoma diagnosis. Ethnic differences have to be considered. This study compares the appearance of the optic nerve head between blacks and whites. STUDY DESIGN: This is a retrospective analysis of 225 whites of a Swiss population and 1027 blacks of a Congolese population. Using a matched pairs technique 207 whites and 207 blacks were chosen, regarding age, sex, intraocular pressure and examined eye (right/left). The analysis of the optic nerve head was performed by using the "Heidelberg-Retina-Tomograph II" (HRT). RESULTS: Among the 207 persons of both groups we found 116 females and 91 males. There were 103 right eyes and 104 left eyes examined. The mean age was 45.6 +/- 15.6 years. Compared with European population in the African population we found a greater disc area (2.56 vs. 1.81 mm(2)) as well as a greater cup area (0.65 vs. 0.41 mm(2)) and a greater rim area (1.91 vs. 1.40 mm(2)). Regarding the cup disc area ratio there was no significant difference between both populations found (Kinshasa: 0.24 vs. Basel: 0.21). Although there was no significant difference of the maximum cup depth of both groups we found a deeper mean cup depth in the African population. Furthermore, we found differences regarding the cup shape measure, the RNFL thickness and the height variation contour. CONCLUSION: As already described in different studies, there are significant differences in the morphology of the optic nerve head between blacks and whites. Although blacks are expected to have a greater cup disc area ratio, this fact could not be proved in this study. As a new fact we found a different mean cup depth between Africans and Europeans, which might be explained by the different cup shape of both populations.

[Autogenous tarsus transplant as spacer for treatment of lower lid retraction in Grave's disease]. / Das freie autologe Tarsustransplantat als Spacer zur Behandlung der Unterlidretraktion bei Endokriner Orbitopathie.

BACKGROUND: Lower lid retraction in dysthyroid orbitopathy is of less functional concern than optic neuropathy or diplopia in central positions of gaze. However, it may lead to incomplete lid closure resulting in corneal exposure. Patients often suffer from aesthetic impairment. PATIENTS AND METHODS: A retrospective analysis of 13 consecutive patients treated for lower lid retraction due to Grave's Disease between 2005 and 2007 was undertaken. In spite of regular ophthalmological examinations, specific attention was directed to measurement of the lid fissure width and scleral show for quantification of lower lid retraction. OPERATION: The lower lid is everted and the conjunctiva is opened horizontally underneath the tarsal edge. Lower lid retractors are disinserted and dissected until the lower lid might be elevated in symmetry to the fellow eye. This procedure is continued until 1 mm overcorrection is gained. A free tarsal transplant is harvested from the ipsilateral upper lid tarsus. At least 4 mm vertical tarsus have to be left. Tarsus is sutured with absorbable material. RESULTS: In the 13 patients operated upon (9 women, 4 men) aged 23 - 67 years, scleral show was preoperative 2.7 mm (mean) and postoperative 0.1 mm. Lid fissure width was preoperative 13 mm (10 - 16 mm) and immediately postoperative 10.3 mm (7 - 13). 6 months postoperative the lid-elevating effect was reduced by 0.5 mm in maximum in the 9 patients available for control. The lid closure deficit, which was present in 7 patients before, could be corrected completely in 5 and diminished to 1 mm in 2 patients. CONCLUSIONS: Using this particular technique, functional and aesthetical satisfying results are obtained. The main advantages are renunciation of allogen, xenogeny or synthetic material with its possible risks of slow-virus infection and/or extrusion. Further studies are necessary to evaluate long-term results.

[Comparing applanation and impression tonometry in Central African Bantu people]. / Vergleich der Applanations- und Impressionstonometrie in der zentralafrikanischen Bantu-Bevölkerung.

BACKGROUND: Glaucoma is the main reason for irreversible blindness in the Central African population. Because of the high prevalence, the rapid progression and the limited possibilities of diagnosis and treatment in Africa, glaucoma leads more often to blindness, compared with other parts of the world. The irreversible character of the glaucoma makes it necessary to recognise this disease as soon as possible. Beside the appearance of the optic nerve and visual field defects, tonometry is considered as an essential part of the diagnosis of glaucoma. This study compares the Shiotz tonometer with applanation tonometry to find out whether the Shiotz tonometer presents similar results in the African population. STUDY DESIGN: In the time between October 2001 and July 2002 in the Democratic Republic of Congo 2020 eyes of 1027 persons were examined. Beside other ophthalmological examinations the intraocular pressure were taken by applanation (Perkins tonometer) and impression tonometry (Shiotz tonometer). RESULTS: A difference of more than 2 mmHg between the two methods was found in 26.5 % of the examined eyes. Among the first 1000 eyes this difference was found in 40 % of the eyes, while among the second part of the examined eyes only in 13.2 % did a difference appear. Both methods showed a good correlation with k = 0.96 (p < 0.01). For short- or long-sighted eyes, a difference between both methods was found more often than for normal eyes. Among the long-sighted eyes the impression tonometry found higher values for the intraocular pressure more often than among the short-sighted eyes. But altogether the applanation tonometry showed higher values more often for short- as well as for long-sighted eyes. There were no correlations between the age of the examined persons and the difference between the two methods. CONCLUSION: Altogether it can be said that for screening impression tonometry shows a satisfactory correlation with applanation tonometry in the hands of a well-trained ophthalmologist, who has done at least 1000 examinations. Differences between the two methods are mainly found for long- or short-sighted eyes.