[Amniotic membrane transplantation in proven ulcerative herpetic keratitis: successful anti-inflammatory treatment in time]. / Amnionmembrantransplantation bei gesicherter ulzerativer Herpeskeratitis: Erfolgreiche Entzündungshemmung zum richtigen Zeitpunkt.

BACKGROUND: In active herpetic keratitis, treatment with systemic and topical aciclovir together with low dosed-out steroids has been successful for few decades. However, in cases with severe herpetic ulcer and melting inflammation, emergency penetrating keratoplasty is necessary, which carries high risk for recurrent herpetic keratitis and rejection. The anti-inflammatory effect of amniotic membrane transplantation can be used as a first surgical step in order to gain time for planned penetrating keratoplasty. The results are analysed in this retrospective case series. PATIENTS: Twelve eyes of 12 patients with clinically highly active herpetic ulcer without healing despite topical and systemic aciclovir were treated with amniotic membrane transplantation. Ten of 12 eyes (83 %) showed positive PCR testing for HSV-1. In one case, the molecular genetic result was negative, one analysis for HSV was not done. For surgery, debridement of the margins and the ground of the ulcer was done with steam heated cauterization. Afterwards, an amniotic membrane was made to cover the defect and fixed with single sutures. Peri- and postoperatively, the patients were treated with systemic aciclovir (4000 mg daily one week, 2000 mg daily 2 weeks) and gentamicin ointment topically. RESULTS: Mean follow-up was 6.8 months (1-12.5). After 25 days in the mean (11-34), nine of 12 patients experienced an intact epithelial corneal surface together with a clinically clear reduction of the inflammation. Three other patients did not recover and were treated with emergency penetrating keratoplasty after 31 days in mean (25-35). Visual acuity did not improve after amniotic membrane transplantation except in one case. CONCLUSION: The known anti-inflammatory potential of amniotic membrane causes a reduction of the inflammatory process in herpetic ulcer. A precondition is a sufficient antiherpetic and anti-inflammatory therapy and a decision for amniotic membrane transplantation in time in order to avoid an emergency penetrating keratoplasty. This gives the opportunity to perform planned penetrating keratoplasty with optimal HLA-match and postoperative immunosuppression.

[Acquired esotropia at advanced age]. / Erworbenes Innenschielen im Alter.

BACKGROUND: Patients, most of whom are in their 8th decade of life, can suffer from a minimal acquired esotropia. They complain of blurred vision instead of diplopia due to their confusion. This is accompanied with the risk that the investigation covers only monocular disturbances. PATIENTS AND METHODS: Of 39 such patients, 22 underwent surgery while 10 were fitted with prisms. Another 3 recovered spontaneously and became, therefore, classified as VIth nerve palsies although no limitation of the abduction could be stated. Four patients refused any therapy, and 2 of them recovered in the course of many years. RESULTS: After 2 to 7 years, the individuals corrected with prisms were still compensated while within the operated cohort 3 had a recurrence after years. CONCLUSIONS: In almost all cases the prescription of separate glasses for distance with about 3 Delta base out on either side compensates the deviation for several years. In surgical units one finds a summation of chronically decompensated patients with obvious diplopia who need a bimedial recession. Lateral rectus resections are not appropriate as they lead to actual overabduction and final recurrence as well.

[Impairment of safety in navigation caused by alcohol: impact on visual function]. / Beeinträchtigung der Sicherheit im Schiffsverkehr durch Alkohol. Einfluss auf das Visuelle System.

BACKGROUND: So far in Germany, no legally binding standards for blood alcohol concentration exist that prove an impairment of navigability. The aim of our interdisciplinary project was to obtain data in order to identify critical blood alcohol limits. In this context the visual system seems to be of decisive importance. MATERIALS AND METHODS: 21 professional skippers underwent realistic navigational demands soberly and alcoholized in a sea traffic simulator. The following parameters were considered: visual acuity, stereopsis, color vision, and accommodation. RESULTS: Under the influence of alcohol (average blood alcohol concentration: 1.08 per thousand ) each skipper considered himself to be completely capable of navigating. While simulations were running, all of the skippers made nautical mistakes or underestimated dangerous situations. Severe impairment in visual acuity or binocular function were not observed. Accommodation decreased by an average of 18% ( p=0.0001). In the test of color vision skippers made more mistakes ( p=0.017) and the time needed for this test was prolonged ( p=0.004). CONCLUSIONS: Changes in visual function as well as vegetative and psychological reactions could be the cause of mistakes and alcohol should therefore be regarded as a severe risk factor for security in sea navigation.

[Impairment of safety in navigation caused by alcohol: pupillography and measurement of pupil movements]. / Beeinträchtigung der Sicherheit im Schiffsverkehr durch Alkohol. Pupillographie und Augenbewegungsmessungen.

OBJECTIVE: To evaluate data in an interdisciplinary project (ophthalmology, forensic medicine, internal medicine, psychology,and nautical science) in order to identify critical blood alcohol limits in sea navigation. METHODS: A sea traffic simulator was employed for realistic nautical demands on 21 professional experienced skippers under sober and alcoholized conditions (target blood alcohol concentration: 1.0 per thousand ). After simulated navigation, pupil light reflex, spontaneous pupil movements,nystagmus,and saccades were evaluated by pupillography. Modification of the pupillograph enabled us also to measure optokinetic nystagmus. RESULTS: Evaluation of the pupil light reflex revealed obvious changes in the extent of relative contraction and in redilatation time under the influence of alcohol. Diminished vigilance could be observed in all of the skippers when optokinetic nystagmus was tested. CONCLUSION: The pupillograph represents a suitable device for measuring functions of the visual and vegetative systems. Thus, the impact of these functions on nautical capability can be demonstrated. If further investigations such as ophthalmological, medical, psychological, and nautical evaluations are taken into account, it could be determined that blood alcohol levels of 1.0 per thousand may exclude safe navigation.

[Pars plana vitrectomy in cystoid macular edema of different forms of chronic uveitis]. / Pars-plana-Vitrektomie bei zystoidem Makulaödem bei verschiedenen Formen der chronischen Uveitis.

BACKGROUND: Cystoid macular edema (CME) is a common complication in different forms of chronic uveitis. In spite of immunosuppressive and anti-inflammatory therapy, chronic or relapsing courses can occur which may have a negative impact on visual prognosis. Pars plana vitrectomy (PPV) is known to positively influence chronic uveitis. This retrospective study was performed to investigate the role of PPV in the therapy refractive uveitic CME. PATIENTS AND METHODS: PPV for CME was performed in eyes with CME in intermediate uveitis (IMU, n=42), chronic iridocyclitis in juvenile rheumatoid arthritis (CIC, n=14) and multifocal chorioretinitis (MFC, n=12). In none of the eyes had immunosuppressive and/or anti-inflammatory therapy or anti-edema treatment (e.g.acetazolamide) led to regression of the CME. After a postoperative follow-up period of 7 and 106 months all patients were re-examined. RESULTS: Postoperative complete or partial regression of CME was observed as follows: IMU: 25/42 (59.5%), CIC: 8/14 (57.1%),MFC: 5/12 (41.7%). A significant increase in visual acuity of 2 lines and more was observed in 50%,71.4% and 41.7% of eyes, respectively. In the long-term follow-up best functional results were achieved in eyes with IMU. CONCLUSIONS: Response to PPV was variable according to the type of underlying form of uveitis. The lowest success rate could be observed in eyes with MFC. Although the postoperative regression rate of CME was satisfactory in eyes with CIC, long-term visual acuity results were disappointing due to secondary complications of CIC in this young age group. Best results were achieved in patients with IMU (statistically not significant). A multicenter study in a larger series of patients is needed to investigate the exact role of PPV in different forms of chronic uveitis.

[Alcohol-induced morphologic and biochemical corneal changes]. / Alkoholinduzierte morphologische und biochemische Hornhautveränderungen.

In our cornea bank, it was noticed that corneas from donors with alcoholism seemed to be of lower quality than corneas from other donors. High blood ethanol concentrations can induce high alcohol concentrations in aqueous and vitreous humor. This could be demonstrated in the case of a lethal alcohol intoxication. We conducted in vitro experiments to clarify the question of alcohol-induced changes of corneas. The corneas were stored in a standardized culture medium including ethanol, formic acid, methanol, and acetaldehyde in concentrations to be expected in chronic alcoholism. During cultivation over 4 weeks, endothelial morphology and extent of aspartic acid racemization in stromal proteins were evaluated. The extent of aspartic acid racemization served as a biochemical parameter of alcohol-induced protein changes of the corneas. In the in vitro experiments, a drop in the endothelial cell counts could be seen in corneas stored in culture medium with acetaldehyde. The extent of aspartic acid racemization increases in corneas stored in medium containing ethanol, which obviously is the result of alcohol-induced protein degradation. High concentrations of ethanol and its metabolics can be detected in vitreous and aqueous humor in chronic alcoholism. Clearly, these concentrations have a direct toxic effect on the corneal endothelium (acetaldehyde) and on the stromal proteins (ethanol).

Pars-plana vitrectomy in cystoid macular edema associated with intermediate uveitis.

BACKGROUND: Cystoid macular edema (CME) is a common complication in the course of intermediate uveitis. In spite of systemic therapy with steroids or carbonic anhydrase inhibitors, persistence of CME is observed. Pars plana vitrectomy (PPV) is known to influence the course of intermediate uveitis positively. The present study was performed to investigate the role of PPV in the therapy of CME in intermediate uveitis. MATERIALS AND METHODS: Forty-two eyes of 32 patients were re-examined after PPV for CME. In all eyes fluorescein angiography was performed. Average age at the time of surgery was 31.9 years (range 6-64 years). All patients had received systemic corticosteroid and/or immunosuppressive treatment during the course of their disease. In some patients systemic therapy with carbonic anhydrase inhibitors was performed. The mean duration of postoperative follow-up was 20.2 months (range 6-102 months). RESULTS: Preoperative visual acuity (VA) in all eyes was between 1/10 and 0.5. Total regression of CME after surgery was observed in 18 of 42 eyes (42.8%), partial improvement in 7 eyes (16.7%). In 13 of 42 eyes (30.9%) the CME remained unchanged. Twenty-one of 42 eyes (50.0%) experienced a postoperative improvement of VA of 2 lines or more. In 18 of 42 eyes (42.8%) there was no change; in 3 eyes (7.2%) VA was less. In the long-term follow-up the corresponding results were slightly worse (17/17/8 eyes) due to secondary complications. In the majority of patients systemic medical therapy could be reduced or discontinued. CONCLUSION: Pars-plana vitrectomy led to regression of CME in 59% of cases and to subsequent improvement of VA in 50% of eyes with intermediate uveitis. PPV should be considered soon after medical therapy has been shown to be ineffective.

[Astigmatism-oriented perforating keratoplasty. A possibility for minimizing postoperative astigmatism?]. / Astigmatismusorientierte perforierende Keratoplastik. Eine Möglichkeit zur Minimierung des postoperativen Astigmatismus?

BACKGROUND: This pilot study examined whether astigmatism of donor corneas can be evaluated postmortem, and whether there is an effect on the astigmatism following keratoplasty. METHODS: The corneoscleral rims of donors were marked after measurement by a hand keratometer in the 12 o'clock position. We examined 38 patients after penetrating keratoplasty and divided them into three groups. The 12 o'clock position of the donor cornea was fixed in the same position as the recipient (group A, n = 12), or the donor corneas were transplanted with the axis in opposition to the axis of the recipient (group B, n = 12) or in the same orientation (group C, n = 14). Development of postoperative astigmatism was compared with controls (group D, n = 40). RESULTS: In group B we found a new orientation of the astigmatism axis within 2-4 months; in group C the axis maintained the original orientation of the recipient. Mean postoperative astigmatism was 3.5 +/- 1.5 dpt in group A, 2.1 +/- 1.3 dpt in group B, 5.8 +/- 1.6 dpt in group C, and 3.4 +/- 1.5 dpt in group D. After suture removal the axis orientation persisted in all groups. CONCLUSION: This study shows the possibility of evaluating corneal astigmatism in donor eyes. The astigmatism of the donor cornea itself directly influences the postoperative axis of astigmatism in recipient eyes. Astigmatism after corneal grafting can be reduced by orienting the donor astigmatism against the axis of the recipient.

[Postmortem evaluation of corneal astigmatism after astigmatism oriented penetrating keratoplasty]. / Postmortale Evaluation des kornealen Astigmatismus nach Astigmatismus-orientierter perforierender Keratoplastik (AOpKP).

BACKGROUND: Reduction of astigmatism following penetrating keratoplasty can be achieved if the graft is oriented according to astigmatism parameters in donor and host (AOPKP). Postmortem evaluation of these parameters is therefore essential. The aim of our investigation was to compare postmortem measurements using a hand-held keratometer with those of the living donor's astigmatism. METHOD: The 72-year-old female patient had undergone AOPKP on her right eye. After death the astigmatism in the right eye was evaluated 4.5 h postmortem using a hand-held keratometer. After explantation, the eyeball was examined by computer-assisted topography (TMS-1). RESULTS/CONCLUSION: We could show that hand keratometry in situ is reliable for evaluating astigmatism in donor eyes after death. As far as our AOPKP study is concerned, these results are of great interest. Reduction of postoperative astigmatism following penetrating keratoplasty is only possible if data on astigmatism of the donor and host corneas are available.