[Geriatric ophthalmologic co-management : A case report of interdisciplinary collaboration]. / Geriatrisch-ophthalmologisches Co-Management : Ein Fallbeispiel interdisziplinärer Zusammenarbeit.

This case report details the assessment and interdisciplinary collaboration in the management of an 81-year-old patient presenting with acute visual impairment, dizziness, general weakness, gait disturbances and fear of falling. A holistic geriatric evaluation revealed orthostatic dysregulation and an underlying multifactorial gait disorder exacerbated by visual impairment. Ophthalmological findings included left central retinal artery branch occlusion and cataracts. A comprehensive geriatric assessment showed frailty, impaired mobility and decreased functional abilities. Subsequent patient-centered interdisciplinary approaches included treatment for retinal ischemia, orthostatic testing, medication reconciliation, physiotherapy and occupational therapy. This case emphasizes how interdisciplinary collaboration between ophthalmology and geriatrics enables proactive assessment and intervention to reduce the risk of functional decline and loss of autonomy in visually impaired patients, which is of particular relevance considering the increasing prevalence of visual impairment in the ageing population.

[Predictive Value of OCT-Controlled Early Response of Macular Edema Secondary to Retinal Vein Occlusion After Intravitreal Bevacizumab Therapy]. / Prognostischer Wert des frühen OCT-kontrollierten Ansprechens des konsekutiven Makulaödems der retinalen venösen Verschlüsse nach intravitrealer Gabe von Bevacizumab.

INTRODUCTION: The goal of this study was to examine the response of macular edema (ME) secondary to retinal vein occlusion (RVO) to predict macular edema course and re-injection intervals. MATERIAL AND METHODS: Twenty-four eyes from 24 patients with ME secondary to RVO, both central (CRVO) and branch (BRVO), were retrospectively included. All eyes received intravitreal bevacizumab therapy (1.25 mg/0.1 ml). Repetitive optical coherence tomography (OCT) examinations were performed to document the early macular edema response to treatment and the course of the disease during the first three monthly injections until the last follow-up 105 days after the first injection. RESULTS: A significant ME reduction is present as early as three hours after the first injection of bevacizumab. This significant reduction of central retinal thickness (CRT) is present until the third post-injection day. The greatest reduction occurs during the first 24 hours. Patients who reach a CRT less than 300 µm after 24 hours (day 1) have no recurrence after 30 days. Patients with a CRT over 300 µm on day 1 have a 50% rate of recurrence after 30 days. The favorable results of the first group are still present during the last follow-up examination, 105 days after the first injection. DISCUSSION AND CONCLUSION: An OCT examination, 24 hours after the first bevacizumab injection, has a prognostic value and can identify the patients that can tolerate longer intervals between injections, this results in fewer bevacizumab injections during the course of the disease. This way an individualization of the treatment, opposed to a fixed therapy pattern, can be implemented. Also, patients with poor prognosis can be identified early and treatment can be altered or intensified accordingly.

Ophthalmic surgeries on post mortem porcine eyes with picosecond ultrashort laser pulses.

Purpose: This work demonstrates significant advantages in ophthalmic surgeries through the use of picosecond ultrashort laser pulses instead of state-of-the-art nanosecond laser pulses. These ultrashort lasers shall serve as universal tools more effectively combining advantages of high precision, low impact and economic advantages compared to existing instruments. Methods: As samples, we used post-mortem porcine eyes on which we performed the experiments with both picosecond and nanosecond lasers. Performed surgeries were laser iridotomy, (post-) cataract treatment/capsulotomy and selective laser-trabeculoplasty. Pulse widths were between 12 ps and 220 ns with pulse energies between 30 µJ and 10 mJ at 532 nm and 1,064 nm. Additionally, we investigated accompanying shock waves, cavitation bubbles, and heat effects during the ablation processes. Results: For all surgeries, significant differences were observed between picosecond and nanosecond pulses: It was possible to scale the pulse energy down to 10 of microjoules rather than requiring millijoules, and resulting tissue ablations are much more precise, more deterministic and less frayed. The shock wave and cavitation bubble investigation revealed major differences in pressure between picosecond pulses (0.25 MPa, 50 µJ) and nanosecond pulses (37 MPa, 5 mJ). The heat input during ablation could be lowered by two orders of magnitude. Conclusion: Picosecond ultrashort laser pulses show substantial benefits for several ophthalmic surgeries, with regard to ablation precision, shock wave generation and heat input. They are better than state-of-the-art ophthalmic nanosecond lasers in all aspects tested.

Influence of fibronectin on the adherence of Staphylococcus epidermidis to coated and uncoated intraocular lenses.

PURPOSE: To determine the effect of the modification of intraocular lens (IOL) surface properties on the adhesion of Staphylococcus epidermidis caused by fibronectin (FN) as the predominant proadhesive glycoprotein of the eye's initial foreign body reaction. SETTING: University of Saarland, Homburg/Saar, Germany. METHODS: Eleven IOL types were tested. The IOLs were of poly(methyl methacrylate), acrylate, or silicone. Some were surface modified with heparin or polysaccharide coating. The IOLs, unadsorbed or preadsorbed with fibronectin (FN), were incubated with [(3)H]-thymidine-labeled S epidermidis Rp62a, and the amount of adherent microorganisms was determined. RESULTS: Attachment of S epidermidis adhesion to various types of IOLs, both unadsorbed and FN precoated, varied significantly. The attachment to highly adhesive IOLs was almost 4-fold greater than that to low-adhesive IOLs. Attachment to FN precoated IOLs was generally enhanced compared with attachment to unadsorbed IOLs. Heparin surface modification resulted in no or a modest reduction in bacterial adhesion compared with unmodified IOLs. Bacterial adhesion was highly statistically significantly less on IOLs with polysaccharide surface modification. CONCLUSIONS: There was significant variability in S epidermidis adhesion to IOLs as a function of design, material, surface modification, and FN preadsorption. Application of the findings may foster new developments to further reduce the major complication in cataract surgery, infective endophthalmitis.

Pharmacologic prevention of posterior capsule opacification: in vitro effects of preservative-free lidocaine 1% on lens epithelial cells.

PURPOSE: To assess the in vitro effectiveness of preservative-free lidocaine 1% in removing lens epithelial cells (LECs) from the anterior capsule and to evaluate the effect of lidocaine on the LECs. SETTING: Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: Eight rabbits (16 eyes) were used in the study. After the rabbits were killed, the eyes were enucleated and divided into 2 groups. In Group 1 (n = 8 eyes), LECs were exposed to preservative-free lidocaine 1% or balanced salt solution (BSS) for 1, 2, or 5 minutes. The anterior capsules were then stained with trypan blue and alizarin red. Photomicrographs of each capsule were taken and analyzed for LEC damage. In Group 2 (n = 8 eyes), hydrodissection was performed with 1 of the agents, followed by phacoemulsification and cortical cleanup. The LEC attachment to the anterior capsule was evaluated by histopathology. RESULTS: Anterior capsule fragments irrigated with BSS showed no LEC nuclear staining; ie, no direct toxic effect. In those irrigated with preservative-free lidocaine 1%, the LECs showed mild toxicity; some cells showed blue nuclear staining. After hydrodissection with lidocaine, the capsules were almost free of LECs; after hydrodissection with BSS, the capsules showed a normal layer of LECs attached to the anterior capsule. CONCLUSIONS: Preservative-free lidocaine 1% may help diminish the amount of live LECs by facilitating cortical cleanup, by loosening the desmosomal area of cell-cell adhesion with decreased cellular adherence, or by a direct toxic effect. The use of this agent may help prevent posterior capsule opacification.

Bipseudophakia: clinicopathological correlation of a dropped lens.

PURPOSE: To examine postmortem human globes containing an anterior chamber and a posterior chamber intraocular lens (IOL). SETTING: Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Charleston, South Carolina, USA. METHODS: The globes were sectioned at the equator, and the anterior and posterior segments were macroscopically examined. Gross photographs were taken using the Miyake-Apple posterior photographic technique. Histological sections were cut and stained with hematoxylin and eosin, periodic acid-Schiff, and Masson's trichrome. RESULTS: Histopathological findings included a large Soemmering's ring, a tear in the posterior capsule, 1 haptic of the anterior chamber IOL displaced into the iridectomy, thin and atrophic corneal epithelium, separation of Bowman's layer and stroma by fibrovascular tissue, and atrophy of the retinal ganglion cell layer and nerve fiber layer. CONCLUSION: In cases in which secondary IOL implantation is indicated, removing the dislocated IOL appears to be a reasonable choice.

Scanning electron microscopic and histologic evaluation of the AcrySof SA30AL acrylic intraocular lens. Manufacturing quality and morphology in the capsular bag.

PURPOSE: To evaluate the properties of the AcrySof(R) SA30AL (Alcon Laboratories, Inc.) single-piece foldable posterior chamber intraocular lens (IOL). SETTING: Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: Two nonimplanted clinical-quality AcrySof IOLs were examined by gross, light, and scanning electron microscopy (SEM). In addition, 2 eyes implanted with this IOL obtained post-mortem, the first such eyes accessioned in our laboratory and the first described to date, were examined using the Miyake-Apple posterior photographic technique and by histologic sections. RESULTS: Scanning electron microscopy of the SA30AL IOL showed excellent surface finish. The edge of the optic was square (truncated) and had a matte (velvet or ground-glass) appearance, a feature that may minimize edge glare and other visual phenomena. A well-fabricated square or truncated optic edge was demonstrated. Miyake-Apple analysis revealed that the SA30AL IOL showed appropriate fit and configuration within the capsular bag. Histologic correlation of the IOL's square edge and its relation to the capsular bag and adjacent Soemmering's ring were noted. CONCLUSIONS: The AcrySof SA30AL IOL is a well-fabricated lens that situates well in the capsular bag. The truncated optic and its relationship to adjacent structures show a morphological profile that has been shown to be highly efficacious in reducing the rate of posterior capsule opacification.

Correlation between different measurements within the eye relative to phakic intraocular lens implantation.

PURPOSE: To obtain measurements of the white-to-white distance and the anterior chamber and ciliary sulcus diameters in phakic human eyes obtained post-mortem to find a correlation between these measurements. SETTING: David J. Apple, MD Laboratories for Ophthalmic Devices Research, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. METHODS: Twenty-two phakic human eyes obtained from eye banks within 24 hours of death were evaluated. The following measurements were performed: white-to-white distance, anterior chamber diameter with a plastic sizer after a small limbal incision, and anterior chamber and ciliary sulcus diameters after fixation and sagittal section of the eyes. The first 10 eyes were studied at the 6 o'clock to 12 o'clock meridian and the last 12 eyes, at the 3 o'clock to 9 o'clock meridian. RESULTS: A positive correlation was found between the white-to-white measurements and the anterior chamber diameter in the 10 eyes studied at the 6 o'clock to 12 o'clock meridian but not in the 12 eyes studied at the 3 o'clock to 9 o'clock meridian. The latter is the meridian frequently used by surgeons to perform white-to-white measurements and thus choose the overall size of the phakic intraocular lens to be implanted. No correlation was found between the white-to-white measurements and the ciliary sulcus diameter in the 2 meridians. CONCLUSION: Experimental studies using cadaver eyes are helpful in evaluating sizing techniques for phakic IOL implantation as well as in better understanding the anatomical relationships between ocular structures.

Rates and causes of intraoperative removal of foldable and rigid intraocular lenses: clinicopathological analysis of 100 cases.

PURPOSE: To analyze the rates of and reasons for intraoperative explantation of foldable and rigid intraocular lenses (IOLs) to determine the complication profile of each IOL design. SETTING: Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: The study comprised data analysis of foldable (n = 85) and rigid (n = 15) IOL specimens that were explanted immediately after primary implantation. RESULTS: Eighty-five foldable intraoperative explants were accessioned. These comprised 14.5% of the 586 foldable IOL explants received between January 1988 and September 2000. There were 15 rigid poly(methyl methacrylate) (PMMA) intraoperative explants out of 2077 rigid explant specimens (0.7%). Fifty-one (60%) of the foldable IOLs requiring intraoperative explantation were the 1-piece silicone plate-haptic large-hole design, and 29 (34.1%) were the 3-piece silicone polyimide-haptic design. The most frequent reason for explantation of both designs was optic damage, 37.3% in the large-hole design and 55.2% in the polyimide design. Optic damage did not occur in rigid PMMA IOLs. CONCLUSION: Some foldable IOL designs have a higher risk of damage during surgical insertion than rigid designs. Two modern foldable IOLs, the silicone plate-haptic large-hole and the silicone polyimide-haptic, appear to be more prone to damage during folding, loading, and implantation than other IOLs.

Evaluation of 3 modern single-piece foldable intraocular lenses: clinicopathological study of posterior capsule opacification in a rabbit model.

PURPOSE: To assess the development of posterior capsule opacification (PCO) with 3 modern single-piece foldable intraocular lenses (IOLs) in a histopathological study and to compare the potential preventive effects of the IOL design and biomaterial in retarding PCO. SETTING: Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: Thirty-one rabbit eyes were randomly operated on with phacoemulsification and implantation of 3 single-piece foldable lenses: a hydrophilic acrylic design, the Rayner Centerflex 570H (n = 11); a hydrophobic acrylic design, the Alcon AcrySof SA30AL (n = 10); and a silicone large-hole plate design, the Staar AA-4203VF (n = 10). Central PCO (CPCO), peripheral PCO (PPCO), and Soemmering's ring formation were evaluated 3 weeks after surgery using the Miyake-Apple posterior photographic technique. Histological sections of each globe were prepared to document capsular bag status and performance of IOL geometry. RESULTS: The acrylic IOLs (Centerflex and AcrySof) had lower CPCO and PPCO scores than the silicone plate IOL (P <.05). There was no significant difference in Soemmering's ring formation among the 3 models. Pathological evaluations revealed effective blockage of migrating lens epithelial cells (LECs) at the site of the truncated optic edge of the Centerflex and AcrySof IOLs, even in the presence of large amounts of retained/regenerative cortical material. CONCLUSIONS: The AcrySof IOL has a hydrophobic surface and the Centerflex a hydrophilic surface, but no correlation to these characteristics could be identified. The single-piece AcrySof optic geometry created a clear-cut barrier effect equal to that of its 3-piece predecessor. The anatomic profile of the Centerflex IOL shows the same characteristics. The optics of both acrylic lenses have square truncated edges that functionally block ingrowth of migrating LECs toward the central visual axis, leaving clear posterior capsules. The square optic edge was an appropriate geometric configuration to create a barrier effect. There was no effect of the biomaterial on PCO prevention.

Effect of haptic angulation on posterior capsule opacification in modern foldable lenses with a square, truncated optic edge.

PURPOSE: To analyze the effect of different haptic angulations on posterior capsule opacification (PCO) in a modern foldable intraocular lens (IOL) with a square-edged optic designed to reduce the incidence of PCO. SETTING: Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: Ten Dutch Belted, serum Pasteurella-free pigmented rabbits of the same age and sex had bilateral phacoemulsification with endocapsular IOL implantation. The eyes were implanted with Centerflex IOLs (Rayner) with haptic angulations of 0 degree (n = 8), 5 degrees (n = 4), 10 degrees (n = 4), or 15 degrees (n = 4). RESULTS: There was no statistical difference in central PCO, peripheral PCO, and measured IOL decentration among the angulation groups. CONCLUSION: With the Centerflex IOL, haptic angulation did not seem to be a significant factor influencing PCO. It appears that the barrier effect of the IOL's truncated, square-edged optic overrides the angulation factor in preventing PCO.

[Thrombotic thrombocytopenic purpura (Moschcowitz's disease)]. / Augenveränderungen bei thrombotisch-thrombozytopenischer Purpura (Moschcowitz-Syndrom).

BACKGROUND: TTP is a rare haematological disease consisting of thrombocytopenia, haemolytic anaemia, fever, neurological symptoms and renal failure. PATIENT: A 63-year-old female patient presented to our clinic with bilateral progressive loss of visual acuity accompanied by metamorphopsia. Ophthalmoscopy revealed pigmentepithelial choroidal atrophy secondary to the occlusion of chorioidal vessels and disseminated intraretinal and diffuse vitreal haemorrhage. Fluorescein angiography showed an obvious hyperfluorescence in the areas of choroidal atrophy as well as perivascular leakage. The patient had a history of TTP, as diagnosed by internal medicine. CONCLUSION: Vascular damage in TTP is due to disseminated hyalin clots of fibrin platelets which aggregate in the small capillaries, caused by a disorder of the endothelium-thrombocyte interaction. When evaluating patients with occlusion areas of the choriocapillaris, Moschcowitz's disease should be taken into consideration even in elderly patients.

Evaluation of neodymium:yttrium-aluminum-garnet capsulotomies in eyes implanted with AcrySof intraocular lenses.

PURPOSE: As of December 31, 2000, the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser posterior capsulotomy rate for the Alcon AcrySof intraocular lens (IOL) as measured in our database was 3.3%. This was the lowest of any IOL model used in the United States. Only 12 of 361 cases required treatment. We analyzed possible surgical reasons that may have been responsible for the posterior capsule opacification (PCO) in this small group. Special attention was given to the three surgical factors that we had previously identified as being important for PCO reduction: (1) quality of cortical clean up, (2) type of haptic fixation, and (3) continuous curvilinear capsulorhexis (CCC) size and shape. DESIGN: Comparative autopsy tissue analysis. PARTICIPANTS: Three hundred sixty-one human eyes obtained postmortem with Alcon AcrySof IOLs, accessioned between January 1995 and December 2000 from Lions Eye Banks. METHODS: The eyes were evaluated by the Miyake-Apple posterior photographic technique. MAIN OUTCOME MEASURES: The area and intensity of Soemmering's ring and type of fixation were studied in 361 eyes. The size and shape of the CCC and relation of the CCC edge to the IOL's optic rim were analyzed in 168 eyes. RESULTS: The amount of Soemmering's ring formation was significantly larger in the group of IOLs requiring Nd:YAG capsulotomy (Nd:YAG group). The not in-the-bag fixated IOLs required more Nd:YAG capsulotomies. Although the trend was clear, the number of specimens was not large enough to acquire statistical significance. The Nd:YAG group showed a highly significant difference compared with the No Nd:YAG group with regard to the amount of clock hours of the CCC edge on the optic rim's surface (P < 0.001). Mean CCC diameters were significantly larger in the Nd:YAG group (P < 0.05). CONCLUSIONS: The amount of Soemmering's ring correlates with the quality of cortical clean up. Cells within the Soemmering's ring are the direct precursors of PCO. This study confirms our previous laboratory studies and the clinical assumption that the incidence of PCO and thus the need for Nd:YAG capsulotomy is correlated with the cortical clean up. A second clinical assumption, that poor IOL fixation increases the risk of PCO, is also strongly suggested in this study. This study also verifies the relation of the CCC to PCO and the Nd:YAG laser, namely that a relatively small CCC without tears is best to prevent this complication. Use of a high-quality IOL combined with diligent attention to these three surgical factors should lower further the incidence of PCO.

Epithelial downgrowth after clear cornea phacoemulsification: report of two cases and review of the literature.

OBJECTIVE: To report two cases of diffuse epithelial downgrowth after clear cornea phacoemulsification and to review the different treatment options for this ominous disease. DESIGN: Two interventional case reports. METHODS: Retrospective review of two eyes from two different patients in whom epithelial downgrowth developed 7 and 3 months after uneventful clear cornea phacoemulsification. In the first case, the epithelial invasion seemed to be growing from the temporal incision site onto the corneal endothelium toward the visual axis. Cryotherapy was applied to the affected cornea, with control of the growing membrane. A penetrating keratoplasty was performed to restore visual function. In the second patient, the membrane was attached to the iris and posterior cornea and was confirmed by diagnostic argon laser photocoagulation. This case was surgically treated with en bloc excision and a corneoscleral graft. MAIN OUTCOME MEASURES: Visual acuity at the final follow-up visit. RESULTS: Surgical treatment of the epithelial downgrowth was different for both patients. In the postoperative period, a best-corrected visual acuity of 20/60 and 20/30 was achieved in each case. No regrowth of the membrane was observed. CONCLUSIONS: Treatment of epithelial downgrowth is controversial. We present two cases of epithelialization of the anterior chamber with either clinical or histologic confirmation after clear cornea sutureless phacoemulsification. Surgical treatment should be attempted promptly to obtain a good visual prognosis.

Snowflake degeneration of polymethyl methacrylate posterior chamber intraocular lens optic material: a newly described clinical condition caused by unexpected late opacification of polymethyl methacrylate.

OBJECTIVE: To report 25 cases of gradual, but sometimes progressive, late-postoperative degeneration of polymethyl methacrylate (PMMA) optics of posterior chamber (PC) intraocular lens (IOL) implants, often resulting in a clinically significant visual decrease long after the implantation, sometimes to a severity that required IOL explantation/exchange. DESIGN: Analysis of explanted PC IOLs, clinical histories, and photographs. PARTICIPANTS: We analyzed 25 case histories/photographs and/or explants from 18 patients implanted in the 1980s to mid-1990s with three-piece PC IOLs with PMMA optics and with polypropylene or PMMA haptics. The IOL optic from each case had characteristic snowflake or crystalline opacifications. This condition occurred with more than one manufacturer and in some cases was restricted to certain lot numbers. METHODS: The explanted IOLs (n = 10) were studied by gross inspection and by light and scanning electron microscopy, as well as confocal and energy dispersive spectroscopy. MAIN OUTCOME MEASURES: The snowflake lesions were noted within the IOL optics. The nature of these lesions was investigated. RESULTS: Assimilation of clinical information with pathologic and morphologic profiles of all cases suggested that the snowflake opacification was a small spherical lesion surrounded by an outer pseudocapsule composed of compressed, degenerated PMMA, with a central core containing convoluted fragments of PMMA. The lesions were classified into four clinical and pathologic grades according to their density and severity. CONCLUSIONS: This is the first clinicopathologic correlative report on this complication. We postulate that manufacturing variations in some IOL models fabricated in the 1980s and early 1990s are responsible. The snowflake lesions seem to represent a destruction of the PMMA material. The cluster of lesions in implanted lenses manufactured by Surgidev was less progressive than some other models, including lenses made by IOPTEX Research Corporation. This identification of a condition previously unreported is important to alert clinicians regarding these perplexing lesions that may otherwise be considered idiopathic, with no obvious clinical hint as to their origin. The prevalence noted thus far is still too low to in any way suggest that this condition would occur in 100% of PMMA IOLs from these manufacturers. However, these late-occurring lesions, present in lens models that were implanted in hundreds of thousands of patients in the last decade or so, could have constituted a true epidemic, except that many of the patients are now deceased.