Three Cases of Spontaneous Hyphaema.

Background Spontaneous anterior chamber bleeding is a rare event. We present three photodocumented cases treated in our clinic. History and Findings Three patients sought medical assistance in our clinic because of bleeding inside the eye and/or visual impairment. None of them had a history of trauma or intraocular surgery. Treatment and Outcome Two patients had oral anticoagulation, which was discontinued. These cases were treated with topical steroids. The third patient had no anticoagulation and no topical steroids were used in treatment. Topical intraocular pressure-lowering drugs were administered as needed. In all three cases, the anterior chamber bleeding stopped spontaneously. No intervention was required. Even after resolution of the bleeding, there were no signs of iris abnormalities. Conclusions In cases of spontaneous anterior chamber bleeding without a history of trauma, oral anticoagulation, hypertension and iris abnormalities such as microaneurysm, pseudoexfoliation, iridocyclitis or neovascularisation have to be considered.

[One Year Experience with Quality Control of Cataract Surgery Using an Internet-Based EUREQUO Database]. / Ein Jahr Erfahrung mit der Qualitätssicherung der Kataraktoperation (EUREQUO) an einem öffentlichen Spital.

Purpose Quality control is particularly important in invasive medicine. As cataract surgery is the most frequently performed and most successful ophthalmic surgery, quality control should become mandatory. Patients and Methods Retrospective analysis of all cataract procedures performed in a 12 months period (01. 07. 2014 - 30. 06. 2015) at our hospital, using an internet-based EUREQOU database. This database is easy to use and allows local results to be compared with all participants in Switzerland and elsewhere in Europe. Results During one year, 904 cataract procedures were performed at our hospital. Of these, 892 with complete data were compared to 2918 operations performed in Switzerland and 274,644 in other European countries. Our sample contained more patients with markedly reduced visual acuity (< 0.1; 8.4/4.8/3.5 %; KSW/Switzerland/Europe), more patients with glaucoma (28.1/13.9/7.1 %) and more patients with pseudoexfoliation (22.8/11.5/0.56 %). Despite our training of young ophthalmic surgeons, the rate of capsular complications was as low (0.67/0.34/0.67 %) as in other series. Four to 6 weeks after surgery, the majority of patients achieved a best corrected visual acuity of ≥ 0.8 (79.2 vs. 87.4 % in Europe, not enough data from Switzerland). Biometric prediction error (79.2 % within ± 0.75 D) was within the target range, but in the lower quartile. Conclusions Despite the relatively high number of complex patients in our hospital, quality control reveals that we performed cataract surgery with low complication rates and good results. Although quality control is rapid and easy, only three centres in Switzerland are participating.

Sweet but dangerous - the role of immunoglobulin G glycosylation in autoimmunity and inflammation.

Glycosylation is well-known to modulate the functional capabilities of immunoglobulin G (IgG)-mediated cellular and humoral responses. Indeed, highly sialylated and desialylated IgG is endowed with anti- and pro-inflammatory activities, respectively, whereas fully deglycosylated IgG is a rather lame duck, with no effector function besides toxin neutralization. Recently, several studies revealed the impact of different glycosylation patterns on the Fc part and Fab fragment of IgG in several autoimmune diseases, including systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). Here, we provide a synoptic update summarizing the most important aspects of antibody glycosylation, and the current progress in this field. We also discuss the therapeutic options generated by the modification of the glycosylation of IgG in a potential treatment for chronic inflammatory diseases.

[Role of ocular pulse amplitude in glaucoma]. / Stellenwert der okulären Pulsamplitude beim Glaukom.

The ocular pulse amplitude is defined as the difference between diastolic and systolic intraocular pressure. The ocular pulse is generated by the pulsatile ocular blood flow in the choroid. It is dependent on the dynamics of the cardiovascular system, the rigidity of the ocular vessels on one side and the biomechanical properties of the eye on the other side. In addition the influence of outflow facility of the aqueous humor, the level of the intraocular pressure itself and last but not least the rigidity of the sclera on the ocular pulse amplitude is until now not clear. Dynamic contour tonometry (Pascal®) does not only measure intraocular pressure almost independent of corneal thickness and curvature but also allows easy and fast measurement of ocular pulse amplitude on the slit lamp. The ocular pulse amplitude in healthy subjects is between 1.2 and 4 mmHg. If the ocular pulse amplitude is larger than 1.2 mmHg spontaneous pulsations of the central retinal vein are visible on fundoscopy. In patients with ocular hypertension the ocular pulse amplitude is larger than in normal subjects but this is mainly due to higher IOP levels. In patients with manifest open-angle glaucoma the ocular pulse amplitude stays initially within the normal range. In more advanced stages of the disease and especially in patients with ocular perfusion pressure dependent optic neuropathy the ocular pulse amplitude is gradually reduced. Due to the various factors influencing ocular pulse amplitude a direct correlation between reduced ocular pulse amplitude and reduced ocular perfusion pressure has not been established as yet. New approaches investigating the variations of the ocular pressure Fourier spectral analysis are promising, especially when simultaneous analysis of the arterial blood pressure is performed. These techniques may allow a fast and easy discrimination between healthy and glaucomatous patients in the near future. If ocular pulse amplitude exhibits a massive inter-ocular asymmetry in the presence of symmetrical ocular findings of extraocular vascular pathologies (i.e. carotid stenosis) are the most likely cause and therefore should be excluded.

Training in cataract surgery in Spain: analysis of the results of a survey of the European Board of Ophthalmology in a Spanish cohort.

INTRODUCTION: A survey conducted by the European Board of Ophthalmology (EBO) revealed significant differences in the surgical training of the ophthalmology residents in Europe, including a disparity between the sexes and a variation in the experience on cataract surgery (CC) between them. This study is about the Spanish sub-cohort of the survey, and its objective is to present and analyse the peculiarities of ophthalmology training in Spain within the European context, as well as discussing ways to harmonise and improve that training throughout the EU. METHODS: We analyse data of the Spanish participants in the EBO exams, defining subgroups by the Autonomous Communities existing in Spain. RESULTS: 93 of 135 requested participants (68.9%) responded. A 60.2% passed the EBO exam between 2021 and 2022, being mostly women (65.59%) aged 31 years old on average. The 91.4% were right-handed, coming from 13 of the 17 Spanish autonomous communities, although mostly from the Community of Valencia, Madrid and Catalonia. Respectively, 16.1%, 3.2% and 8.7% of the respondents said they have completed 10 or more training sessions on animal eyes, synthetic eyes and through the virtual reality simulator. This training was correlated with greater self-confidence in the management of a posterior capsular tear during surgery (p .025). All respondents manifested to have already performed stages of the CC. The average number of operations reported was 181.6 with regional disparities. A significant difference is observed between the sexes against women (-28.3%, p 0.03). DISCUSSION: Ophthalmologists in Spain, much more than other European countries, have greater opportunities for surgical training, with surgical procedures during the residency, that nearly triples those made by the others. Spanish women refer, like their European colleagues, to be in disadvantage in learning opportunities about cataract surgery. The Simulation Based Medical Education (SBME) allows to respond to the training deficit and complements the training on the patient. Although we demonstrate a significant correlation between the number of procedures carried out and self-confidence to operate simple cases, the SBME would be a complementary tool in self-confidence in front of a complication like capsular rupture. CONCLUSION: Spain massively adopts the model named by us "surgery for all", despite the underrepresentation of women in this area, emphasising a need for cultural change that the SBME could facilitate.

[Lens exchange for subluxation of posterior chamber lenses implanted in the capsular bag or in the ciliary sulcus]. / Linsenaustausch bei subluxierten Kapselsack- und Sulkuslinsen.

PURPOSE: There are an increasing number of patients with decreased vision due to dislocated posterior chamber lenses, with pseudoexfoliation being the main risk factor. Various techniques for refixation of the subluxated posterior chamber IOL have been described. Experience with our technique of IOL-explantation, anterior vitrectomy and implantation of an Artisan anterior chamber lens are presented. PATIENTS AND METHODS: In a retrospective study design all lens exchanges with implantation of an Artisan anterior chamber lens performed between 2003 and 2012 are analyzed. The study included 65 eyes of 61 patients (age 79.6 ± 9.2 years: 43-98). The majority of eyes (46/65; 70.8%) had Sundown Syndrome (late in-the-bag intraocular lens dislocation), in 19 eyes the posterior chamber lens was implanted primary or secondary into the ciliary sulcus. In the 46 eyes with Sundown Syndrome cataract surgery with implantation of a posterior chamber lens in the capsular bag was performed 7.4 ± 3.7 (1-22) years before subluxation within the bag. Pseudoexfoliation was the main risk factor in 42/46 (91.2%) of these eyes. A capsular tension ring (CTR) was implanted during cataract surgery in 34/46 (73.9%) eyes. The 34 IOLs with a CTR luxated significantly earlier (p < 0.02 Mann-Whitney U) than the 12 IOLs without a CTR (6.6 ± 3.6 years; median 5.8 vs. 9.4 ± 3.1 years; median 9.2). RESULTS: The average visual gain was 0.2 logMAR in the group of luxated capsular bag lenses and 0.12 logMAR in the group of luxated sulcus lenses. Postoperative IOP decompensation was seen in 17/65 (26.2%) eyes (requiring IOP-lowering surgery in 8 eyes), 7 eyes developed corneal decompensation, 5 eyes had central retinal vein occlusion and one eye developed postoperative endophthalmitis. CONCLUSIONS: Lens exchange with implantation of an Artisan anterior chamber lens has become a routine procedure to improve vision in patients with subluxated IOLs. Postoperative IOP decompensation and vascular problems are the major complications.

[First experience with the Heidelberg Edge Perimeter® on patients with ocular hypertension and preperimetric glaucoma]. / Erste Erfahrungen mit dem Heidelberg-Edge-Perimeter® bei Patienten mit okulärer Hypertension und präperimetrischem Glaukom.

BACKGROUND: The white-on-white computerised static perimetry is not very sensitive to detect a beginning visual field loss. A newer technique to test the central visual field with a flicker defined form technology (FDF) is the Heidelberg Edge Perimeter® (HEP). PATIENTS AND METHODS: A study with 90 eyes from 50 patients (mean age 59 ± 14 years) with ocular hypertension and/or optic nerve suspicious for glaucoma without detectable visual field loss in the Octopus® perimetry (Program dG-2) with the Heidelberg Edge Perimeter® was performed. The "mean defect" (MD), the "pattern standard deviation" and the glaucoma hemifield test (GHT) were calculated and compared with the indices of the Octopus®. RESULTS: Despite normal visual field findings in the Octopus® perimetry (MD < 2.0 dB) we detected in 48 out of 90 eyes (53 %) pathological visual fields in the HEP examination. CONCLUSIONS: As a new research method the Heidelberg Edge perimetry® seems to be more sensitive than conventional static perimetry in early detection of visual field alterations in patients between ocular hypertension and incipient glaucoma.

[Mechanical dilatation of the pupil in phacoemulsification surgery: first experiences with the 6.25 mm Malyugin-ring]. / Mechanische Pupillenerweiterung zur Kataraktoperation: erste Erfahrungen mit dem 6,25 mm Malyugin-Ring.

PURPOSE: Inadequate mydriasis may cause major problems in phacoemulsification surgery. Usually 4 iris retractors are used to allow adequate pupillary dilatation. Implantation of a Malyugin ring to maintain a 6.25 mm pupil is a new alternative. PATIENTS AND METHODS: A Malyugin ring was used in 46 eyes of 39 patients (aged 80.1 ± 6.2 years). The ring is im- and explanted with a disposable shooter through the main incision. Indications for the use of the ring were inadequate mydriasis due to pseudoexfoliation (n = 27), intraoperative floppy iris syndrome (n = 5), the combination of PEX and IFIS (n = 11), extensive posterior synechiae (n = 2) or inadquate mydriasis after long-term pilocarpine treatment (n = 1). RESULTS: In 44/46 eyes phacoemulsification with implantation of foldable posterior chamber lens was performed without complications. In 2 eyes with massive phakodonesis an Artisan anterior chamber lens had to be implanted after anterior vitrectomy because of total zonulolysis. There where no complications associated to the use of the device and with increasing experience duration of implantation as well as explantation was reduced to 2 - 4.5 min (median 2:51 min). CONCLUSIONS: In cases of phacoemulsification surgery with inadequate mydriasis implantation of a Malyugin ring is a simple, safe and fast alternative to iris-retractors; it allows better pupil-size without additional stab incisions.

Comparison of histopathological findings with duplex sonography of the temporal arteries in suspected giant cell arteritis.

INTRODUCTION: In clinical practice the temporal artery biopsy (TAB) in suspected giant cell arteritis (GCA) is still believed to be the "gold standard". The purpose of this study was to compare the histopathological findings of the TAB with duplex sonography of the temporal artery. PATIENTS AND METHODS: In our retrospective study we analysed 85 consecutive patients (52 female, mean age 71.5, range 55 - 91 years; 33 male, mean age 71.6, range 44 - 91 years) with suspected GCA who underwent TAB in our clinic between January 1999 - February 2011. All patients received a preoperative duplex sonography, 57 patients including description of the temporal arteries. RESULTS: 38 of 85 (44.7 %) of the artery biopsies were proven positive for GCA by histopathology. Interpretation of the duplex sonography was congruent of histopathological interpretation of the biopsy in 39 patients (68.4 %) and incongruent in 18 patients (31.6 %). Sensitivity of duplex-sonography was 44.4 %, specificity 90 %, positive predictive value 80 %. DISCUSSION: Duplex sonography is a non-invasive and very helpful diagnostic tool to guide the clinician in cases of suspected GCA but needs considerable skills. It shows a good specificity and relatively high positive predictive value as there are only few false positive results. A negative report however does not rule out GCA, so that in our opinion the TAB - at least in those cases - should still be performed.

[Trabeculectomy with mitomycin C supplemented with cross-linking hyaluronic acid: a pilot study]. / Erste Erfahrungen mit einem retikulierten Hyaluronsäurepräparat bei der Trabekulektomie.

BACKGROUND: Besides antimetabolites (5-fluorouracil [5-FU]), cytostatic agents (mitomycin C [MMC]) and topical steroids, various substances have been used for the modulation of wound healing in filtering glaucoma surgery. The anti-inflammatory effects of hyaluronic acid and its space-occupying properties may be useful in filtering as well as in non-filtering glaucoma surgery. PATIENTS AND METHODS: In a non-randomised pilot study cross-linking hyaluronic acid (HealaFlow) was injected below the scleral flap and under the conjunctiva in 66 patients undergoing filtering surgery. All 66 patients (age 70.3 +/- 9.6 years; 41 - 88) had a standard trabeculectomy with MMC (0.25 % for 3 min). Glaucoma diagnoses were pseudoexfoliation glaucoma in 32 cases, primary open-angle glaucoma in 32 cases, ICE syndrome in one case and Axenfeld/Rieger in one case. RESULTS: Intraocular pressure (IOP) levels were reduced from preoperatively 22.3 +/- 6.0 mmHg (12 - 40) with 2.7 +/- 1.0 (1 - 4) IOP-lowering medications to 11.9 +/- 5.1 mmHg (2 - 26) after 29.8 +/- 12.4 weeks (13 - 56) follow-up. Fifty-nine of the 66 patients (89.4 %) did not need IOP lowering medications at the end of the follow-up, 52 / 66 patients (78.8 %) had an IOP < or = 14 mmHg, 47 of these 52 patients (90.4 %) without medication. Argon laser suturolysis had to be performed in 28 / 66 eyes (42.4 %), 40 / 66 patients (60.6 %) required 1 - 4 subconjunctival injections of 15 mg (0.3 mL) 5-fluorouracil. CONCLUSIONS: Injections of HealaFlow below the scleral flap and the conjunctiva at the end of the surgery along with intraoperative application of MMC showed promising IOP-lowering effects in trabeculectomy. A prospective randomised study is required to confirm these preliminary results.

[Ocular pulse amplitude: a new biometrical parameter for the diagnose of glaucoma?]. / Okuläre Pulsamplitude als biometrischer Messwert in der Glaukomdiagnostik.

BACKGROUND: Dynamic contour tonometry (DCT) enables accurate transcorneal measurements of the intraocular pressure and ocular pulse amplitude (OPA). In this study, we investigated whether this new biometrical parameter can characterize different glaucoma types and serve as a helpful tool in the diagnosis and therapy of the disease. PATIENTS AND METHODS: A total of 441 eyes of 222 patients were included. Pressure measurements were performed with contour and applanation tonometry. RESULTS: Mean OPA was 3.1+/-1.4 mmHg. Eyes with ocular hypertension showed significantly higher OPA values (3.6+/-1.3 mmHg) than healthy eyes (3.1+/-1.4 mmHg) and eyes with low-tension glaucoma (2.9+/-1.4 mmHg). After trabeculectomy, the values were significantly lower (2.4+/-1.3 mmHg) than in healthy eyes. CONCLUSION: The size of the OPA seems to be characteristic for different types of glaucoma and directly dependent on intraocular pressure levels. Further investigation is indicated to clarify its diagnostic usefulness.

Retinal degeneration in the rd mouse in the absence of c-fos.

PURPOSE: Apoptosis is the final common death pathway of photoreceptors in light-induced retinal degeneration and in several animal models for retinal dystrophy. To date, little is known about gene regulation of apoptosis in the retina. The expression of the immediate early gene c-fos is upregulated concomitant with apoptosis in light-induced photoreceptor degeneration and in the rd mouse, an animal model for inherited retinal degeneration. In a recent study it was shown that c-Fos is essential for light-induced apoptosis of photoreceptors in vivo. To determine whether c-Fos is also involved in the apoptotic pathway of inherited retinal degeneration, rd/rd, c-fos -/- double-mutant mice have been generated. METHODS: Double-mutant mice (rd/rd, c-fos -/-) were crossbred from c-fos+/- mice and rd/rd mice. Their genotype was determined by polymerase chain reaction analysis of genomic DNA. Wild-type control mice and homozygous rd mice were killed at 2-day intervals from postnatal day (P)9 through P21. Double-mutant mice were killed at postnatal days P9, P11, P13, P15, and P21. To determine levels of apoptosis in the retina, eyes were enucleated and processed for light microscopy and in situ nick-end labeling. Total retinal DNA was extracted from isolated retinas for DNA fragmentation analysis. RESULTS: Morphologic, histochemical, and biochemical analyses showed that the time course of apoptosis and the outcome of photoreceptor degeneration in rd/rd, c-fos-/- double-mutant mice was indistinguishable from that in rd mice carrying functional c-fos. CONCLUSIONS: These data suggest that in contrast to its role in light-induced photoreceptor degeneration, c-Fos is not essential for apoptosis in the rd mouse.

Reversal of topical antiglaucoma medication effects on the conjunctiva.

OBJECTIVE: To determine whether the adverse effects of antiglaucoma medications could be reversed before filtration surgery, potentially reducing the risk of subsequent failure. METHODS: One month before surgery, 30 patients who were receiving multiple antiglaucoma medications underwent an inferior bulbar conjunctival biopsy, ceased using sympathomimetic drops, and began treatment with topical corticosteroid, (1% fluorometholone four times daily). At the time of surgery two conjunctival biopsy specimens were obtained, one from the operation site (superior bulbar region), and one from the inferior bulbar region. The biopsy specimens were quantitatively analyzed by light microscopy. In addition, the outcome of first trabeculectomy for 16 of these patients was compared with that of 16 matched patients who had not undergone an altered preoperative regimen of topical therapy. RESULTS: During a 1-month period a notable decrease occurred in the number of fibroblasts and inflammatory cells throughout the conjunctiva. Inferior bulbar conjunctiva was found to be representative of superior bulbar conjunctiva with respect to these changes. Furthermore, evidence comparing the matched patients suggested that the altered preoperative regimen may have improved the success rate of trabeculectomy. CONCLUSIONS: The preoperative regimen used reversed the adverse conjunctival effect of topical medication. The regimen may be of clinical benefit in improving the success rate of trabeculectomy.

What do glaucomatous visual fields really look like in fine-grid computerized profile perimetry?

Analysis of the visual fields of 20 glaucoma patients by Octopus automatic perimeter, using 229 F2 programs consisting of 30 degrees long profiles with 1 degree resolution and double measurements of the light sensitivity threshold, revealed that: (1) there is a positive correlation between mean loss and mean short-term fluctuations; (2) short-term fluctuations tend to be larger with increasing loss of sensitivity; (3) however, small short-term fluctuations were also seen in areas of greatly reduced sensitivity; (4) analysis of the F2 programs showed 12 different abnormal patterns; (5) the most frequently found, 'increased scatter with normal sensitivity', appears to be the earliest perimetric sign of glaucoma, and (6) progression of the glaucomatous damage produces a 'grey area of increased scatter', usually accompanied by reduced sensitivity with a poorly defined lower and upper threshold. It is shown that a relative scotoma does not consist of a sharply bordered area with definite loss of sensitivity, but instead of a region of increased scatter with poorly definable borders. It is indicated that these sensitivity disturbances cannot be detected without extensive threshold perimetry. These findings can, furthermore, explain why quite large differences occur from one visual field examination to the next without the involvement of actual pathological changes. For combined display of several F2 programs a new mode of graphical representation is introduced.

Membrane formation in the chamber angle after failure of argon laser trabeculoplasty: analysis of risk factors.

AIM: Membrane formation in the chamber angle induced by argon laser trabeculoplasty (ALT) can be a cause of treatment failure. Identification of risk factors for membrane formation was the primary aim of this retrospective study. METHODS: Semithin sections of trabeculectomy specimens obtained in a 2 year period were examined by light microscopy. 122 eyes which were treated with one or more ALTs before trabeculectomy were identified. In 46 eyes, a sufficient amount of trabecular meshwork was obtained to permit morphological analysis. RESULTS: Eyes treated with ALT had a significantly higher incidence of membrane formation (p=0.001). In 23/46 specimens a cellular and collagenous membrane was observed covering the entire trabecular meshwork. In 14/23 specimens (61%), this membrane was readily visible at low power magnification (x40). Comparison of these eyes with those without membrane formation revealed a significant difference in the number of ALTs (mean 2.07 (SD 0.73) v 1.48 (0.59); p=0.026) and in preoperative IOP (32.0 (9. 7) v 26.2 (8.4) mm Hg; p=0.04). CONCLUSIONS: Membrane formation in the chamber angle is a frequent cause of ALT failure. The major risk factor is the number of ALTs performed.

Axonal loss from acute optic neuropathy documented by scanning laser polarimetry.

BACKGROUND/AIMS: Retinal nerve fibre layer analysis by scanning laser polarimetry has been shown to facilitate diagnosis of glaucoma while its role in glaucoma follow up is still unclear. A major difficulty is the slow reduction of retinal nerve fibre layer thickness in glaucomatous optic neuropathy. Eyes of patients were studied after acute retrobulbar optic nerve lesion in order to evaluate the usefulness of scanning laser polarimetry in documenting retinal nerve fibre layer loss over time. METHODS: Five patients who suffered severe retrobulbar optic neuropathy have had repeated measurements of the retinal nerve fibre layer using scanning laser polarimetry at various intervals, the first examination being within 1 week of injury. RESULTS: All eyes showed a marked decrease in peripapillary retinal nerve fibre layer thickness, which followed an exponential curve and occurred predominantly within 8 weeks of injury. Compared to a previous study using red-free photographs, scanning laser polarimetry showed retinal nerve fibre layer loss earlier in the course of descending atrophy. CONCLUSION: Scanning laser polarimetry is useful for early detection and documentation of retinal nerve fibre layer loss following acute injury to the retrobulbar optic nerve. It seems to be a promising tool for follow up of individual glaucoma patients.

Single intraoperative applications of 5-fluorouracil during filtration surgery: early results.

Experimental studies from our laboratory have suggested that single exposures to 5-fluorouracil (5-FU) would have a similar effect to subconjunctival injections of 5-FU and a less permanent effect on subconjunctival fibroblasts than mitomycin C (MMC). Thirty four eyes of 33 glaucoma patients with an increased risk of filtration surgery failure were treated with a single intraoperative 5 minute exposure of sclera and subconjunctival tissues to 5-FU, 25 mg/ml. The follow up period ranged from 3-9 months, during which two high risk eyes failed completely and one required topical beta blockers to control intraocular pressure. No low/moderate risk eyes failed. Single 5 minute intraoperative exposures to 5-FU are convenient, inexpensive, have no significant corneal side effects, and may be a useful adjunctive treatment to optimise the results of glaucoma filtration surgery, particularly in the large group of low/moderate risk patients.