[Combined glaucoma and cataract operation with foldable posterior chamber lens implantation. Long-term outcome and complications]. / Kombinierte Glaukom- und Kataraktoperation mit faltbarer Hinterkammerlinsenimplantation. Langzeitergebnisse und Komplikationen.

BACKGROUND: Glaucoma patients who need filtering surgery very often have cataracts as well. Combined glaucoma/cataract surgery entails a higher rate of complications and may endanger the results of glaucoma surgery. PATIENTS AND METHODS: This retrospective study investigated 223 eyes in 169 patients with uncontrolled glaucoma and cataracts. Each eye received filtering surgery and simultaneous phacoemulsification with implantation of a foldable posterior chamber lens. Mean follow-up was 32.5 months (6-57). RESULTS: Mean intraocular pressure was lowered from 24.6 +/- 6.2 to 16.4 +/- 3.4 mmHg (P > 0.0001). Visual acuity improved from 0.25 (0.01-0.5) to 0.5 (0.01-1.0). Preoperatively the mean number of medications was 2.4 (1-6) and postoperatively 1.3 (1 or 2). The most common perioperative complications were choroidal detachment (20.2%) and fibrin reaction in 10.1%; those occurring later than 4 weeks postoperatively were posterior capsule opacification requiring YAG laser capsulotomy (11.5%) and scarring of filtering bleb (7.7%). CONCLUSION: Complications encountered in the combined procedure were due mainly due to cataract surgery of glaucomatous eyes with narrow pupils and posterior synechiae. A shallow anterior chamber occurred in only one case. Despite complications the success rate in lowering intraocular pressure was comparable to that observed in filtering surgery alone.

[Selective excimer laser ablation of the trabecular meshwork. Clinical results]. / Punktuelle Excimerlaserablation des Trabekelwerks. Klinische Ergebnisse.

PURPOSE: Examination of the efficacy of pore formation in the trabecular meshwork by excimer laser to reduce intraocular pressure in glaucoma eyes. PATIENTS AND METHODS: In 27 consecutive eyes with chronic simple glaucoma and 8 eyes with low-tension glaucoma, 3 to 5 pores were ablated into the trabecular meshwork with an excimer laser (308 nm, 35-55 mJ/mm2), creating an open communication between the anterior chamber and Schlemm's canal. This was accomplished by the use of a 400-micron quartz fiber and a modified Trokel goniolens. All patients were candidates for trabeculectomy because visual fields continued to deteriorate in spite of maximum medication. RESULTS: Intraocular pressure was median reduced by 7 mmHg (range 10.5 to 1.5 mmHg) in 22 of 27 eyes with chronic simple glaucoma over a median follow-up of 7 months. In 12 eyes, further medication has to be continued, yet at a lower dose and lower level of intraocular pressure. In five eyes therapy failed. In three of these eyes, a trabeculectomy had to be performed. In eight eyes with low-tension glaucoma, a median reduction of intraocular pressure of 5 mmHg (range 10 to 0.5 mmHg) was accomplished over a median follow-up of 7 months. In five of these eyes, further medication on a lower level was continued. No further surgery was necessary. CONCLUSIONS: With the microsurgical method of pinpoint ablation of the trabecular meshwork by excimer laser, intraocular pressure was reduced in 30 of 35 eyes over a median follow-up period of 7 months. These results encourage us to continue the development of this procedure, perhaps with a microendoscope. The minimal trauma to the eye of this procedure leaves all other options of surgery open.

[Targetted ablation of the trabecular meshwork with excimer laser in primary open-angle glaucoma]. / Punktuelle Ablation des Trabekelwerks mit dem Exzimerlaser beim primären Offenwinkelglaukom.

The trabecular meshwork and the inner wall of Schlemm's canal constitute 75% of the outflow resistance of the aqueous. Attempts to improve the outflow facility with laser beams have not been satisfactory because they produced thermal effects with coagulation of the trabecular meshwork. With the excimer laser tissue can be removed with minimal thermal effects and necrosis. This results in minimal scar formation. With these qualities the excimer laser lends itself very well for ablation of the trabecular meshwork. It should be possible to create an open connection between the anterior chamber and Schlemm's canal. The goal of our experiments is selected ablation of the trabecular meshwork and the inner wall of Schlemm's canal in order to create pores and enhance the outflow facility. First experiments were carried out on pig and cadaver eyes, followed by eyes destined for enucleation because of malignant melanomas. Finally, we treated 6 patients with open-angle glaucoma. In 4 cases intraocular pressure was reduced by 11 mmHg over a follow-up time of 5 months. In 2 cases IOP rose by 2 mmHg in spite of medication. These preliminary results encourage us to continue with our investigation because there could be a possibility of an effective glaucoma therapy.

[Heterotopic fundus. An easily missed abnormality]. / Fundus heterotopicus. Eine leicht zu übersehende Fehlbildung.

This study demonstrates 12 patients with "tilted disc syndrome" which includes an inferior conus and inversion of the optic disc, sectorial ectasia of the fundus, and refractive scotoma. Knowledge of the anomaly can help to prevent the patient from repeated neurologic and neuroradiologic examinations to exclude a cerebral tumor.

Matched group study of surgical resection versus cobalt-60 plaque radiotherapy for primary choroidal or ciliary body melanoma.

We report the results of a nonrandomized, matched-group, survival and visual preservation study of patients with a choroidal or ciliary body melanoma managed by microsurgical resection of the tumor versus cobalt-60 episcleral plaque radiotherapy. Each treatment group consisted of 30 patients. All patients were matched on a case-by-case basis in terms of tumor size (largest linear tumor dimension), location of the anterior tumor margin relative to the ora serrata, location of the posterior tumor margin relative to the equator, and age at the time of treatment. Although the estimated actuarial 5-year survival probability was slightly greater in the resection group (85.2%) than in the cobalt plaque group (81.8%), this difference was neither clinically impressive nor statistically significant. In contrast, there was a substantially higher rate of early posttreatment severe visual loss in the resection group (P = .0008, Mantel-Haenszel test).

Matched group study of preenucleation radiotherapy versus enucleation alone for primary malignant melanoma of the choroid and ciliary body.

We report the results of a nonrandomized, matched group survival study comparing 29 patients with a choroidal or ciliary body melanoma managed by enucleation alone to 29 patients managed by enucleation following external beam ocular irradiation (20 Gy in five fractions over 5-7 days just prior to enucleation). Variables on which the patients in the two groups were matched included age at time of enucleation, largest linear tumor dimension, location of the anterior tumor margin relative to the equator and ora serrata, melanoma cell type, and extrascleral tumor extension. The cumulative 5-year survival in the enucleation alone group was 57.9% (SE = 9.9%), whereas that in the preenucleation radiation therapy group was 63.9% (SE = 12.2%). This difference is not statistically significant (p greater than 0.5, Mantel-Haenszel test). The authors discuss the strengths and limitations of their study and the implications of their results.

Localized suprachoroidal hematomas. Ophthalmoscopic features, fluorescein angiography, and clinical course.

We describe the ophthalmoscopic characteristics, fluorescein angiographic features, and clinical course of four patients with a localized suprachoroidal hematoma. Each of the four patients developed a darkly pigmented fundus lesion a short time following uncomplicated intraocular surgery. In every case, the lesion appeared ophthalmoscopically similar to a choroidal malignant melanoma. However, fluorescein angiography showed neither choroidal fluorescence blockage nor the double-circulation pattern characteristic of choroidal melanomas. Instead, each lesion exhibited a central fluorescein pattern similar to that of the surrounding uninvolved choroid, relative marginal hypofluorescence, and overlying choroidal folds. Ultrasonography revealed acoustic hollowness of each lesion without choroidal excavation. The lesions disappeared completely within 1 to 2 months, leaving no visible trace. We discuss the differential diagnosis of these lesions and stress the diagnostic value of fluorescein angiography.

Cobalt-60 plaque radiotherapy vs enucleation for posterior uveal melanoma.

We compared the survival of 302 patients with a primary choroidal or ciliary body melanoma treated by cobalt-60 plaque radiotherapy between 1976 and 1982 with the survival of 134 patients treated by enucleation during the same period. Tumor size, location of the anterior margin of the tumor, and patient age at the time of treatment were identified as simultaneous significant clinical variables for predicting melanoma-specific mortality by multivariate Cox proportional hazards modeling. We computed a prognostic index for each patient based on this model and found that patients in the enucleation group had slightly higher values of this index than did patients in the cobalt-60 plaque radiotherapy group. Risk ratios for the treatment effect computed from a Cox model incorporating prognostic index and the treatment variable were found to be approximately equal to 1, both for analysis of melanoma-specific mortality and total mortality. These results indicate that when one controls for differences in prognostic index between the groups, cobalt-60 plaque therapy and enucleation are essentially equivalent in their effect on survival.

[The regression behavior of choroid melanoma following radiotherapy--a new prognostic parameter?]. / Das Regressionsverhalten des Aderhautmelanoms nach Strahlentherapie--ein neuer prognostischer Parameter?

The present paper reports on follow-up examinations of 246 patients after Ruthenium106 treatment of choroidal melanomas (follow-up time 1.8 to 13 years). In January 1988, 212 patients were alive and free of metastases; 15 had died, 12 of them of melanoma metastases, and 17 could not be followed up. In a retrospective analysis of factors influencing tumor-related mortality, the rate of regression of irradiated tumors was found to be particularly significant. The mean time taken to reduce tumor volume by half was 4.4 months in patients who died of metastases, as against 6.6 months in a matched group of survivors. Using discriminance analysis, the difference was found to be highly significant (P = 0.0058). In the total patient population, a significant correlation was found between pretreatment tumor volume and the probability of metastases (P = 0.058). It may be concluded, though with the qualification that the number of tumor-related deaths was small, that the tumor regression rate is an important factor in the prognosis for patients with Ruthenium-treated malignant choroidal melanomas.

Vitreous seeding associated with melanocytoma of the optic disc.

The authors describe an unusual case of melanocytoma of the optic disc associated with seeding of extracellular pigment or melanin-containing macrophages into the overlying vitreous. The possible mechanisms responsible for this clinical picture are discussed.

Semimacroscopic examinations of the surface pattern of small intestinal mucosa in Crohn's disease.

The mucosal surface pattern of surgical specimens from small intestine affected by Crohn's disease are studied using Alcian-green staining of whole mounts. The semimacroscopic appearance of the mucosa is described. Our findings include i.a. malformation and enlargement of villi-often to extreme degree-villi frequently showing small vesicles on their apical region. Polypoid structures were found to be avillous as well as covered by normal or abnormal villi. The semimacroscopic observations are compared with observations from conventional light microscopy. The villus enlargement is in the first stages caused by lymphatic dilatation and later by oedema and inflammation.