Management of moderate-to-severe dry eye disease using chitosan-N-acetylcysteine (Lacrimera®) eye drops: a retrospective case series.

PURPOSE: Dry eye disease is a highly prevalent condition that causes tear film instability, ocular discomfort, and visual disturbance. Lacrimera eye drops are approved for the short-term treatment of dry eye disease. We aimed to evaluate the clinical outcome of patients with moderate-to-severe dry eye disease treated with Lacrimera up to 1 month during routine clinical practice. METHODS: We retrospectively collected data from 25 patients with dry eye disease from the start of Lacrimera treatment up to 1 month of follow-up period. We analyzed standard clinical parameters to follow the course of the patients' dry eye signs and symptoms. RESULTS: Based on corneal staining data, we found that the percentage of patients with intact corneas raised from 12 to 64% after 1 month of Lacrimera treatment. During this period, we also observed an increase in both tear breakup time (p < 0.05) and Schirmer's score (p < 0.001), with lower values indicating severer signs. Lacrimera eye drops were judged by 29% of the patients to be effective at relieving eye symptoms. CONCLUSIONS: Lacrimera appears to be safe and effective in the treatment of dry eye disease, as assessed by corneal staining, tear breakup time, and Schirmer's analyses. Our data suggest that the regenerative effect of Lacrimera eye drops peaks at 2 weeks and is sustained for at least 1 month when administered for a longer period of time.

Diagnosis and treatment of ocular chronic graft-versus-host disease: report from the German-Austrian-Swiss Consensus Conference on Clinical Practice in chronic GVHD.

PURPOSE: Ocular chronic graft-versus-host disease (cGVHD) is one of the most frequent long-term complications after hematopoietic stem cell transplantation and is often associated with significant morbidity and reduced quality of life. METHODS: The German/Austrian/Swiss Consensus Conference on Clinical Practice in cGVHD aimed to summarize the currently available evidence for diagnosis and (topical) treatment and to summarize different treatment modalities of ocular cGVHD. The presented consensus was based on a review of published evidence and a survey on the current clinical practice including transplant centers from Germany, Austria, and Switzerland. RESULTS: Ocular cGVHD often affects the lacrimal glands, the conjunctiva, the lids (including meibomian glands), and the cornea but can also involve other parts of the eye such as the sclera. Up to now, there have been no pathognomonic diagnostic features identified. The main therapeutic aim in the management of ocular cGVHD is the treatment of inflammation and dryness to relieve patients' symptoms and to maintain ocular integrity and function. Therapy should be chosen in the context of the patient's overall condition, systemic immunosuppressive therapy, symptoms, ocular surface integrity, and inflammatory activity. The consensus conference proposed new grading criteria and diagnostic recommendations for general monitoring of patients with graft-versus-host-disease for use in clinical practice. CONCLUSION: The evidence levels for diagnosis and treatment of ocular cGVHD are low, and most of the treatment options are based on empirical knowledge. Topical immunosuppression, for example, with cyclosporine, represents a promising strategy to reduce inflammation and dryness in ocular cGVHD. Further clinical trials are necessary to elucidate risk factors for eye manifestation, complications, and visual loss and to evaluate staging criteria and diagnostic and therapeutic measures for ocular cGVHD.

Bacterial Ghosts as antigen and drug delivery system for ocular surface diseases: Effective internalization of Bacterial Ghosts by human conjunctival epithelial cells.

The purpose of the presented investigation was to examine the efficiency of the novel carrier system Bacterial Ghosts (BGs), which are empty bacterial cell envelopes of Gram-negative bacteria to target human conjunctival epithelial cells, as well as to test the endocytic capacity of conjunctival cells after co-incubation with BGs generated from different bacterial species, and to foreclose potential cytotoxic effects caused by BGs. The efficiency of conjunctival cells to internalize BGs was investigated using the Chang conjunctival epithelial cell line and primary human conjunctiva-derived epithelial cells (HCDECs) as in vitro model. A high capacity of HCDECs to functionally internalize BGs was detected with the level of internalization depending on the type of species used for BGs generation. Detailed analysis showed no cytotoxic effect of BGs on HCDECs independently of the used bacterial species. Moreover, co-incubation with BGs did not enhance expression of both MHC class I and class II molecules by HCDECs, but increased expression of ICAM-1. The high rates of BG's internalization by HCDECs with no BG-mediated cytotoxic impact designate this carrier system to be a promising candidate for an ocular surface drug delivery system. BGs could be useful for future therapeutic ocular surface applications and eye-specific disease vaccine development including DNA transfer.

Biometry and refractive outcome of eyes filled with silicone oil by standardized echography and partial coherence interferometry.

BACKGROUND: We evaluated the validity of calculations for refractive outcome in cataract surgery in silicone oil-filled eyes. The retrosilicone space (RSS) was included in these calculations. METHODS: In a prospective study the axial length (AL) of silicone oil-filled eyes was measured. with standardized A-scan echography (SAE) and partial coherence interferometry (PCI). Meldrum's formula was used to transform the velocity of ultrasound within the vitreous cavity. To investigate whether refractive outcome can be calculated accurately, we assessed the difference between precalculated and final refractive outcome. Furthermore, we determined the advantages and disadvantages of SAE and PCI. A minor aim was to assess whether the AL of the two eyes differed significantly. RESULTS: In 85% of 117 eyes the difference between precalculated and postsurgical refraction was smaller than 1 diopter spherical and statistically not significant (p>0.2). The mean AL was 24.1 mm (range 20.0-31.4 mm). The difference in outcome between the two methods was without statistical significance: the AL difference was 0.4 (+/-2.6) mm on measurement with SAE and 0.04 (+/-0.46) mm with PCI. PCI has the advantage that it can be performed more easily, without contact, while echography is advantageous in the presence of advanced cataracts. In supine position an oil-free fluid space behind the silicone oil was detected with echography. The mean dimension of this space was 1.9 (+/-0.67) mm and it was taken into consideration for IOL calculation. The mean AL difference between the two eyes was 0.4 mm, but the difference was greater than 1 mm in 26% of the patients. CONCLUSION: The AL of eyes filled with silicone oil can be measured reliably with SAE and PCI. In supine position the RSS has to be considered to obtain more accurate IOL calculations.

Tissue damage at anterior capsule edges after continuous curvilinear capsulorhexis, high-frequency capsulotomy, and erbium:YAG laser capsulotomy.

PURPOSE: To compare the effect of erbium:YAG laser photocapsulotomy (ELC), continuous curvilinear capsulorhexis (CCC), and high-frequency capsulotomy (HFC) on anterior capsule edges using light microscopy (LM) and transmission electron microscopy (TEM). SETTING: Department of Ophthalmology, Department of Histology and Embryology II, University of Vienna, Vienna, Austria. METHODS: Five anterior capsule membranes were obtained experimentally by ELC, which was performed with the Oertli MicroLaser photoemulsification tip in eyes from 5 human cadavers. Thirty anterior capsule membranes were obtained during cataract surgery by CCC (n = 15) or, in cases with poor or missing red fundus reflexes, by HFC (n = 15). Continuous curvilinear capsulorhexis was performed conventionally with a manual, bent, 27-gauge cannula, and HFC was performed according to Klöti. Membranes were processed and examined by LM and TEM according to standard procedures. RESULTS: The edges obtained by ELC showed mild signs of denaturation and mechanical disruption, tears, and micro-tears. Lens capsule edges obtained by CCC were smooth with no irregularities in any specimen; the edges were beveled anteriorly to posteriorly with no evidence of tearing. Edges produced by HFC were considerably wider; the surfaces showed distinct denaturation, preformed tears, and micro-tears. The edges were surrounded by a nonhomogeneous mass, which consisted mainly of denatured lens capsule material. CONCLUSIONS: Of the 3 techniques, CCC produced the mildest tissue damage. The histological damage at ELC edges was relatively mild and intermediate compared with that seen at CCC and HFC edges. These observations suggest that ELC is an appropriate option for anterior capsulotomy in cataract surgery.

Influence of operator experience on the performance of ultrasound biometry compared to optical biometry before cataract surgery.

PURPOSE: To compare measurements performed with the IOLMaster (Carl Zeiss, Meditec AG) with those obtained by applanation ultrasound (US) and manual keratometry and to evaluate the effect of operator experience on US biometry. SETTING: Department of Ophthalmology, University of Vienna, Vienna, Austria. METHODS: The axial length (696 eyes) and anterior chamber depth (ACD) (462 eyes) were measured in 377 patients with cataract using the IOLMaster and applanation US. To assess the effect of operator experience on the biometric results, the operators were divided into 2 groups: experienced and less experienced in performing US biometry. The difference in measurements between the methods and the variability of the difference were compared between the 2 groups. RESULTS: Applanation US measured axial length and ACD shorter than the IOLMaster; the mean numerical difference was 0.13 mm and 0.19 mm, respectively (P<.01). For axial length, the absolute difference was smaller with experienced operators than with less experienced operators (0.15 mm versus 0.22 mm) (P<.01). For ACD, experienced operators obtained a smaller difference between measurement techniques (0.21 mm versus 0.29 mm; P<.05). CONCLUSIONS: Experienced US operators had less difference and lower variability in the difference between applanation US and IOLMaster readings for axial length and ACD measurements. The noncontact optical method, which is essentially operator independent, gave significantly more reliable biometry before cataract surgery, especially in the case of less experienced operators.

Cataract surgery and silicone oil removal: visual outcome and complications in a combined vs. two step surgical approach.

PURPOSE: To compare visual outcome and complications of two surgical strategies for patients who needed cataract surgery and silicone oil removal. METHODS: A prospective, nonrandomized study was performed to compare two groups of patients who had cataract surgery and silicone oil removal from April 1998 to January 2002. From April 1998 to November 1999, patients had two surgical sessions with cataract surgery before silicone oil removal (Group 1), and from December 1999 to January 2002, patients underwent combined cataract surgery and silicone oil removal in a single session (Group 2). RESULTS: Thirty-five patients were included in each group. The postoperative visual acuity improved by at least two lines of Snellen in 13 patients (37.1%) in Group 1 and 15 (42.8%) patients in Group 2 (P=0.63). The mean visual improvement was 0.12 lines and 0.13 lines in groups 1 and 2 (P=0.62). Complications in groups 1 and 2 included transient intraocular pressure rise (25.7% versus 28.5%), retinal detachment (14.2% versus 11.4%), fibrin reaction (5.7% in both groups), and persistent intraocular pressure rise (2.8% in both groups). CONCLUSION: The visual outcome and complication rates were similar in both groups. Combined surgery offers the advantages of a single surgical event and a faster visual rehabilitation. We therefore suggest a surgical approach with combined cataract surgery and silicone oil removal in selected patients with a stable retinal situation.

Long-term impairment of the lacrimal glands after radioiodine therapy: a cross-sectional study.

Impairment of the lacrimal glands after external radiation has been well documented, but there are only a few reports on the effects of radioiodine therapy on the lacrimal glands. Long-term effects of high-dose radioiodine therapy on tear secretion have not previously been studied. We investigated 175 eyes of 88 patients with a history of radioiodine therapy for thyroid carcinoma (68 females, 20 males; mean age 55+/-16 years, range 17-81 years) and compared them with a sex- and age-matched control group ( n=39). All patients had been given at least 2.96 GBq iodine-131 (maximal administered activity 22.3 GBq (131)I). An ophthalmological investigation was performed 64+/-71 months (range 3-317 months) after initial radioiodine therapy by a single ophthalmologist. Lacrimal gland function was evaluated with three different function tests. External eye morphology was considered, and detailed ophthalmological history-taking was performed. Patients with factors known to affect lacrimal gland function (contact lenses, autoimmune disorders, history of additional radiation exposure) were excluded from the study. A total of 81 patients (92%) had at least one abnormal function test indicating impaired lacrimal gland function. Schirmer's tear test was decreased (<10 mm/5 min) in 47 of the 88 patients and definitely abnormal (<5 mm/5 min) in 35 patients. A tear film break-up time of <10 s was found in 78 patients, and 62 patients had a definitely abnormal break-up time of <5 s. The lacrimal lipid layer was impaired in 43 patients. The function tests were all significantly altered in the study group as compared with the controls ( P<0.005, P<0.001, P<0.001, respectively). Both subjective symptoms of dry eye ( P<0.01) and changes in the external eye morphology ( P<0.001) were significantly more prevalent in the study group. Our findings suggest that in the majority of patients, lacrimal gland function may be permanently impaired after high-dose radioiodine therapy. All three layers of the tear film are involved and there is a pronounced long-term effect on the tear film stability.

Identification of estrogen and progesterone receptor mRNA expression in the conjunctiva of premenopausal women.

PURPOSE: The purpose of the present study was to identify the expression of estrogen and progesterone receptor mRNA and of estrogen and progesterone receptor protein in the conjunctiva of healthy women. METHODS: Specimens of conjunctival tissue of 10 premenopausal women (age range, 13-38 years) were obtained during ophthalmic surgery in patients under general anesthesia. Specimens of approximately 4 mm(2) were taken from superior, nasal, or temporal bulbar conjunctiva adjacent to the bulbus and were immediately deep frozen with liquid nitrogen. Four women underwent strabismus surgery, two had phacoemulsification, and four had vitrectomy. Only three women were taking oral contraceptives. The expression of estrogen receptor (ER)-alpha, ERbeta, and progesterone receptor (PR) mRNA was analyzed by RT-PCR. Western blot analysis on nuclear extracts was performed with the anti-ERalpha mouse monoclonal antibody AB-15, the anti-ERbeta mouse monoclonal antibody 6B12, and the anti-PR mouse monoclonal antibody PgR 636. RESULTS: In two samples, ERalpha, ERbeta, and PR mRNAs were not accessible because of highly degraded RNA. In the remaining eight samples, an appearance rate of 100% was obtained for all three mRNAs. Similarly, an appearance rate of 100% was obtained for ERalpha, ERbeta, and PR protein in nine tissue samples accessible for analysis; one sample could not be analyzed due to a low amount of tissue. CONCLUSIONS: This study confirms the existence of estrogen and progesterone receptors in the human conjunctiva of premenopausal females. Because the proteins of estrogen and progesterone were also found in this study's specimens, the data indicate that the conjunctiva is a target site for sex steroids. Future studies are needed to elucidate the role of these receptors in ocular diseases involving the conjunctiva.

Results of hydrophilic acrylic, hydrophobic acrylic, and silicone intraocular lenses in uveitic eyes with cataract: comparison to a control group.

PURPOSE: To evaluate the uveal and capsular biocompatibility of hydrophilic acrylic, hydrophobic acrylic, and silicone intraocular lenses (IOLs) in eyes with uveitis. SETTING: Department of Ophthalmology, University of Vienna, Vienna, Austria. METHODS: This prospective study comprised 72 eyes with uveitis and 68 control eyes having phacoemulsification and IOL implantation by 1 surgeon. Patients received 1 of the following IOLs: foldable hydrophilic acrylic (Hydroview, Bausch & Lomb), hydrophobic acrylic (AcrySof, Alcon), or silicone (CeeOn 911, Pharmacia). Postoperative evaluations were at 1, 3, and 7 days and 1, 3, and 6 months. Cell reaction was evaluated by specular microscopy of the anterior IOL surface and the anterior and posterior capsule reaction, by biomicroscopy. RESULTS: Small round cell deposition was observed on all IOLs in the immediate postoperative period, especially in eyes with uveitis. This reaction decreased 3 to 6 months after surgery. Although the CeeOn 911 had a higher mean grade of small cells, there was no statistical difference between the 3 IOL types after 6 months in the uveitis and control groups. Foreign-body giant cells (FBGCs) increased after 1 week to 1 month. The AcrySof IOLs had the highest number of FBGCs; after 6 months, there was a statistically significant difference between the AcrySof and Hydroview uveitis groups (P =.036) and the AcrySof and CeeOn 911 uveitis groups (P =.003) but there was no difference among the 3 IOL types in the control group. Lens epithelial cell outgrowth persisted on the Hydroview IOLs in control eyes and regressed on all 3 IOL types in uveitic eyes and on the AcrySof and CeeOn 911 IOLs in control eyes (P =.0001). Anterior capsule opacification (ACO) was more severe on all IOL types in uveitic eyes and on the CeeOn 911 IOL in control eyes. Posterior capsule opacification (PCO) was more severe in uveitic eyes. The Hydroview group had more severe PCO than the AcrySof and the CeeOn 911 groups in uveitis and control eyes. Six months postoperatively, the difference was significant (P =.0001). There was no significant difference between the AcrySof and CeeOn 911 IOLs. CONCLUSIONS: Intraocular lens biocompatibility is inversely related to inflammation. Hydrophilic acrylic material had good uveal but worse capsular biocompatibility. Hydrophobic acrylic material had lower uveal but better capsular biocompatibility. Silicone showed a higher small cell count (mild) and more severe ACO but achieved PCO results comparable to FBGC results and better than those with the AcrySof lens 6 months after surgery. Despite the differences in IOL biocompatibility, all patients benefited from the surgery.

Is acupuncture an useful tool for pain-treatment in ophthalmology?

Pain that does not respond to conventional treatment procedures makes it necessary to look for alternative methods. Acupuncture is an ancient procedure with empirical effects on pain. Previous studies established the increased output of messengers at neuronal junctions in spinal cord and hypothalamic locations, especially of endorphins which inhibit the perception of pain. We treated several painful symptoms with acupuncture and evaluated the outcome of the treatment. Patients with various kinds of therapy-refractory pain and patients in whom conventional treatment methods could not be applied were included in the study. The diagnoses included glaucoma. Tolosa-Hunt-Syndrome, ophthalmic migraine, blepharospasm, and dry eyes. In one case acupuncture was used for analgesia during surgery. Acupuncture was performed with sterile disposable needles, at points known to have an empirical analgesic effect. The stimulation was adapted to the patient's individual needs. VAS assessments before and after acupuncture were compared. The t-test was used for statistical evaluation. Acupuncture had no side effects, but reduced pain to a variable extent. Especially in cases of severe pain and in surgery, very effective pain reduction was achieved. In general, pain was significantly reduced in all patients by the use of acupuncture. A statistically significant effect was noted (p < 0.05). Further studies should be conducted to demonstrate the specific effect in larger patient populations. Monitoring neurotransmitter activity will possibly help to illustrate the effect.