[Glaucoma and nanophthalmos]. / Glaukom und Nanophthalmus.

The term nanophthalmos refers to a clinically small eye that appears morphologically normal. A nanophthalmos is characterized by hyperopia but can also be associated with various secondary pathologies, such as angle-closure glaucoma. In particular, the perioperative risks associated with a nanophthalmic eye necessitate examination of the anatomical characteristics, which can result from the disproportional size of intraocular tissues despite structural normality. These include a small anterior chamber depth, scleral thickening and anomalies of the vein plexus, which are predisposing factors for the formation of angle-closure glaucoma. The resulting therapeutic challenges in the nanophthalmic eye can be countered with iridectomy, lensectomy, vitrectomy and cyclophotocoagulation. The definition, genetics and clinical findings of nanophthalmos are discussed with a focus on the complication of glaucoma and its treatment.

[Vision Loss after Silicone Oil Surgery]. / Visusverlust nach Silikonölchirurgie.

Silicone oil is an intraocular tamponade that is essential for the treatment of complicated retinal detachment. As a long-term tamponade, it improves retinal reattachment and visual outcome. Unexpectedly, surgery with silicone oil tamponade may result in irreversible visual loss of unknown origin. In this report, we provide a general overview of unexplained visual loss after surgery with silicone oil. The frequency of such reports has increased continuously in recent years. The German Retina Society - supported by Retinanet (http://retina-net.uni-koeln.de) - has initiated data collection to gather information about such cases, in cooperation with Cologne University Eye Hospital. Ophthalmologists can provide data about cases of unexplained visual loss anonymously via the "Cologne Clinical Trials Centre" or via augenklinik-silikonoel@uk-koeln.de.

[Glaucoma Drainage Devices: Tube versus Trabeculectomy Study]. / Glaukomdrainageimplantate und ihre Bedeutung: Tube-versus-Trabekulektomie-Studie.

While trabeculectomy with mitomycin C has previously been the gold standard in penetrating glaucoma surgery, glaucoma drainage implants used early within glaucoma surgery were examined in the course of the tube versus trabeculectomy (TVT) study. Glaucoma drainage implants are now being used earlier, as materials are tissue-compatible and surgery has been improved. While in the past, the use of such implants was often carried out after multiple preoperations, implants are now being used at an earlier stage. Glaucoma drainage implants are typically still used in the pseudophakic eye, where 1-2 glaucoma preoperations (e.g. trabeculectomy) have already been performed.

[Spontaneous intraocular hemorrhage under oral anticoagulation : Apixaban in comparison to phenprocoumon]. / Spontane intraokulare Blutungen unter oraler Antikoagulation : Apixaban im Vergleich zu Phenprocoumon.

BACKGROUND: To determine and compare the frequency of intraocular hemorrhage in patients who underwent oral anticoagulation with apixaban or phenprocoumon. METHODS: A retrospective analysis of patients under oral anticoagulant medication (apixaban or phenprocoumon) seen between January 2015 and June 2015 at the department of ophthalmology, University of Muenster Medical Center was performed. Vitreal or retinal hemorrhage in addition to clinical information including age, gender, best corrected visual acuity, concomitant diseases, concomitant medication and therapy were obtained. Bleeding frequency in both groups was compared using Fisher's exact test. RESULTS: A total of 172 patients were included with a mean age = 74.0 ± 10.6 years, 57.0% (n = 98) male and 43.0% (n = 74) female. In the phenprocoumon group 147 patients (3.4%, n = 5) developed a retinal or vitreal hemorrhage. In the apxiban group 25 patients (36%, n = 9) developed a retinal or vitreal hemorrhage. There was a significant correlation between the group and bleeding risk (p < 0.001). CONCLUSION: There was a significant correlation between medication (apixaban vs. phenprocoumon) and bleeding risk in this study population. Further studies with more patients especially in patients with a high risk of hemorhage, age-related macular degeneration (AMD) and proliferative diabetic retinopathy are needed.

[Revision surgery in episcleral glaucoma drainage devices]. / Revisionschirurgie bei episkleralen Glaukomdrainageimplantaten.

Episcleral glaucoma drainage devices (e.g., Ahmed or Baerveldt drainage device) are often used at a late stage in the care of glaucoma patients. At this stage other surgical techniques, such as trabeculectomy or viscocanaloplasty, have failed. However, the trend towards earlier implant surgery is supported by large randomized trials. Physicians should be aware of typical complications and, if possible, these should already be avoided by careful surgical technique. In this review article, we focus on postoperative hypotension, postoperative pressure increases, implant exposure, and possible corneal decompensation.

[Postoperative Follow-Up of Glaucoma Drainage Devices]. / Nachsorge von epibulbären Glaukomdrainageimplantaten.

There is an increasing trend towards using glaucoma drainage implants. The postoperative management of such devices depends on their technical characteristics and specific complications. The Baerveldt glaucoma implant with its larger surface area has been shown to lower mean intraocular pressure more effectively than the Ahmed-FP7 implant. As a non-valve implant, however, it has been associated with a higher rate of severe complications, particularly ocular hypotension. Moreover, glaucoma implants may induce diplopia if they interfere with extraocular muscles. Topical treatment with antibiotics and steroids is necessary in cases of intraocular inflammation. In refractory cases, the tube may even have to be removed. Surgical reposition of the tube may be indicated when it is severely dislocated. Increased intraocular pressure is primarily treated by pressure-lowering medications during postoperative follow-up. If topical glaucoma medication is insufficient to control increases in intraocular pressure due to encapsulation, a second implant may be considered or the capsule surrounding the implant may be excised to reduce outflow resistance or additional cyclodestructive procedures can be performed. Chronic hypotension may be treated with tube ligation or occlusion. Severe corneal oedema may require lamellar keratoplasty. Conjunctival erosions with tube exposure or tube retractions also require surgical correction.

Long-Term Outcomes of External Dacryocystorhinostomy in the Age of Transcanalicular Microendoscopic Techniques.

Purpose. This study aimed to evaluate long-term results of external dacryocystorhinostomy (DCR) at a tertiary eye care center specializing in lacrimal duct surgery in Germany. Methods. The medical records of 1010 patients with acquired nasolacrimal duct obstruction (NLDO), who had undergone lacrimal duct surgery at a tertiary eye care center, were reviewed. Only adult patients who had undergone external DCR were included. The evaluation included the following parameters: age, gender, duration of symptoms, patient satisfaction, previous dacryocystitis, complication rates, and surgical outcome. Results. 154 eyes of 146 patients (14.5%) could be included in the study. The average age was 64.1 ± 29.7 years. 66.4% of patients were females and 33.6% were males. Acute or chronic dacryocystitis was found in 81 patients (55.5%). Overall, 82.8% of patients had full resolution of symptoms. The success rate of external DCR for patients with previous episodes of dacryocystitis was 82.7% compared to 83.4% for patients without dacryocystitis in their medical history. Conclusion. In cases in which transcanalicular microendoscopic techniques are contraindicated (e.g., after dacryocystitis) or in complex cases where microendoscopic procedures have failed (revision surgery), external DCR is still the surgical treatment of choice with very good postoperative success.

[Complexities of Medical Glaucoma Therapy--the Elderly Patient in Focus]. / Umsetzung und Schwierigkeiten bei Tropftherapien--der ältere Glaukompatient im Fokus.

In order to treat glaucoma with medication successfully, the patient needs to participate actively in the process. "Adherence", formerly "compliance", describes the willingness and capacity to follow the prescribed regimen every day. It is not trivial to measure adherence and persistence, as this quite often relies on self reports by the patient or speculations by the physician. Hence, the overall reported adherence may vary from 5 to 95 %. In general, the following categories have been defined for reduced adherence: medication-related factors, patient-related factors, environmental factors and social factors. Age has been found to intensify or modify many of these factors. Older adults often face various challenges, due to motor disabilities, reduced visual acuity or impaired cognitive capabilities. In patients with movement disorders or tactile limitations, the target area can be reached more successfully with standard eye drop bottles than with single-use dose units. This should be considered if antiglaucoma eye drops are prescribed in the elderly. Frequency of application is a main factor influencing adherence. Monotherapy--as provided with prostaglandins--or drops with a fixed combination have proven to support adherence significantly. A significant boost for self-monitoring activities is initiated by the growing market of electronic devices, like smartphones. For instance, they can provide acoustic alarms as reminders to apply the eye drops. It is evident that any external support or disease-related information by family members, the medical practitioners, support groups or even electronic devices may improve adherence and persistence, even in patients with severe impairments.

[Ease of handling of first and second generation rebound tonometers]. / Handhabung von Reboundselbsttonometern der ersten und zweiten Generation.

PURPOSE: To evaluate the ease of handling of two rebound tonometers, which are designed for self-measurement of intraocular pressure (IOP) in a clinical setting by untrained patients. METHODS: After self-measurement of the IOP with the rebound tonometers iCare ONE and iCare HOME, participants were asked to complete a questionnaire containing different subitems concerning ease of operation using a visual analog scale (1 = very good to 5 = very poor). Moreover, the feasibility and duration of measurement were tested. RESULTS: A total of 147 subjects participated in this study. The mean score for general handling ability was 2.79 ± 1.01 for the iCare ONE and 1.85 ± 0.87 for the iCare HOME (p < 0.001). The evaluation of the subitems sense of safety (iCare ONE: 2.71 ± 1.03 and iCare HOME: 1.87 ± 0.81, p < 0.001) and comfort of measurement (iCare ONE: 2.07 ± 1.01 and iCare HOME: 1.66 ± 0.72, p < 0.001) also showed a significant discrepancy between the two tonometers. Participants needed significantly less time for a single valid measurement when using the iCare HOME tonometer (mean 66.14 ± 61.54 s) compared to the iCare ONE tonometer (mean 81.54 ± 69.51 s, p < 0.001). CONCLUSIONS: A better handling of the iCare HOME rebound tonometer in comparison to the iCare ONE tonometer can be deduced on the basis of the subjective assessments of patients and the shorter duration of measurements. Moreover, the iCare HOME received a significantly better evaluation for all subitems. The accuracy of measurements using the iCare HOME still needs to be clarified.

[Traumatic Lacrimal Duct Stenosis: Demographics and Success Rate of Surgical Procedures for Secondary Treatment]. / Traumatische Tränenwegsstenosen: Epidemiologie und Erfolgsraten nach sekundärer operativer Intervention.

BACKGROUND: Traumatic lacrimal duct stenosis can be the result of sharp trauma of the eyelid, indirect trauma or surgery in the nasoorbital region, as well as burns, chemotherapy and radiation of the facial region. The aim of the study is to present the demographics, patient satisfaction, and course of different surgical procedures for secondary treatment of traumatic lacrimal duct stenosis. METHODS: We retrospectively reviewed the medical records of 50 patients who required surgery for traumatic lacrimal duct stenosis from 2009 to 2011 at the University Eye Hospital in Muenster. The evaluation included the following criteria: age, sex, duration of symptoms, complication rate and the rate of recurrence. We systematically evaluated the medical data and asked the patients about the recent symptoms via telephone questionnaire. RESULTS: 60 eyes of 50 patients were included (18 women; 32 men; age: 51.8 ± 17.1 years); 34 eyes (56.7 %) had already had operations of the lacrimal system. The success rate was 58.1 %. The mean postoperative follow-up was 52.3 ± 10.7 months. In 11 cases (18.3 %), a dakryocystorhinostomy (DCR) was necessary. CONCLUSION: Traumatic lacrimal stenosis is more common in men, and has a poorer prognosis than lacrimal duct stenosis from other causes.

[Current aspects on the management of normal tension glaucoma]. / Aktuelle Aspekte zum Management des Normaldruckglaukoms.

In a considerable proportion of glaucoma patients (25-50 %) the intraocular pressure (IOP) is not elevated higher than 22 mmHg at first diagnosis and during subsequent follow-up controls. Although the IOP level remains in the low range < 22 mmHg, progression of glaucoma can still occur. A multitude of different factors are assumed to be involved in glaucoma progression, such as very low nocturnal diastolic blood pressure values, a low mean ocular perfusion pressure, extensive fluctuations in perfusion (e.g. in cases of vascular dysregulation), an increased vulnerability of the optic nerve support structures, an increased translaminar pressure gradient and various underlying systemic diseases. The most important evidence-based aspect of treatment in normal tension glaucoma is pharmaceutical or surgical reduction of the IOP by 30 % or more in comparison to the initial pressure level. Vascular and neuroprotective concepts of treatment for normal tension glaucoma have been strongly advocated and the object of experimental and clinical studies. As yet a clear clinical benefit has not been proven by large prospective randomized studies.

[Rebound tonometry after vitreoretinal surgery]. / Reboundtonometrie nach vitreoretinaler Chirurgie.

PURPOSE: The aim of this study was to analyze the practicability and comparability of the Icare rebound tonometer (RT) versus the Schiötz indentation tonometer (SIT) and the Goldmann applanation tonometer (GAT) for measuring intraocular pressure (IOP) in patients after pars plana vitrectomy (PPV). METHODS: A total of 100 eyes from 100 patients who underwent vitreoretinal surgery in the Department of Ophthalmology, University of Cologne were included in this prospective analysis. The IOP was measured using RT preoperatively, on the day of surgery and 2 days after surgery, using SIT on the day of surgery and GAT preoperatively and 2 days after surgery. For the evaluation eyes were divided into subgroups with respect to the endotamponade selected and the IOP level. RESULTS: The mean preoperative IOP for all enrolled eyes was 15.4 ± 8.0 mmHg for RT and 16.1 ± 7.9 mmHg for GAT. Bland-Altman analysis revealed a bias between RT and GAT of - 0.6 mmHg. Bland-Altman analysis for the postoperative course of all eyes revealed a bias of 3.0 mmHg between RT and SIT on the day of surgery and no bias between RT and GAT in the further postoperative follow-up. CONCLUSION: Rebound tonometry seems to provide precise IOP values after vitreoretinal surgery. Divergence from SIT values on the day of surgery is presumably due to a general tendency of SIT to underestimate IOP values. Therefore, RT can be used in the clinical routine after vitreoretinal surgery as an alternative to GAT.

[Glaucoma filtering surgery in the elderly over eighty years old: an analysis of postoperative risks]. / Antiglaukomatöse Filtrationschirurgie bei alten Glaukompatienten ab dem 80. Lebensjahr: Analyse der postoperativen Risiken.

BACKGROUND: Aim of this retrospective study was to identify the postoperative complications following trabeculectomy with mitomycin C in patients aged 80 years or older at the time of surgery. Additionally, the corresponding risk factors for postoperative complications were analysed. MATERIAL AND METHODS: During a defined period between 2005 and 2009 all trabeculectomies in this age group at the Department of Ophthalmology, University of Cologne were identified. Second eye surgery and re-trabeculectomies in the same eye were excluded from data collection. Postoperative ocular hypotony (< 6 mmHg) and hypertony (> 20 mmHg), bleeding, corneal erosion, re-surgery and prolonged postoperative duration of hospital stay were defined as complications. RESULTS: One hundred and twenty eyes of 120 patients were included. The mean age was 83.4 years, 62.5 % patients were female. Eighty nine percent of the eyes were pseudophakic, the mean visual field defect was - 17.3 dB, the mean preoperative intraocular pressure under pressure-reducing medication was 24.1 mmHg. Considering the perioperative complications there was no significant difference depending on the age (80-85 years, n = 79 and > 85 years, n = 41), depending on the type of anesthesia (general, n = 80 and local, n = 40) or depending on antiplatelet (APT)/anticoagulative (ACT) therapy (APT, n = 55 and ACT, n = 16). The postoperative duration of the hospital stay showed significant correlations with the occurrence of corneal erosions, postoperative ocular hypertony, loss of anterior chamber and choroidal detachment. CONCLUSIONS: The postoperative risks of antiglaucomatous filtering surgery did not increase with age or comorbidity. However, even minor perioperative complications had direct implications on the duration of the hospital stay.

[Clinical value of ab-interno trabecular surgery in the management of glaucoma]. / Stellenwert der Ab-interno-Trabekelchirurgie in der Glaukombehandlung.

Ab-interno trabecular surgery does not damage sclera and conjunctiva in glaucoma patients and does not prejudice subsequent anti-glaucomatous filtration or drainage device surgery. As only trabecular resistance is surgically modified, the level of intraocular pressure (IOP) can usually not be reduced in the lower teens. Consequently, incisional ab-interno trabecular surgery is a valuable option in early glaucoma stages with moderate IOP elevation, especially in combination with cataract surgery. Ab-interno trabecular surgery is an insufficient surgical tool in normal pressure glaucoma, but also in glaucoma patients with very high IOP peaks.

Secondary subconjunctival implantation of a biodegradable collagen-glycosaminoglycan matrix to treat ocular hypotony following trabeculectomy with mitomycin C.

AIM: Biodegradable collagen glycosaminoglycan matrices (CGM) have been introduced to glaucoma filtration surgery in order to prevent scarring of the filtering bleb. In this retrospective case series, we describe a new surgical concept for treating symptomatic ocular hypotony following filtration surgery with mitomycin C by a secondary subconjunctival implantation of a CGM. METHODS: Depending on bleb morphology, a CGM implant with a diameter of 6 or 12 mm was placed subconjunctivally on the scleral flap in 12 eyes displaying symptomatic ocular hypotony with (n=2) or without (n=10) bleb leakage. Median period between trabeculectomy and this intervention was 4.5 months (range, 1-72 months). RESULTS: Mean intraocular pressure significantly increased from 4.4±1.4 mm Hg to 9.9±2.8 mm Hg (p<0.0001) over a median follow-up of 6 months (range, 2-18 months). Mean visual acuity improved significantly (p=0.0012). Postoperative complications included implant re-exposure in one eye and persistent choroidal detachment requiring resurgery in another eye. CONCLUSIONS: Subconjunctival implantation of CGM may present an additional surgical tool in the treatment of symptomatic ocular hypotony after filtering surgery. The mechanism of action may be counter-pressure to the scleral flap and secondary wound healing around the CGM scaffold. Long-term observations are needed to fully evaluate this new surgical concept.

[Combined cataract and glaucoma surgery. Current options]. / Kombinierte Katarakt-Glaukom-Chirurgie. Aktuelle Optionen.

Trabeculectomy is no longer the gold standard for combined cataract glaucoma surgery considering the successful results following cataract surgery combined with trabeculotomy, viscocanalostomy and canaloplasty. The main disadvantage of these mostly non-penetrating procedures is the induction of conjunctival scarring which jeopardizes subsequent filtering surgery. Ab interno glaucoma surgery, including trabecular surgery and endocyclophotocoagulation, does not interfere with the conjunctival situation. These surgical options have a relatively minor risk profile for combined cataract glaucoma surgery compared to traditional filtering surgery; however, the pressure reducing efficacy of these ab interno approaches is limited with respect to the absolute reduction of intraocular pressure (IOP) and the achievable level of IOP. This has to be kept in mind when planning surgery.

[Cataract surgery in glaucoma patients. Perioperative aspects]. / Kataraktchirurgie beim Glaukom. Perioperative Aspekte.

The development of intraocular pressure (IOP) following standard cataract surgery is extremely dependent on the type of glaucoma and the prognosis is especially good for primary angle-closure glaucoma. Cataract extraction usually induces a mid-term and long-term increase of IOP in a well-working filtering bleb. Concerning the choice of intraocular lens (e.g. multifocal or toric) the surgeon has to consider the probability of subsequent incisional glaucoma surgery and the risk of decentration of the capsular bag (e.g. in exfoliative glaucoma or hydrophthalmos). According to the results of recent studies topical prostaglandin therapy does not seem to increase the risk of postoperative macular edema if given before cataract surgery.

[Is prophylactic YAG iridotomy useful in pigment dispersion syndrome?]. / Was bringt die prophylaktische YAG-Iridotomie beim Pigmentdispersionssyndrom?

Despite theoretical considerations concerning the advantage of iridotomy in eyes with pigment dispersion syndrome or early pigment glaucoma, there is a lack of clinical evidence that this procedure has a long-term effect in preventing glaucoma damage under these circumstances. However, several factors may contribute to this lack of evidence, e.g. the statistical problem of a low conversion rate from pigment dispersion syndrome to pigment glaucoma or the inclusion criteria in the studies treating patients older than 40 years or genetic dispositions in pigment glaucoma that are not yet fully clear. On the basis of current data the decision for YAG iridotomy should only be taken in patients younger than 40 years, if the midperipheral iris shows an inverse bowing and the intraocular pressure is normal or slightly increased with no progressive signs of optic nerve damage. In cases of insufficient intraocular pressure and visual defects due to glaucomatous optic nerve damage, incisional glaucoma surgery is usually necessary especially in younger patients with a long life expectancy.

[Juvenile glaucoma in propionic acidemia]. / Juveniles Glaukom bei Propionazidämie.

Propionic acidemia (PA) is a rare autosomal recessive disorder resulting from deficiency of the biotin-dependent enzyme propionyl-CoA carboxylase, which is necessary for the catabolism of branched chain amino acids and odd-chain fatty acids. Although optic atrophy was documented in four cases, no glaucomatous optic atrophy has yet been described. This article describes the first case of a 12-year-old boy with PA showing bilateral glaucomatous optic disc atrophy due to dysgenetic changes of the angle of the anterior chamber.