[Prevalence of glaucoma in obstructive sleep apnea]. / Glaukomprävalenz bei obstruktiver Schlafapnoe.

BACKGROUND: A causal relationship between glaucoma and obstructive sleep apnea has been postulated in several clinical studies but also refuted by others. The aim of this study was to determine the prevalence of glaucoma in a cohort of patients with well-established obstructive sleep apnea in comparison to the published data on this topic. METHODS: A total of 100 consecutive patients (male:female 80:20, mean age 59 ± 11 years SD) with polysomnographically established obstructive sleep apnea underwent an ophthalmological examination including tonometry, static perimetry and dilated fundus photography. Visual fields and fundus photographs of the patients were classified as glaucomatous or non-glaucomatous by two independent examiners. RESULTS: The prevalence of glaucoma in the study patients was 2 % which corresponded to the published prevalence of glaucoma in the normal population. Intraocular pressure did not correlate with the respiratory index, body mass index or sex. CONCLUSION: The data from this study shed doubt on a causal relationship between obstructive sleep apnea and glaucoma.

[Sleep apnoea and glaucoma]. / Schlafapnoe und Glaukom.

Several lines of evidence suggest an association between (normal-tension) glaucoma and sleep apnoea syndrome (SAS). It is hypothesised that the glaucomatous damage may result from impaired perfusion of the optic nerve head secondary to repetitive prolonged apnoeas. Therefore, screening for SAS in suspectible glaucoma patients is recommended.

[Treatment of a female patient with sickle-cell anemia during cardiac surgery with cardiopulmonary bypass]. / Tratamiento de una paciente con drepanocitosis homocigota durante la cirugía cardiaca con circulación extracorpórea.

A 17-year-old girl with drepanocytic (sickle-cell) anemia who was being treated with hydroxyurea and periodic blood transfusions through a Hickman-type catheter was admitted for periodic episodes of fever. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Massive right atrial thrombosis with pulmonary embolism and bacterial endocarditis were detected by computed tomography. Surgery with a beating heart and cardiopulmonary bypass was undertaken. Drepanocytic anemia in individuals homozygous for hemoglobin S is a rare condition in Spain but we are beginning to see a few cases, in which management during anesthesia will be more complicated. High-risk surgery can be carried out in these patients without adverse events if the anesthesiologist is guided by a complete blood workup and takes precautions during and after surgery to control hydration, oxygenation, temperature, and the acid-base balance.

Is the PASCAL-Tonometer suitable for measuring intraocular pressure in clinical routine? Long- and short-term reproducibility of dynamic contour tonometry.

PURPOSE: Dynamic contour tonometry (DCT) is a new technique to measure intraocular pressure (IOP). In several studies no correlation between IOP values and corneal thickness was shown with DCT. This is in contrast to the gold standard, Goldmann applanation tonometry (GAT). The authors evaluated the reproducibility (RP) of DCT compared to GAT, a prerequisite for its introduction into clinical routine. METHODS: IOP was measured with both DCT and GAT in 50 subjects with normal cornea. To evaluate the short-term RP, four DCT and four GAT measurements were performed at day 1 in a randomized order. Long-term RP was determined by one additional measurement per method at day 2, 5, and 8. RESULTS: The short-term RP was defined as the mean value of all standard deviations (SD) of the individual measurements at day 1. Short-term RP was 1.1 mmHg for GAT and 1.2 mmHg for DCT. For long-term reproducibility, mean SD was 1.2 mmHg for GAT and 1.5 mmHg for DCT. Bland-Altman revealed a good agreement of the two methods. However, mean DCT values were on average 0.8+/-1.1 mmHg higher than GAT values. A significant correlation was observed between GAT and CCT (r2=0.15, p=0.006), but not between DCT and CCT (r2=0.032, p=0.21). CONCLUSIONS: Short- and long-term reproducibility of DCT is comparable to that of GAT. GAT is more affected by CCT than DCT, measuring higher IOPs in eyes with higher central corneal thickness.

[Excimer laser trabeculotomy: minimally invasive glaucoma surgery]. / Minimal-invasive Glaukomchirurgie: Excimer-Laser-Trabekulotomie.

Excimer laser trabeculotomy (ELT) is a minimally invasive method for reducing intraocular pressure. It can be performed as a stand-alone procedure or in combination with cataract surgery in just a few minutes. Laser spots are applied in the anterior chamber angle via an endoscopic camera or a gonio lens. In contrast to argon laser trabeculoplasty, shunts between the anterior chamber and Schlemm's canal are prepared by a photoablative laser, thus improving the outflow of aqueous humour. Best results can be expected in patients with moderately elevated intraocular pressure and cataract undergoing the combined procedure.

[Steroid glaucoma after laser in situ keratomileusis]. / Steroidglaukom nach LASIK.

BACKGROUND: A steroid-induced glaucoma may develop after bilateral laser in situ keratomileusis (LASIK) with normal intraocular pressure in applanation tonometry. METHODS: We present the case of a 32-year-old patient who underwent bilateral LASIK for myopia. Postoperatively, a steroid-induced glaucoma developed. After the steroid therapy was stopped applanation tonometry showed normal values. A slight corneal opacity was interpreted as a keratokonjunctivitis sicca because of occupational noxa. One year after LASIK, the patient presented with high intraocular pressure (IOP), maximally excavated optic nerve head and extensive visual fields defect in both eyes. CONCLUSION: Elevated IOP after LASIK can lead to fluid accumulation in the interface. In this case applanation tonometry can underestimate the intraocular pressure. Even when steroid therapy is stopped, the elevated pressure can persist. This complication after LASIK is very rare and can cause severe damage if not diagnosed.

[Primary open-angle glaucoma and systemic diseases]. / Primäres Offenwinkelglaukom und Allgemeinerkrankungen.

The exact pathomechanism of primary open-angle glaucoma (POAG) is still not completely understood. Besides elevated intraocular pressure, which has been identified as a major risk factor, there is mounting evidence for the involvement of systemic factors in the development of glaucomatous damage. Systemic peculiarities described in POAG include cardiovascular, endocrine, neurodegenerative, and sleep alterations. However, some of the studies available on systemic findings in glaucoma patients are contradictory, making further research necessary to identify the exact role of such disturbances in the pathogenesis of the damage. Another difficulty is that many studies are limited by their small sample size, their retrospective nature, and potential selection bias, thus making data interpretation more difficult. Moreover, it is not always clear whether we are dealing with coincidence or a true association between glaucoma and a particular systemic disease. Nevertheless, there is ample evidence for the involvement of vascular factors such as vascular dysregulation and blood pressure in the pathogenesis of POAG.

[High tech in the diagnosis of glaucoma]. / Hightech in der Glaukomdiagnostik.

Scanning laser tomography (HRT, HRT II), scanning laser polarimetry (GDx nerve fibre analyser, GDx VCC), retinal thickness analyser (RTA) and optical coherence tomography (OCT, stratus OCT) provide objective measurements of the optic disc and the retinal nerve fibre layer suitable for the follow-up of glaucoma patients. Their ability to diagnose early glaucomatous damage is still limited but promising technical advances in this field can be expected in the future. For the moment, clinical examination and fundus photography still remain the gold standard for the assessment of glaucomatous optic disc and retinal nerve fibre layer damage.

[Laser surgery for glaucoma: excimer-laser trabeculotomy]. / Laserchirurgie und Glaukom: Excimer-Laser-Trabekulotomie.

BACKGROUND: Excimer-laser trabeculotomy (ELT) is a new, minimally invasive surgical procedure for the treatment of open-angle glaucoma that can easily be combined with cataract surgery. We herein report our experience with ELT as a stand-alone procedure and ELT plus cataract surgery. METHODS: A total of 135 patients with open-angle glaucoma (n = 128) or ocular hypertension (n = 7) (M : F = 49 : 86, mean age 69.7 +/- 1.2 years) were included in this study. Patients were divided into 2 groups: a) ELT as a stand-alone procedure (n = 75), b) combined cataract and ELT procedure (n = 60). Both groups were further divided into 2 subgroups: 1) Preoperative IOP > 22 mmHg, 2) Preoperative IOP < or = 22 mmHg. Kaplan-Meier survival curves were calculated. Success criterion was 20 % decrease of IOP and IOP < or = 21 mmHg and postoperative IOP-lowering medication < or = preoperative IOP-lowering medication. Follow-up time was 1 year. RESULTS: Group a) ELT, 1) preoperative IOP > 22 mmHg, 2) preoperative IOP < or = 22 mmHg: Kaplan-Meier survival curves showed a success rate of 57 % in subgroup 1 and of 41 % in subgroup 2. Group b) Combined cataract and ELT procedure, 1) preoperative IOP > 22 mmHg, 2) Preoperative IOP < or = 22 mmHg: success rate was 91 % in subgroup 1 and 52 % in subgroup 2. CONCLUSION: ELT is a promising IOP-lowering technique both as a stand-alone procedure and in combination with cataract surgery. It is especially suitable for patients with high preoperative IOP levels.

[Anti-infective drug therapy in ophthalmology--Part 2: viral infections]. / Antiinfektive medikamentöse Therapie in der Augenheilkunde--Teil 2: Virale Infektionen.

In this review ophthalmological diseases caused by herpes simplex virus, varicella zoster virus, Epstein-Barr virus, cytomegaly virus or adenovirus are described briefly. The main therapeutic options are discussed placing emphasis especially on prospective randomised trials.

[Visual object and space perception battery: normal values for children from 8 to 12]. / Testbatterie für visuelle Objekt- und Raumwahrnehmung (VOSP): Normwerte für 8- bis 12-Jährige.

BACKGROUND: Diagnostics of central visual perception is a relevant branch of developmental medicine and neuropsychological diagnostic efforts of morphological or functional lesions of the brain. However, no assessment battery for testing the central-visual perception in German-speaking children exists. PROBANDS AND METHOD: In 30 children, aged 8 - 12 years, the Visual Object and Space Perception Test Battery (VOSP) was applied. RESULTS: The group values were documented as standard values. Instructions and aims of the tests were well comprehended by the children. CONCLUSION: The VOSP is well applicable to children. Further studies examining correlation between the VOSP and clinical data are warranted.

[Primary intraocular lymphoma with unusual clinical presentation and poor outcome]. / Primäres intraokuläres Lymphom mit untypischer Klinik und ungünstigem Verlauf.

BACKGROUND: Primary intraocular lymphoma is a distinct subset of primary non-Hodgkin's lymphoma of the CNS. In general, the primary non-Hodgkin's lymphoma of the CNS is rare, accounting for 1 % of all non-Hodgkin's lymphomas and less than 1 % of all intraocular tumors. HISTORY AND SIGNS: A 70-year-old man was hospitalized in June 2002 because of acute loss of vision on his left eye. A severe vitreous hemorrhage was observed. Ultrasound showed solid subretinal lesions at the posterior fundus. Diagnostic vitreous surgery including a biopsy was performed. An intraocular malignant B-cell lymphoma was determined by immunohistochemistry. General screening revealed no further manifestations of the lymphoma. THERAPY AND OUTCOME: The patient initially refused any therapy until a painful secondary neovascular glaucoma with complete loss of visual function developed, thus prompting us to perform an enucleation. The following immunohistochemical examination confirmed the initial diagnosis. A chemotherapy with high-dose methotrexate and leucovorin rescue was initiated. CONCLUSIONS: Primary intraocular lymphoma can present as diffuse uveitis refractory to corticosteroids. Diagnosis can be difficult and is often delayed.

[Visual function in developmental dyslexia. Opthalmological and neuropsychological results]. / Visuelle Funktionen bei Legasthenie. Ophthalmologische und neuropsychologische Befunde.

BACKGROUND: We aimed to test children with developmental dyslexia for possible alterations of their spatial and visuoperceptual ability. METHODS: A total of 31 children with developmental dyslexia were included in the study. All children underwent a complete ophthalmological and orthoptic examination. Neuropsychological testing was performed using the Visual Object and Space Perception Battery (VOSP) and the subtest "Gestalt Closure" of the Kaufman Assessment Battery for children. Even though the VOSP is validated and standardized for adults, no normal values for children exist thus far. Therefore, a sex- and age-matched control group was tested. In addition, the parents of the dyslectic children completed the Child Behavior Checklist for Ages 4-18 (CBCL/4-18). RESULTS: All children presented normal ophthalmological and orthoptic findings. Performance in the VOSP subtests "progressive silhouettes test'" and "number location" was significantly reduced in dyslectic children when compared to controls ( p<0.0003 and p<0.046, respectively). There was also a tendency towards lower values in the subtest "position discrimination" ( p=0.07). In the other subtests no significant difference between dyslectic children and controls was observed. The results of the subtest "Gestalt Closure" of the K-ABC and the CBCL/4-18 were within normal ranges. CONCLUSION: The study demonstrates that developmental dyslexia is not based on ocular deficits, but indicates possible disturbances of visual-spatial cognition and visual-spatial perception in dyslectic children.

Iris transillumination defects in patients with primary open angle glaucoma.

PURPOSE: To examine the incidence and pattern of iris transillumination defects in patients with primary open angle glaucoma (POAG) with and without vascular dysregulation, in comparison to controls. METHODS: We prospectively examined 24 patients with POAG (M/F 10:14; mean age 59 +/- 14, range 21-76 years) and 23 controls (M/F 10:13; mean age 52 +/- 15, range 25-86 years). Vascular dysregulation was presumed if patients had a typical medical history of vasospasm and a pathological result in nailfold capillaroscopy. Iris transillumination defects were visualized by video-taped, digitized diaphanoscopy and assessed by two blinded observers. RESULTS: We found significantly more iris transillumination defects in POAG than in controls (54.2% vs. 8.7%; chi2 = 8.85; df = 1; p = 0.002). The defects in POAG showed a characteristic radially-streaked pattern different from those described, for instance, in pigment dispersion syndrome, pseudoexfoliation syndrome, and acute glaucoma. Glaucoma patients with vascular dysregulation had a tendency to a higher incidence of transillumination defects than non-vasospastic patients, though this finding was not significant. CONCLUSIONS: Patients with POAG have a higher incidence of iris transillumination defects than controls. The underlying mechanisms are not yet clear and call for further investigation.

Peripheral vasospasm and nocturnal blood pressure dipping--two distinct risk factors for glaucomatous damage?

PURPOSE: To evaluate the relationship between peripheral vasospasm and circadian blood pressure rhythm in patients with primary open angle glaucoma (POAG). METHODS: Nail-fold capillaroscopy, combined with a cold provocation test, and 24-hour blood pressure monitoring was carried out in 130 patients with POAG (M:F 58:72; mean age 60 +/- 14 years), 99 with high-tension glaucoma (HTG) and 31 with normal-tension glaucoma (NTG). Peripheral blood flow parameters were compared for patients with a nocturnal fall in mean systemic blood pressure (MBP) of less than 10% (non-dippers), patients with a nighttime MBP fall of 10-20% (dippers), and patients with a nighttime MBP fall of more than 20% (over-dippers). RESULTS: Patients with POAG showed a significantly lower blood flow velocity both at baseline (p < 0.01) and after cold provocation (p < 0.02) and a significantly higher percentage of cold-induced blood-flow standstill (p < 0.0001) in the nail-fold capillaroscopy than normal controls. The numbers of non-dippers (50), dippers (66) and over-dippers (14) did not differ between the HTG and NTG group. There were no significant differences between non-dippers, dippers, and over-dippers in peripheral blood flow parameters. CONCLUSIONS: Our findings indicate that vasospasm and low blood pressure may be distinct risk factors for glaucomatous damage. It also appears that screening for vascular dysregulation and systemic hypotension should not be restricted to NTG patients alone.

Melatonin MT-1-receptor immunoreactivity in the human eye.

AIM: To examine the distribution of melatonin 1a (MT1) receptors in the human eye. METHODS: Seven normal human eyes were examined by immunohistochemical staining of paraffin sections, using an anti-MT1 primary antibody and an ABC detection system. RESULTS: MT1 receptor immunoreactivity (MT1-IR) was detected primarily in the inner segments of rods and cones and in retinal ganglion cells. In addition, MT1-IR was present in the adventitia of retinal arteries and veins, including the papillary region, but absent in ciliary and choroidal vessels. Mild staining of corneal endothelial cells and keratocytes was observed in all but two eyes. CONCLUSION: MT1-IR is present in various ocular tissues with the highest density in photoreceptor cells and ganglion cells. The physiological function of these receptors deserves further investigation.

Do angiographic data support a detailed classification of hypertensive fundus changes?

The eye is a target organ as well as an established prognostic indicator of arterial hypertension. Based on the ophthalmoscopically visible alterations, several classifications, the majority of them grading hypertensive fundus changes into four stages, have been suggested. Moreover, assessment of hypertensive alterations of the perivoveal microcirculation has become possible by means of fluorescein angiography. However, it has not yet been evaluated whether an angiographic equivalent for the ophthalmoscopic classifications exists. We therefore compared the perifoveal microcirculation of hypertensive patients who were staged according to the classification of Neubauer, a modification of the classification of Keith and Wagener, among each other and with that of normal subjects. According to Neubauer, who distinguishes between fundus hypertonicus (stages I-II) and hypertensive retinopathy (stages III-IV), we divided the patients (n = 143) into four groups: stage I (n = 49), stage II (n = 72), stage III (n = 16), and stage IV (n = 6). All patients underwent fluorescein angiography performed with a scanning laser ophthalmoscope. By means of digital image analysis we quantified the following parameters: (1) perifoveal intercapillary area (PIA), (2) the area of the foveal avascular zone (FAZ), and (3) capillary blood velocity (CBV). All patients with arterial hypertension demonstrated a rarefaction of the perifoveal capillary bed and a decrease of capillary blood velocity as compared with normal subjects. Significant changes of PIA (P < 0.05) and CBV (P < 0.05) were seen between mild (I-II) and severe stages (III-IV) of hypertensive retinopathy, but neither between stages I and II nor between stages III and IV. Our findings indicate significant angiographic differences between mild and severe form of hypertensive retinopathy, however, unlike in ophthalmoscopy, a differentiated division into four stages is not possible.

Cold feet and prolonged sleep-onset latency in vasospastic syndrome.

People with vasospastic syndrome have cold hands and feet and abnormal vasoconstriction after local cold exposure. Normally there is a circadian rhythm of distal vasodilation, with onset in the early evening, which directly influences ability to fall asleep. We gave a sleep questionnaire to 32 patients with primary vasospastic syndrome and 31 healthy controls. People with vasospasticity had significantly prolonged sleep-onset latency both at onset of night-time sleep and after nocturnal disturbance. This prolonged latency could be associated with impaired capacity for distal vasodilation.

Vasospasm, its role in the pathogenesis of diseases with particular reference to the eye.

Vasospasm can have many different causes and can occur in a variety of diseases, including infectious, autoimmune, and ophthalmic diseases, as well as in otherwise healthy subjects. We distinguish between the primary vasospastic syndrome and secondary vasospasm. The term "vasospastic syndrome" summarizes the symptoms of patients having such a diathesis as responding with spasm to stimuli like cold or emotional stress. Secondary vasospasm can occur in a number of autoimmune diseases, such as multiple sclerosis, lupus erythematosus, antiphospholipid syndrome, rheumatoid polyarthritis, giant cell arteritis, Behcet's disease, Buerger's disease and preeclampsia, and also in infectious diseases such as AIDS. Other potential causes for vasospasm are hemorrhages, homocysteinemia, head injury, acute intermittent porphyria, sickle cell disease, anorexia nervosa, Susac syndrome, mitochondriopathies, tumors, colitis ulcerosa, Crohn's disease, arteriosclerosis and drugs. Patients with primary vasospastic syndrome tend to suffer from cold hands, low blood pressure, and even migraine and silent myocardial ischemia. Valuable diagnostic tools for vasospastic diathesis are nailfold capillary microscopy and angiography, but probably the best indicator is an increased plasma level of endothelin-1. The eye is frequently involved in the vasospastic syndrome, and ocular manifestations of vasospasm include alteration of conjunctival vessels, corneal edema, retinal arterial and venous occlusions, choroidal ischemia, amaurosis fugax, AION, and glaucoma. Since the clinical impact of vascular dysregulation has only really been appreciated in the last few years, there has been little research in the according therapeutic field. The role of calcium channel blockers, magnesium, endothelin and glutamate antagonists, and gene therapy are discussed.