[Corneal ulcers in systemic autoimmunologic diseases]. / Hornhautulzera bei systemischen Autoimmunerkrankungen.

BACKGROUND: Keratolysis is a rare severe complication following systemic autoimmunologic diseases. Despite of complex therapeutic treatments, the prognosis is very poor. PATIENTS: Ten eyes from seven patients with corneal ulcers were reported (age 45 - 73 years, mean 63 years; 6 women, 1 man). The corneal ulcer was perforated in 7 eyes. Five patients suffered from rheumatoid arthritis, and one patient developed a Sjögren's syndrome. Besides, one patient had shown both autoimmunologic diseases. After clinical attendance, visual acuity in the eyes with nonperforated ulcers was between 0.1 and 0.4, and in the eyes with perforated ulcers between light perception and 0.2. RESULTS: In 7 eyes with perforated corneal ulcers an emergency tectonic conjunctival plasty and, 1 - 2 days later, a keratoplasty had been performed. Postoperatively, local therapies had been initiated with antibiotic and immunosuppressive eyedrops as well as with conventional drops for dry-eye symptoms. Because of the autoimmunologic diseases of the patients, a systemic immunosuppressive therapy had been arranged. Follow-up period had been between 4 weeks and 3,5 years (mean 16 months). In the three eyes with nonperforated ulcers which received an antibiotic and immunosuppressive treatment, visual acuity was found at 1 / 20 and 0.4. However, in spite of stabilized findings in the 5 eyes with perforated ulcers, the visual acuity was in this case only between light perception and 0.05. One patient with a perforated ulcer and one patient with a recurrent corneal perforation after keratoplasty refused further operative procedures. Finally, both eyes had to undergo evisceration. CONCLUSIONS: Despite of intensive local and systemic immunosuppressive as well as operative therapies, corneal ulcers associated with autoimmunologic diseases (rheumatoid arthritis, Sjögren's syndrome) may cause a marked decrease of visual acuity or the loss of an eye. With regard to the healthy eye, an immunosuppressive therapy for life is most important.

[Fusarium keratitis]. / Fusarium-Keratitis.

The case of a previously healthy 48-year-old patient (not a contact lens wearer) with a Fusarium keratitis is reported. He had developed a deep corneal ulcer with total stromal infiltration (Fusarium ssp.). An intensive topical and systemic antiinfectious medication was initiated, along with some procedures (keratoplasty, rinsing of the anterior chamber). However, the infection progressed (endophthalmitis), and an enucleation was necessary. Despite modern drug therapy and surgical intervention, fungal keratitis can cause an enucleation.

[Terson syndrome--a contribution to the timing of operation for pars plana vitrectomy]. / Terson-Syndrom - Beitrag zum Operationszeitpunkt der Pars-plana-Vitrektomie.

PURPOSE: This study aimed to investigate the possible differences in final outcome in patients with Terson syndrome (1996 - 2005) with regard to the time of vitrectomy after the acute event. METHOD: Eighteen eyes from eleven patients with Terson syndrome are reported. All eyes showed considerable haemorrhages without any tendency of resorption. Eleven eyes were operated within 3 months after the acute injury. In seven eyes pars plana vitrectomy was performed 4 - 6 months after the acute event because of the patient's poor general state of health. In three patients only one eye was impaired. RESULT: Seven eyes with Terson syndrome which were operated 4 - 6 months after injury showed severe complications intra- and postoperatively (ring-shaped proliferations with traction at the posterior pole, optic disc atrophy and maculopathy). On average, 2.4 operations were necessary. Within a mean postoperative observation period of 3.9 years (8 months to 8.5 years), the visual acuity was between light perception and 0.7 (mean: 0.25). In eleven eyes, however, pars plana vitrectomy was performed already 1 - 3 months after the acute event. In these cases few complications occurred intra- and postoperatively. On average, only 1.1 operations were necessary. After the clinical attendance (observation period: one weak to four years, mean: 2.1 years) the visual acuity amounted to between light perception and 0.8 (mean: 0.6). In one eye a sudden spontaneous blood resorption took place. CONCLUSION: Because of severe complications and in view of an early rehabilitation of the patients, vitrectomy has been recommended for eyes with bilateral Terson syndrome and with poor or absent tendency of blood resorption. Vitrectomy should be performed at least in one eye within three months after the acute event.

[Subjective sensations after intravitreal injection of bevacizumab]. / Subjektives Empfinden nach intravitrealer Bevacizumab-Injektion.

BACKGROUND: The group of anti-VEGF drugs is a new option for ophthalmologists in the therapy for acute and chronic macular oedema. First studies have revealed a stabilisation and increase of best corrected visual acuity as well as a decrease of retinal thickness, objectively measured with optical coherence tomography. The effects on subjective sensations are not always correlated with the objective changes. PATIENTS AND METHODS: From May to July 2006, 43 patients were treated with 1.25 mg bevacizumab, administered by sterile intravitreal injection. 30 patients had an age-related macular degeneration, 9 patients a diabetic retinopathy with macular oedema, 3 patients had a chronic macular oedema caused by retinal vessel occlusion and one patient had a retinal pigment detachment. The age ranged from 45 to 84 years (median: 70 years). General and special ophthalmological anamnesis, best corrected visual acuity and retinal thickness measured by optical coherence tomography were taken. Complete follow-up examinations were performed four and eight weeks after injections. In these postoperative controls the patients were also asked about their subjective sensations after the injection of bevacizumab, controlled by means of a numerical rating scale. RESULTS: The best corrected visual acuity (ETDRS) decreased from 9.2 letters (range from 0 to 40) to 13.1 letters (range from 0 to 42; p < 0.05) after four weeks, further four weeks later to 15.8 letters (range from 0 to 44; p < 0.05). The subjective sensations increased significantly at four weeks (0.54 points; range from - 1 to + 3; p < 0.05) and at eight weeks light regression (0.28 points; range from - 3 to + 3; p < 0.05). All patients reported a brightening "dark central blot". The available metamorphopsias improved at four weeks (18 patients), and at eight weeks 5 patients reported improvement. For none of ther patients did the metamorphopsia disappear completely. CONCLUSIONS: The intravitreal injection of bevacizumab shows beneficial results in terms of an increase of best corrected visual acuity. However, on comparing these results with the subjective sensations after injections there is a discrepancy. The subjective sensations are found to be only slightly better. More investigations, also after repeated injections are necessary.

[Advanced glycation end products and pseudoexfoliation--correlation between clinical outcome and histological findings]. / Zur Bedeutung von Advanced Glycation End Products (AGE's) beim Pseudoexfoliationssyndrom (PXS)--Korrelation klinischer Ergebnisse mit immunhistologischen Untersuchungen an humanen Linsenkapseln.

BACKGROUND: Pseudoexfoliation syndrome (PXS) as a stress-induced microfibrillopathy often shows a prolonged postoperative course. Formation of advanced glycation end products (AGEs) might be also associated with an increased oxidative stress. This study investigated for the first time immunohistochemically lens capsules of PXS patients for the AGE carboxymethylysine (CML) and correlated the findings with the clinical outcome of the patients. METHODS: 55 patients (22 male, 33 female; mean age 73.9 +/- 14.1 years) with PXS and pseudoexfoliation glaucoma (PXG) after cataract extraction were included. All lens capsules could be investigated immunohistochemically for the AGE CML. Both preoperative biometric data as well as intra- and postoperative courses were included in the investigations, followed by a correlation analysis of the immunohistochemical findings. RESULTS: 29 PXS and 26 PXG patients with a mean axial length of 23.1 +/- 1.1 mm were explored. Both groups showed a postoperative decrease of intraocular pressure and a moderate increase of visual acuity. Intraoperatively, 6 zonulolyses occurred and postoperatively 11 patients showed problems like increases of intraocular pressure. Immunohistochemically, CML could be detected in most of the epithelial cells of the lens capsules but only in a small part of the pseudoexfoliation (PEX) fibrils. A correlation between positive CML immunoreaction and the clinical course was not detectable. CONCLUSIONS: Cataract extraction in patients with PEX glaucoma shows different specialities and risks. The AGE CML was detectable in human lens capsules. A direct correlation between clinical course and immunohistochemical reaction of the PEX fibrils could not be found. Overall, CML seems not to be a valuable predictive factor for the clinical course in patients with PXS and PXG.

[Selenium and cataract--risk factor or useful dietary supplement?]. / Selen und Katarakt--Risikofaktor oder sinnvolle Nahrungsergänzung?

BACKGROUND: The exact role of selenium in cataract development is still unclear. Both protective and toxic effects and mechanisms have been postulated in the past. Accordingly, the selenium contents in human lenses and blood sera in different forms of cataract were investigated. METHODS: 123 patients (76 female and 37 male) with a mean age of 69.8 years (range: 17 to 91 years) were enrolled in this study. Overall, 84 lenses (after ECCE) and 110 blood serum samples were investigated by atomic absorption spectroscopy. Interpretation of data was accompanied by exact preoperative investigations including Scheimpflug techniques. RESULTS: A significant increase of selenium content of the lenses was found with increasing lens opacification and colouration. Lenses with a mature cataract showed the highest selenium contents in the lens compared to other cataract forms. Opposite results were detected in blood serum. Lenses of diabetics showed already at a younger age changes in selenium content. Smokers showed both decreased selenium contents in the lens and decreased selenium concentration in blood serum. CONCLUSIONS: An obvious correlation between the type of cataract and selenium content of the lens seems to exist. The question by which mechanism selenium acts directly or by selenium-dependent enzymes acts lens opacification remains speculative up to now.

[Histological and immunohistological investigations in human epiretinal membranes]. / Histologische und immunhistologische Untersuchungen humaner epiretinaler Membranen.

BACKGROUND: The exact mechanisms involved in the development of epiretinal membranes are still poorly understood. This study aimed to investigate human epiretinal membranes with the help of different histological and immunohistological methods in order to find new concepts for the development of these membranes. METHODS: 79 epiretinal membranes of patients (28 male, 51 female) undergoing a pars plana vitrectomy were included in this study. The mean age of the patients was 67.3 +/- 12.1 years. Preoperative diagnosis was diabetic retinopathy (n = 57), panuveitis (n = 4), PVR-ablatio (n = 16) and Coats disease (n = 2). All epiretinal membranes were histological and immunohistological investigated (aquaporin and with smooth muscle actin [SMA]). RESULTS: Within the investigated membranes very different cell and tissue structures were found. They varied from extracellular matrix-rich membranes to membranes with high cell density and proliferative activity (fibroblasts). In immunohistological studies highly differentiated vessel structures were identified (aquaporin-endothelial cells). A typical characterisation and comparison to clinical findings is demonstrated with the help of selected samples. CONCLUSIONS: Human epiretinal membranes vary in their histological structure according to their underlying disease. Histological and immunohistological investigations may help to characterise these membranes and to understand the complex origin mechanism of these structures. This provides the basis for further studies with potential antiangiogenic drugs.

[Surgical treatment of cyclodialysis]. / Operative Behandlung der Zyklodialyse.

PURPOSE: Cyclodialysis is a rare complication following blunt traumatic bulb injuries or surgical interventions. When treatment with cycloplegics or steroids is ineffective in attaching the ciliary body, cyclodialysis should be surgically treated. However, for reliable diagnosis and surgical therapy, an exact identification (size and extent) of the cyclodialysis cleft is imperative. Ultrasound biomicroscopy (UBM) provides the appropriate information. CASE REPORT: Four patients (19 to 65 years old, mean 45 years) with a detached ciliary body are described. Three patients had suffered an injury, and one patient presented with a prior trabeculotomy. The diagnosis was established with UBM. The location of the cyclodialysis cleft ranged between 2 and 3 o'clock (mean 2.4 o'clock). In spite of an intense treatment with cycloplegics and steroids no reattachment of the cyclodialysis took place. Therefore, a surgical intervention was performed. The span between the injury and trabeculotomy, respectively, and the cyclodialysis operation ranged from 3 to 30 months (mean 12 months). On average, visual acuity was increased from 0.3 preoperatively to 0.6 postoperatively, and the intraocular pressure was 6 mm Hg before and 15 mm Hg after operation. Symptoms preoperatively found without exception (choroidal detachment, papilledema "e vacuo", macular edema) had a complete recovery after operation. CONCLUSION: In cases where drug therapies are unsuccessful in attaching the ciliary body, an operative fixation is recommended. UBM is a very useful tool for making an exact diagnosis and defining the location of cyclodialysis as well as for follow-up of surgical treatment.

[Listeria monocytogenes endophthalmitis]. / Endogene Endophthalmitis, verursacht durch Listeria monocytogenes.

PURPOSE: Listeria monocytogenes is a rare cause of endogenous endophthalmitis. Controversy exists concerning clinical progress and prognosis in this bacterial infection. However, only a few reports about the clinical features have been previously published in the literature. CASE REPORT: The case of a 24-year-old woman is reported. She developed an endogenous endophthalmitis within 3 weeks. The patient received a pars-plana vitrectomy showing Listeria monocytogenes in the vitreous body. An intensive antibiotic therapy was initiated (local, subconjunctival, intravitreal and systemic). Visual acuity was increased from hand motion to 0.5 by the end of the clinical attendance and to 1.0 three months later. There were no hints concerning systemic manifestation of listeriosis or granuloma formation. CONCLUSION: Frequently, endogenous endophthalmitis has a very poor prognosis. However, the presented case report describes a very prosperous progress of endogenous endophthalmitis caused by an infection with Listeria monocytogenes.

[Spectral separation in ocular fundus autofluorescence images in patients suffering from age-related macular degeneration]. / Spektrale Differenzierung in Eigenfluoreszenzbildern des Augenhintergrunds von Patienten mit altersabhängiger Makuladegeneration.

INTRODUCTION: Alterations in the intrinsic ocular fundus fluorescence are under discussion particularly in connection with age-related macular degeneration. However, further knowledge of the chemical substrate of fluorescence is necessary. METHOD: Ocular fundus autofluorescence was observed using a fundus camera. The fluorescence emission was recorded using a 3-chip CCD camera. For comparison, the fluorescence spectra of lipofuscin, A2-E, FAD, NADH(2) and AGE's were recorded by the Jena ophthalmo-spectrometer. RESULTS: In contrast to the homogeneous intrinsic fluorescence of a normal fundus, the fluorescence images of patients suffering from AMD showed remarkable local differences. The detected fluorescence spectra showed remarkable overlaps. DISCUSSION: We introduced a new technique enabling the detection of spectral differences in images of ocular fundus autofluorescence. Besides the fluorescence of lipofuscin, we found a green one in patients suffering from nonexudative AMD.

[The optics of retinal blood vessels and their significance for scanning laser Doppler flowmetry]. / Die Optik retinaler Blutgefässe und ihre Bedeutung für die Scanning-Laser-Doppler-Flowmetrie.

Recently, the scanning laser Doppler flowmetry (SLDF) has been developed as a standard method for the quantification of retinal blood flow. However, the measured quantities flow, volume, and velocity depend on the angle between the direction of the blood flow and of the light. The underlying theory assumes isotropic illumination of the vessel. This assumption, however, is not valid for light back-scattered from retinal vessels. This paper investigates the contribution of different pathways of the light to the SLDF signal by a Monte Carlo simulation. It is shown that the light measured on a vessel having a thickness of 50 microns is predominantly back-scattered from the blood inside the vessel, whereas the measurement on vessels 20 microns in diameter or less also includes light transmitted through the vessel.

[Prognosis of postoperative endophthalmitis]. / Prognose der postoperativen Endophthalmitis.

BACKGROUND: The outcome of 20 patients is summarized in a retrospective study to identify clinical findings that influence the long-term prognosis of postoperative endophthalmitis. PATIENTS: Between 1991 and 1997 a total of 20 patients with postoperative endophthalmitis were admitted. Median age was 80 years (range: 9-95), 11 patients were male, 9 female. Sixteen pars-plana vitrectomies, 2 anterior vitrectomies and 2 rinsings of the anterior chamber without vitrectomy were performed. Furthermore, all patients received intraocular and systemic antibiotic treatment. For microbiological investigation, specimens from vitreous, anterior chamber and conjunctiva were sent in. Long-term outcome was controlled for an average of 14 months after treatment of the endophthalmitis (range: 4-36 months). RESULTS: At the end of treatment, 40% of patients had a visual acuity of 0.4 or better, 80% had 1/20 or better. Patients with a preoperative visual acuity of at least hand movement had a better postoperative visual outcome than patients with only light perception. Visual acuity was better in patients with chronic endophthalmitis than in patients with acute or subacute endophthalmitis. In patients with chronic or subacute endophthalmitis, improvement of visual acuity was found some months after the operation more often than in patients with acute endophthalmitis. However, in 40% of cases with an acute onset, no improvement or even worsening of the visual acuity was documented. Best postoperative results were found after infection with Staphylococcus epidermidis and Propionibacterium acnes. CONCLUSION: Important prognostic factors of postoperative endophthalmitis are visual acuity, the onset of the endophthalmitis (acute, subacute or chronic) and the microbiological findings. At the time of surgery and antibiotic treatment, visual acuity should be at least hand motion to expect an improvement in the visual outcome.