Refractive lens exchange for correction of high myopia.

PURPOSE: To evaluate the efficiency and safety of refractive lens exchange for the correction of high myopia. METHODS: We made a prospective study of the results of refractive lens exchange in 72 eyes that had undergone this surgical procedure between January 1996 and January 2001. Lens extraction by phacoemulsification was done by one surgeon on 34 patients. Follow-up was five months to five years (mean 48 months). The postoperative refractive target was emmetropia or a low degree of myopia. We compared pre- and postoperative uncorrected visual acuity, and preoperative best-corrected visual acuity with postoperative uncorrected visual acuity. Intra- and postoperative complications were recorded. RESULTS: In 72.2% of the eyes best-corrected visual acuity (BCVA) was > or = 0.5 before surgery. Four years after refractive lens exchange, uncorrected visual acuity (UCVA) was > or = 0.5 in 58.3% of eyes, and the proportion of eyes with BCVA > or = 0.5 increased to 83.3%. The sphere was fully corrected in 70.8% of cases, remained within 1.0 D of emmetropia in 87.5% and within 2.0 D of emmetropia in 95.8%. Posterior capsule opacification developed in 22 eyes (30.5%) and was treated with neodymium:YAG (Nd:YAG) laser capsulotomy. Cystoid macular edema with retinal detachment occurred in one eye. No wound leakage or eye infections were observed during five years' follow-up. CONCLUSIONS: Refractive lens exchange seems to be an effective alternative for the correction of high myopia, helping people over 40 years of age regain their distant vision.

Limbal-conjunctival autograft transplantation for recurrent pterygium.

PURPOSE: To assess the usefulness of limbal-conjunctival autograft transplantation (LCAT) for the treatment of recurrent pterygium. PATIENTS AND METHODS: Seventeen eyes with advanced recurrent pterygium underwent LCAT All had already been treated at least twice either by simple excision (n=15) or by conjunctival rotation autograft (n=2). Three eyes (17.65%) had symblepharon at the time of surgery, so LCAT was combined with amniotic membrane transplantation. The autograft was taken from the supero-lateral part of the same eye and transferred to the area where the pterygium had been excised. RESULTS: During 6-18 months of follow-up no postoperative complications occurred. In 15 eyes (88.24%) no pterygium recurrence was recorded; recurrence occurred in two eyes (11.76%) after 8 and 5 months. In three eyes with a combined symblepharon formation, remission of both pterygium and symblepharon growth was obtained. CONCLUSIONS: LCAT seems to be a promising and safe procedure for recurrent pterygium.

Profile of cytokines in aqueous humor from corneal graft recipients.

AIM: Due to the immune privilege of the anterior eye chamber, the success rate of corneal transplantation can reach 90%. The aim of this study was to determine cytokine profile in aqueous humor of patients undergoing corneal transplantation, and to establish whether cytokine profile at the time of surgery influenced corneal graft outcome. METHODS: Proinflammatory (TNF-beta and IFN-gamma) and immunosuppressive (TGF-beta2) cytokine levels were measured in aqueous humor and serum of 44 patients. Non-inflammatory corneal diseases included keratoconus (n=8), bullous keratopathy (n=7), and stromal dystrophy (n=3). Inflammatory diseases included corneal scars (n=10), graft rejection (n=5), pending perforation (n=4), chemical burns (n=4), rejection/ uveitis (n=1), infectious keratitis (n=1), and perforated ulcer (n=1). Control aqueous humor and sera were obtained from cadavers without corneal pathology. RESULTS: The concentration of TGFbeta2 in the aqueous humor in non-inflammatory corneal diseases was similar to that of controls (2,605+/-204 pg/mL vs 2,200+/-100 pg/mL). In inflammatory corneal diseases, the concentration of TGFbeta2 in aqueous humor was significantly lower (1,400+/-375 pg/mL, p<0.001). TNF-beta was detected in the aqueous humor of 16 out of 26 patients with inflammatory corneal diseases and in all patients with stromal dystrophies, but was undetectable in cases of keratoconus and bullous keratopathy. Low levels of IFN-gamma were present in all aqueous humor samples. Patients' sera contained significantly less cytokine (up to 252 pg/mL) then their aqueous humor (p<0.001). We have set an arbitrary cut-off point for TGF-beta2 level in aqueous humor at 1,500 pg/mL and divided all investigated samples (from 44 patients and 10 controls) into two groups, one with high and the other with low TGF-beta2 concentration. The coefficient of contingency showed that patients with high TGF-beta2 concentration in their aqueous humor had significantly greater chance for graft acceptance than those with low TGF-beta2 concentration (p<0.001). CONCLUSION: High TGFbeta2 concentrations in the eyes without intraocular inflammation suggest its immunosuppressive role in human eyes. High concentration of TGFbeta2 (>1,500 pg/mL) was associated with graft acceptance. Also, absence of proinflamatory TNFbeta increased the graft acceptance, but independently from TGFbeta2.

The role of HLA-DRB1 matching in corneal grafting.

The aim of the study was to evaluate the role of HLA-DRB1 (Human Leukocyte Antigens) matching in corneal transplantation. Fifty-two patients were observed. Low-risk group consisted of 28 patients and high-risk group consisted of 24 patients. All the patients and donors were tissue typed with Polymerase Chain Reaction (PCR) on the HLA-DRB1 gen. The primary corneal disease preceding keratoplasty was keratopathia (15), leucoma (10), keratoconus (7), Re-KPP (6), impending perforation (4), combustio corneae (3), degenerative disorders (2), keratoglobus (1), keratouveitis (1), corneal maculae (1), and corneal melting syndrome (1). The graft rejection frequency was higher in the group of high-risk patients (29%) than in the group of low risk patients (7.1%). The rejection rate of compatible grafts was 37% for high risk and 2% for low risk group, while the rejection rate of incompatible was 44% in high risk and 5% in low risk group. We can conclude that HLA-DRB1 matching does not improve corneal graft survival.

Corneal transplantation in children.

The main purpose of the study was to describe the surgical success rate and visual results of penetrating keratoplasty in children. This retrospective study included children that underwent corneal transplantation at the Department of Ophthalmology, General Hospital "Sveti Duh", in the period 1994-1999. Patients' age ranged from 6 to 16 years. Twenty-five corneal transplants were performed in 24 eyes. Corneal pathologies were corneal leucoma, congenital dystrophy, corneal combustion, corneal scar after perforating injury, keratoconus, corneal melting, hematocornea and rekeratoplasty. The follow-up period was at least 6 months. The rate of graft survival was 1 year in 75% of eyes with congenital dystrophy and keratoconus. Hematocornea and rekeratoplasty ended with graft failure. Postoperative visual acuity improvement was recorded in 14 out of 25 eyes. Penetrating keratoplasty in children showed very good surgical success. The final visual outcome was affected by irreversible amblyopia.

Multilayer vs. monolayer amniotic membrane transplantation for deep corneal ulcer treatment.

The purpose of the study was to evaluate the efficacy of multilayer amniotic transplantation (AMT) for reconstruction of corneal stroma and epithelium. Corneal ulcer (28) was a consequence of a previous infectious or neurotrophic keratitis. In the first group (17) ulcer was covered with monolayer AM, while in the other group (11) there were two or more layers of AM situated in the ulcer and the whole cornea was covered with AM sheet. Monolayer AMT was successful in 64% while the multilayer AMT success rate was 72%. AM gradually dissolved within 3-6 postoperative weeks. AM transplantation facilitates rapid healing of corneal epithelium, reduces inflammation and stimulates epithelial cell regrowth. In eyes with deep corneal ulcer multilayer technique proved to be better then monolayer procedure.

Pterygium treatment with limbal-conjunctival autograft transplantation.

The objective of this pilot study was to examine the usefulness of limbal autograft transplantation (LCAT) in the treatment of recurrent pterygium. Eleven eyes with advanced recurrent pterygium underwent LCAT. All eyes were previously treated at least two times either by simple excision (10) or conjunctival rotation autograft (1). In two eyes (18.18%) symblepharon was present at the time of surgery, therefore LCAT was combined with amniotic membrane transplantation. Limbal-conjunctival autograft was taken from supero-lateral part of the same eye and transferred to the area where pterygium was excised. No intraoperative complications occurred. In ten eyes (90.9%) no pterygium recurrence was recorded during the follow-up time, and one (9.1%) recurrence was recorded after 5 months. In two eyes with combined symblepharon formation remission of both pterygium and symblepharon growth was obtained. LCAT proved to be a promising and safe procedure in recurrent pterygium treatment.

The influence of tissue culture on corneal immunogenicity.

In this study we examined whether immunization with heterotopic corneal graft can be suppressed by usage of cultured corneal tissue. Starting from the hypothesis that the corneal antigenicity might change during long-time storage, we compared, in a mouse model, the immunization obtained with fresh and> stored corneas. Heterotopic (chest wall) mice corneal allografts were exchanged between donors and hosts: (1) mismatched at multiple minor H loci and (2) only H-Y mismatched animals. Median survival time (MST) of primary and secondary skin grafts exchanged between mentioned donors and hosts was recorded. Recipient mice were immunized with either: (a) tail-skin graft, (b) fresh cornea graft or (c) corneal graft stored for three weeks in tissue culture. Three weeks later, recipients were challenged with skin graft placed at the opposite side of the chest wall and MST of these skin grafts was recorded. MST of secondary skin grafts in animals that had been immunized by skin served as a control. In case of multiple minor H disparity, MST of a first-set skin graft was 12 days, as compared to 9 days in case of secondary skin graft (P<0.05). MST of secondary skin graft following immunization by both fresh and stored corneas was 10 days. These data suggest that stored corneas don't loose ability to sensitize the multiple minor H disparate host. It also show that both cultured and fresh corneas, when placed in non-privileged site, have same immunizing capacity as skin (MST of 10 and 9 days, respectively; P>0. 1). When only H-Y disparate animals were used, MST of a first-set skin grafts was 26 days and of secondary skin graft 11 days (P<0.01). In case of H-Y disparity, MST obtained after immunization with fresh and stored corneal tissue (19 and 18 days, respectively) was significantly longer as compared to skin (P<0.05). However, no significant difference in MST of secondary skin grafts between recipients of fresh (19 days) and stored corneal grafts (18 days) was recorded. According to our results, the ability of corneal tissue to immunize both multiple minor H mismatched, as well as only H-Y mismatched host, was not influenced by storage in a tissue culture.

Human amniotic membrane in the reconstruction of the ocular surface.

We sought to determine the efficacy of amniotic membrane transplantation (AMT) in the reconstruction of ocular surface. AMT was performed on 40 eyes with following indications: I, persistent corneal ulceration (n = 12); II, impending perforation (n = 6); III, persistent epithelial defect on the corneal graft (n = 6); IV, recurrent pterygia (n = 10), and V, risk of conjunctival scarring (n = 6). Amniotic membrane was prepared from a fresh placenta under sterile conditions, washed with BSS containing penicillin, streptomycin, neomycin and amphotericin B and stored at -80 degrees C in 1:1 InoSol:Glycerol solution. Donor serological test for HIV, HBV and HCV were all negative. Associated surgical procedures according to indication were performed. Healing of the corneal ulcer in Group I was obtained in 67% of eyes at 1-3 weeks after surgery, Group II: AMT was followed by 'a chaud' keratoplasty in 33% and by planned keratoplasty in 67% patients, Group III: healing of the defect in 33% of eyes in 2-5 postoperative weeks, Group IV: no recurrence of pterygium ingrowth in 70% in the follow up period of 6-14 months, and V: 84% of patients had good eye motility without any synechia formation. We concluded that AMT have shown to be effective in enhancing healing of the corneal defects, in prevention of symblepharon formation and recurrent pterygium ingrowth. In case of impending perforation, AMT alone was not a method of treatment but is useful as a first step procedure in preparing the eye for the corneal transplantation.

Timing of cataract surgery in diabetics.

In their retrospective study, the authors investigated the outcome of extracapsular cataract extraction (ECCE) followed by posterior chamber intraocular lens implantation (PCIOL), in 2864 operated eyes, out of which 546 (19%) were in diabetics. The preoperative retinal status was recorded in all subjects. In 6 (1%) patients, laser photocoagulation was performed preoperatively. The obtained visual acuity was 0.4 or better in 90.0% of diabetics and in 91.8% of control subjects, showing no significant difference in the postoperative complications between diabetics and non-diabetics. The results indicated the cataract operation (ECCE + PCIOL) to be a well tolerated surgical procedure in diabetic patients with lenticular opacity, in whom it should be even earlier performed than in nondiabetics, because cataract prevents the diagnosis or treatment of a suspect retinal disorder.

Complications following two methods of posterior chamber intraocular lens suturing.

The aim of this study is to compare complication rates in two different operative techniques applied for the secondary, posterior chamber intraocular lens (PCIOL) implantation with sulcus fixation. 179 eyes with partial or no posterior capsule support underwent surgery. Applied techniques were: transscleral fixation of the IOL by passing with the fixation needle through the sulcus from the inside (70 eyes) or from the outside (109 eyes) of the bulbus. The most frequent intraoperative complications were haemorrhages and vitreous prolaps with no significant difference between used techniques. In the 'from the inside' group, following late postoperative complications developed: astigmatism of > 4D (24%), cystoid macular oedema (20%), pupil distortion (14%), partial posterior capsule opacification (10%), suture exposure (10%), IOL decentration (8%) and hemophthalmus (3%). In the 'from the outside' group same complications showed a decreased rate: 17%, 16%, 8%, 8%, 9%, 5% and 1%, respectively. Other late complications like high intraocular pressure, synechiae and uveitis were adequately represented in both techniques. After 24 months follow-up, best corrected visual acuity > or = 0.8 was achieved in 48.5% of eyes when 'from the inside' and in 57.7% of eyes when 'from the outside' technique was used.

Triple procedure 'a chaud'.

Although it is widely accepted that acute uveitis is the main contraindication for intrabulbar procedures, conditions in the presented group of 24 patients (mean age 63 years, ranging from 35 to 74) required immediate surgery. The corneal pathologies included: perforated corneal ulcer in 12, imminent corneal perforation in ten and corneal melting syndrome in two patients. Partial perforative keratoplasty was accompanied by various combinations of surgical procedures, depending on the preoperative status. In cases of aphakia (N = 5) and anterior chamber pseudophakia (N = 5) secondary PCIOL implantation with sulcus fixation was performed, combined with ACIOL explanation in the latter group. The largest group included patients with complicated cataract (N = 14), where classic triple procedure was performed in ten patients. In three patients, the surgery had to be completed with sulcus fixation of the PCIOL, due to posterior capsule rupture. Associated glaucoma in one patient required trabeculectomy along with triple procedure. Postoperative complications that could not be treated with conservative measures for subsequent corneal decompensation, required rekeratoplasty in three (12.5%) patients. Visual acuity amelioration, ranging from 0.2-0.8, was achieved in seven (29.2%) and nine (37.5%) patients after 3 and 6 months, respectively.

Prognostic value of visual evoked responses in childhood amblyopia.

We assessed the possible clinical utility of pattern reversal visual evoked potentials in predicting the success of pleoptic treatment. Thirty amblyopic children--16 strabismic, 11 anisometropic and three of refractive type (in all cases the amblyopia was monocular)--and ten children without amblyopia (control group) were examined by conventional psychometric methods. Visual evoked potentials (VEP) to pattern reversal stimulation were also recorded. The amblyopic group was treated with occlusion of the preferred eye for three to six months. Psychometric and VEP tests were repeated in 15 amblyopic children after the treatment. The pre-treatment VEP amplitude side-differences (between amblyopic and better fellow eye) were significant, with first positive wave, P1, being invariably lower on the amblyopic side. We correlated the side-differences in visual acuity with the corresponding side-differences in amplitude and latency of the P1 wave. In the former the correlation coefficient was r = 0.47 (p < 0.01), and in the latter r = 0.65 (p < 0.01). Latency was prolonged in the eyes with significantly reduced visual acuity in which the wave form was also typical for amblyopia. We then correlated the difference between pre- and post-treatment visual acuity of the amblyopic eye with the pre- and post-treatment difference in amplitude (correlation coeff. r-0.51 (p = 0.05)) and latency of the P1 wave (correlation coeff. r = 0.40 (p > 0.05)).(ABSTRACT TRUNCATED AT 250 WORDS)

A brief review of the development of ophthalmology in Croatia.

Autochtonous folk medicine practice in Croatia was mostly based on the use of herbs in the treatment of eye diseases. The first document on the presence of medical activity was one in which the Republic of Venice gave Draga Slava permission to practice medicine in 1330. The 19th century was the turning-point for the development of ophthalmology in Croatia. The basis for well-organized clinical, preventive and social ophthalmological care was established. The Cathedra for Ophthalmology was founded in 1920 and its first head was Albert Botteri, who was along with Nizetic, Spanic, Gradilicic and Meixner, the most prominent ophthalmologist in the first half of the century. Zvonimir Pavisic and Kresimir Cupak were the leading persons in Croatian ophthalmology in the second half of the century. Croatian ophthalmologists were organized in the Section for Ophthalmology as the part of the Medical Association of Croatia from 1926 up to 1992, when the Section changed its name to the Croatian Ophthalmological Society, with more than 250 members. Inspite of the difficulties, Croatian ophthalmologists tend to use almost all modern diagnostic and therapeutic methods in use in the world.

Risks of retrobulbar application of anesthetics and drugs.

In spite of hundreds of harmless retrobulbar applications of anesthetics and drugs, a certain risk still exists. In the past ten years in our Department with 7200 retrobulbar procedures performed in local anesthesia and 12500 retrobulbar applications of the drugs (corticosteroids, antibiotics, vasodilatators) 14 incidents were registered. Palpebral chemosis and retrobulbar hematoma or eyeball protrusion were transient in 11 patients. Acute disturbance of the chorioretinal circulation occurred in three patients. In one of them vascular occlusion was total with permanent loss of vision, while in the other two recuperation of vision was the sign that vascular spasm was transient.

Cataract surgery and uveitis.

The authors deal with uveitis and cataract from two aspects. The occurrence of uveitis was analysed both before cataract surgery and postoperatively. The authors found in their material that uveitis occurred before cataract surgery in 1.8% and postoperative uveitis in 1.2% of cases. Special emphasis is put on the occurrence of postoperative complications in such eyes and the indications for the IOL implantation in uveitis patients.

[Implantation of intraocular lenses in patients with diabetes]. / Implantacija intraokularnih leca kod bolesnika s dijabet esom.

The authors analysed and compared three groups of patients who had undergone surgery. In the first group of 72 patients with diabetes and cataract, intraocular lens implantation was carried out. In the second group of 96 patients with diabetes and cataract, cataract surgery was not followed by intraocular lens implantation. The third group of 100 nondiabetic patients, selected by random choice, had intraocular lens implanted after the cataract surgery. Retinal status, postoperative complications and visual acuity were the parameters analysed in correlation with the intraocular lens implantation. In the authors' opinion, the prognosis following cataract surgery and intraocular lens implantation in diabetic patients is good, if diabetic complications do not occur, particularly retinopathy and vitreal hemorrhage which impair the vision considerably. Intraocular lens can be implanted even in cases of maculopathy and preproliferative diabetic retinopathy, provided a thorough diagnostic evaluation has been performed (echography, fluorescein angiography). Laser photocoagulation procedure should also be carried out before surgery and repeated as long as the transparence of the lens enables it. The treatment should be resumed two weeks after the cataract surgery and intraocular lens implantation at the latest. Intraocular lens implantation is contraindicated in proliferative diabetic retinopathy, and especially iridal rubeosis, as the risk of neovascular glaucoma development is considerable.

Postnucleation orbital implants.

A follow-up study of a group of 40 patients after the enucleation completed by the intra-orbital acrylic spherical magnetic implant (Roper-Hall style) is presented. The mean postoperative observation time is 3.3 years. Late complications were present in two patients: the extrusion of the implant in one of them was probably caused by his poor state due to chronic dialysis, while the traumatic luxation of the implant in the other was surgically repaired. Postoperative results in all other patients were satisfactory with the adequate orbital volume substitution and the ability of the prosthesis to twist and turn in any axis without fitting problems.

[Comparative analysis of the results after implantation of a "one piece" and other types of intraocular lenses]. / Usporedna analiza rezultata nakon implantacije "one piece" i drugih modela intraokularnih leca.

The authors analysed the results obtained in 100 patients with the "one piece" posterior chamber lens and compared them with those in 85 patients with soft haptics. All procedures followed the extracapsular cataract extraction. The incidence of intraoperative and postoperative complications was compared. Special attention was paid to the positioning of the implant after a period of at least 6 months. The advantages of "one piece" implant lenses were established and better postoperative results obtained in this group of patients.

The importance of computer observation of postoperative complications in ophthalmology presented on the model of postoperative complications following cataract surgery.

Medical documentation is getting more extensive, it is not standardised and can hardly be used to provide the exact and proper feedback. The crisis of data storage, processing and uninterrupted flow of information is becoming concial in the medical institutions as well. An example of informatic model of observation of postoperative complications following cataract surgery is presented in this work. The model has a very flexible pattern, and can, therefore, with minor changes, be used in observation of all postoperative complications in ophthalmology. It is based on the use of personal computer with professional software support (data base III programme was used for creation of data base, while statistical graphic analysis was carried out by following programmes: MICROSTAT, ABSTAT, STATGRAPHIC and FRAMEWORK). It has to be pointed out that any doctor, after only a short (optional) education, could prepare such models for his own purposes, and could thus assist in overcoming the information in medicine. In conclusion, the authors state computer is simple to work with, fast, economical and precise. Computerisation of health service shall include it in one of the aspects of practical realisation of the third technological revolution.