[Toric add-on intraocular lenses for correction of high astigmatism after pseudophakic keratoplasty]. / Torische AddOn-Intraokularlinsen zur Korrektur hoher Astigmatismen nach pseudophaker Keratoplastik.

Perforating keratoplasty shows good morphological results with a clear cornea; however, a limiting factor is often the resulting astigmatism, which cannot be corrected with either glasses or contact lenses (CL) in up to 20% of the patients. We retrospectively investigated 15 patients after pseudophakic perforating keratoplasty, who received implantation of toric add-on intraocular lenses (IOL) to correct astigmatism. The mean preoperative astigmatism of 6.5 diopter (dpt) could be reduced to a mean postoperative value of 1.0 dpt. The mean visual acuity could be improved from a preoperative value of sc <0.05 (cc 0.6) to a postoperative value of sc 0.4 (cc 0.63). There were no complications except for one case of a lens extension tear. Based on our good experiences we now provide toric add-on IOL to all patients with pseudophakic perforating keratoplasty when this cannot be corrected or only insufficiently corrected by conservative methods.

[Intraoperative Measurement of Refraction with a Hand-Held Autorefractometer]. / Intraoperative Refraktionsmessung mit einem handgehaltenen Autorefraktometer.

PURPOSE: The aim of this study was to evaluate an intraoperative measurement of objective refraction with a hand-held retinomax instrument. METHODS: At the end of cataract surgery objective refraction in a lying position was measured with a retinomax instrument. On the first postoperative day the same measurement was performed with a retinomax and a standard autorefractometer. To evaluate the differences between measurements, the spherical equivalent (SE) and Jackson's cross cylinder at 0° (J0) and 45° (J45) was used. RESULTS: 103 eyes were included. 95 of them had normal cataract surgery. Differences between retinomax at the operative day and the standard autorefractometer were 0.68 ± 2.58 D in SE, 0.05 ± 1.4D in J0 and 0.05 ± 1.4D in J45. There were no statistically significant differences between the groups. CONCLUSION: Intraoperative measurement of the refraction with a retinomax can predict the postoperative refraction. Nevertheless, in a few patients great differences may occur.

[Quo vadis neuroimaging? The eye as window to the brain. Current options and future perspectives]. / Quo vadis Neuroimaging? Das Auge als Fenster zum Gehirn. Heutige Möglichkeiten und Perspektiven für die Zukunft.

A possible manifestation site for multiple sclerosis (MS) is the optic nerve which clinically presents as optic neuritis. In recent years studies have shown that MS patients have a reduced retinal nerve fiber layer (RNFL) thickness. The literature and own investigations could show that MS patients have a thinning of the RNFL (especially in temporal quadrants) with reduction of the total macular volume and this alteration is also correlated with the severity of the disease. Neuromyelitis optica (monophasic) shows an extreme thinning of the RNFL with severe reduction in vision. In neurodegenerative diseases, such as Parkinson's disease and Alzheimer's disease, a thinning of the RNFL is also present mostly in all quadrants. Amyotrophic lateral sclerosis and schizophrenia do not show alterations of the retinal layers with optical coherence tomography.

[The new OCT generation offers deep insights: imaging of the choroid using the Cirrus OCT]. / Die neue OCT-Generation lässt tiefer blicken: Darstellung der Aderhaut mit dem Cirrus-OCT.

BACKGROUND: Until now depiction of the choroid using time domain optical coherence tomography (OCT) (Stratus III) was barely possible. Visualization of choroidal perfusion was carried out using indocyanine green angiography (ICGA). The spectral-domain OCT, such as Cirrus OCT (C-OCT) is able to image the choroid better because it offers higher resolution, increased penetration depth of the scan beam and faster acquisition of A-scan data. The aim of the study was to evaluate the potential of choroidal imaging in patients suffering from macular disease. METHODS: The advanced visualization tool of C-OCT was primarily used and converted to a z-axis topography. Because of a special algorithm developed by our team, targeted imaging of the choroidal vessels was possible through the scanned two dimensional retinal areas. This image offers an extended image of choroidal vessels (large and small vessels) in several levels. In total 20 patients eyes (n = 15 with various macular diseases and n = 5 normal conditions) who underwent C-OCT and ICG angiography (HRA 2) were chosen to participate in this special algorithm. A precise correlation of ICG and choroid OCT in a semitransparent manner was carried out. RESULTS: The first prototype of the recognition software prototype produced clear imaging of the choroid in 100% of cases but only in 55% in the macular region depending on the extent of macular disease. Limitations were low signal intensity and penetration depth as well as a poorly defined retinal pigment epithelium (RPE) and choriocapillaris especially in macular diseases of the RPE layer. After a black and white conversion in OCT using the software it was possible in all cases to integrate the choroidal OCT with the ICG angiogram in a semitransparent manner. This confirms that the choroidal vessels in C-OCT correlated identically with the ICG angiography. In contrast to the ICG where the contrast agent in the vessel emits a signal, the choroidal vessels are visible due to different reflectivity in the merging tissue. CONCLUSIONS: These investigations showed that non-invasive topographic imaging of the choroid using spectral domain OCT, such as Cirrus OCT is now possible. Distinguishability of smaller vessels was excellent. The ICG (perfusion) and C-OCT (morphology) methods are two very different vessel imaging techniques. The integration of both methods is possible. The clinical relevance of the new image information still has to be researched.

[Severe contact lens-associated fungal keratitis]. / Schwerste kontaktlinsenassoziierte mykotische Keratitis.

A 23-year-old man presented with severe contact lens-associated keratitis and descemetocele with pre-existing drug therapy. After 1 week of intensive antibiotic treatment Aspergillus fumigatus was identified. Despite adjusted antimycotic treatment a corneal perforation occurred. Due to peripheral scleral infiltration the cornea was primarily closed with a double layer amniotic membrane in order to avoid a sclerokeratoplasty with a bad prognosis. After 2 weeks the peripheral corneal situation stabilized and a simple keratoplasty á chaud could be performed. After surgery and adjusted drug therapy, no adequate signs of recovery occured. In repeated microbiological testing an additional Candida albicans infection was diagnosed and therapy was readjusted. This resulted in a cure of the corneal infection. After 5 years and a re-keratoplasty the patient presented with a clear corneal transplant and a corrected visual acuity of 20/25.

[Paediatric pseudophakia - refractive changes after primary and secondary intraocular lens implantation]. / Pseudophakie bei Kindern - Refraktionsentwicklung nach primärer und sekundärer Intraokularlinsen-Implantation.

BACKGROUND: A so-called myopic shift after cataract extraction and IOL implantation is known to occur in children. How much is difficult to predict. In this study we report the refractive development in pseudophakic children after primary and secondary IOL implantation. METHODS: The refractive change in all patients receiving an IOL-implantation between 2000 and 2008 with a follow-up of a minimum of 6 months was reviewed (6 - 107 months). Rigid or foldable lenses were implanted by the same technique. Refraction postoperatively and at last follow-up was measured. 62 eyes of 41 patients were reviewed. Patients were divided into three groups based on age at time of surgery: 3 - 4 years, 5 - 6 years and 7 - 12 years. RESULTS: The mean myopic shift was 2.5 D in both study groups, patients with primary and secondary IOL implantation. In the group with 3 - 4-year-old children mean myopic shift was 1.5 D in primary and 1.0 D in secondary implantations, in the group with 5 - 6-year-old children 2.75 D in primary and 3.25 D in secondary implantations and in the group with 7 - 12-year-old children 2.0 D in both primary and secondary implanted IOLs. CONCLUSIONS: We have shown that there are no differences in refractive changes between primary and secondary IOL implantations in our study group. In contrast to other findings we found the lowest myopic shift in the group of 3 - 4-year-old patients. Our results show that a prediction of expected myopic shift in children after IOL implantations remains difficult.

[Postkeratoplasty astigmatism: comparison of three suturing techniques]. / Astigmatismus nach perforierender Keratoplastik: Vergleich verschiedener Nahttechniken.

PURPOSE: The aim of this study was a retrospective analysis of postkeratoplasty astigmatism and best corrected visual acuity (BCVA) in patients following penetrating keratoplasty (PK) and a comparison of three suturing techniques. PATIENTS AND METHODS: In this retrospective analysis penetrating keratoplasty (PK) was carried out on 150 eyes with 3 suturing techniques: single running (SR), double running (DR counterclockwise) and interrupted (IR) sutures. Of the eyes 37 (24.7%) underwent PK with SR sutures, 81 eyes (54%) with DR sutures and 32 eyes (21.3%) had IR. PK for Fuchs' dystrophy was used on 46 eyes (30.7%), on 33 eyes (22%) for keratoconus, on 12 eyes (8%) for herpetic keratitis and on 7 eyes (4.6%) for pseudophakic bullous keratopathy. For trephination a guided trephine system (GTS) was used in 44%, rotortrepan in 46.6% and best trepan in 5.3%. Postkeratoplasty astigmatism and best corrected visual acuity (BCVA) were evaluated 1, 4, 12 and 24 months after surgery (all sutures removed). Subjective and objective refractions and corneal topography were performed to assess astigmatism. The Kolmogorov-Smirnov test (95% significance) was used to evaluate statistical significance. RESULTS: Mean topographic astigmatism 4 months (12 months/2 years) after keratoplasty was 4.9 dpt (5.3/4.1, n=4) for SR, 4.2 dpt (4.0/5.3) for DR and 9.7 dpt (n=7) (4.9, n=8/6.8, n=2) for IR suturing techniques. Mean objective astigmatism 4 months (12 months/2 years) after PK was 5.9 dpt (4.1, n=7/5.0, n=3) for SR, 3.4 dpt (4.5/4.98) for DR and 8.0 dpt (n=3) (6.9, n=4/7.4, n=2) for IR sutures. Mean refractive cylinder 4 months (12 months/2 years) after keratoplasty was 4.5 dpt (3.9/4.9) for SR, 3.2 dpt (3.3/3.6) for DR and 6.2 dpt (3.7/4.7) for IR suturing. Mean BCVA 4 months (12 months/2 years) was 0.3 (0.3/0.4) for SR, 0.3 (0.4/0.5) for DR and 0.3 (0.4/0.4) for IR sutures. BCVA 4 months (12 months/2 years) after PK (GTS only) reached 0.3 (0.3/0.5) for SR and 0.3 (0.4/0.6) for DR suturing. DISCUSSION: Topographic and objective astigmatisms were highest for the IR suturing technique. Topographic astigmatism and refractive cylinder were less in the DR (compared to SR) group 4 and 12 months after surgery (statistically significant). After suture removal (2 years after PK) refractive cylinder was still lower for DR compared to SR but there was no statistical difference between DR and SR regarding topographic and objective cylinders. For the interpretation of these data it should be emphasized that due to the retrospective character of this analysis the number of patients in the subgroups is decreasing with time and as a consequence single (strongly deviating) measurements can have a more powerful impact on the outcome in the individual subgroups.

Abiotrophia defectiva endophthalmitis with retinal involvement and infiltrative keratitis: case report and review of the literature.

We report the exceptional case of a severe intraocular Abiotrophia defectiva infection which developed after cataract surgery. Retinal involvement as a complication of A. defectiva endophthalmitis or the combination of acute-onset endophthalmitis with infiltrative keratitis caused by this pathogen has not been described. Moreover, our report represents the first documented ocular A. defectiva infection in Germany. A. defectiva was identified using biotyping and 16S ribosomal RNA gene sequence analysis. Despite vigorous antimicrobial therapy and repeated ocular surgery, visual outcome was poor.

[Clinical relevance of a new digital integration method (DIM) for the precise integration of OCT and fluorescein angiography (FLA)]. / Die Bedeutung der digitalen Integrationsmethode (DIM) von OCT und FLA für die klinische Anwendung.

BACKGROUND: We describe the establishment of a new digital integration method (DIM) for the anatomically precise and objective correlation of OCT and FLA. The aim of the study was to evaluate the clinical impact of DIM and deduce possible new knowledge in unclear angiographic findings. PATIENTS AND METHOD: DIM uses a newly developed software for the integration of OCT and FLA images of the same date. Corresponding vascular bifurcations and OCT scan position are marked in OCT and FLA images. Pathological areas in OCT or FLA can be marked and compared. A fundus enhancement system (FES) was developed for a better fundus image quality in OCT. Using a retinal tracking system (RTS) eye movements can be compensated. DIM was evaluated in 225 patients with macular diseases. RESULTS: Using FES, the DIM was successful in 95 % of the patients in contrast to 25 % without FES. Using the video system of RTS eye movement artefacts could be compensated in all patients. Cases with clear angiographic findings showed a high correspondence (66 %) with the OCT findings. A discrepancy between FLA and OCT findings was found in 33 %, especially in leakages of unknown origin. DIM was of high value in age-related macular degeneration (AMD), detecting a heterogeneous morphology of serous, solid RPE detachments, retinal cystoid formation and choroidal neovascularisation (CNV) and differentiating it in a precise topography. The lesion size of classic CNV with a hypofluorescent halo was in OCT always larger than in FLA. CONCLUSION: Through the correction of the eye movement artefacts by DIM and FES, a fundamental weak point in the previous OCT pictures is counterbalanced. Using DIM the OCT scan position for the follow-up can now be assessed in a safe and reliable manner which is mandatory for the evidence of OCT studies. The detection of precise morphology (serous RPE detachments) in angiographically unclear phenomena can lead to treatment consequences, e. g., avoiding contraindicated areas in photodynamic therapy. Using the new morphological information new knowledge is obtained on uncertain angiographic phenomena by this integration method (DIM).

[Optical coherence tomography for macula diagnostics. Review of methods and standardized application concentrating on diagnostic and therapy control of age-related macula degeneration]. / Optische Kohärenztomographie in der Makuladiagnostik. Ubersicht der Methode und standardisierte Anwendung--Diagnostik und Therapiekontrolle der altersbedingten Makuladegeneration.

BACKGROUND: Optical coherence tomography (OCT) has gained increasing relevance for follow-up after the treatment of macular diseases especially after anti-VEGF therapy. Therefore it seemed reasonable to develop standardized evaluation strategies and OCT examination guidelines for Stratus OCT III. MATERIALS AND METHODS: Basic guidelines for the Stratus OCT III examination of macular diseases were developed. The first part contains basic advice for the OCT examination with respect to the examiner, patients, image quality, movement artefacts, algorithms, archiving and interpretation of OCT images. The second part consists of the relevance and indications for OCT examination especially in age-related macular degeneration (AMD), subgroups of AMD and follow-up after treatment. The third part demonstrates a brief outlook on future developments, such as the digital integration method (DIM), which provides identical scan localization in follow-up and eliminates any movement artefacts. CONCLUSION: The application of standardized routine scanning and analysis protocols in Stratus OCT III for macular diseases and follow-up examinations provides an optimized, time-saving and comparable use of OCT. Therefore, the relevance and quality of OCT is increased for routine use in outpatient departments, hospitals and also for clinical studies.

[OCT in epiretinal gliosis]. / OCT bei epiretinaler Gliose.

Biomorphometric studies using optical coherence tomography (OCT) in patients with epiretinal membranes reveal a highly reflective membrane, a significant foveal thickening, loss of the foveal depression, and the presence of intraretinal cysts. Epiretinal membranes are more frequently totally adherent than separated with focal points of adherence. Visual acuity correlates with foveal thickness prior to and 6 months after vitrectomy and surgical removal of epiretinal membranes. Foveal thickening regresses postoperatively, but normal values are seldom reached. Marked foveal thickening, nonexistent foveal depression, and extensive cyst formation are supposed to correlate with a rather poor visual outcome. OCT plays a pivotal role in the differential diagnosis of pseudomacular hole in epiretinal membranes and of full-thickness macular hole. In addition to biomicroscopy and fluorescein angiography, OCT images provide valuable information for a structural assessment of the macula, especially in evaluating the postoperative course of macular surgery.

[OCT in macular holes]. / OCT bei Makulaforamen.

The traditional Gass classification of macular holes can now be supplemented by additional and more detailed morphologic information obtained with optical coherence tomography (OCT). The perifoveal vitreous detachment and subsequent anterior foveal traction is considered to be the primary pathomechanism of macular hole formation. In cases of persistent traction on the fovea it may lead to foveal dehiscence. A possible explanation for intraretinal cyst formation may be secondary vitreous body fluid accumulation within the retina. A classification of macular holes based on additional information from OCT images is possible. Thus, OCT is a valuable tool for differential diagnosis of a pseudo macular hole versus macular hole, precise stage classification, therapy decision making process, outcome control after macular surgery, and prognosis prediction.

[Optical coherence tomography in optic pit and associated maculopathy]. / Optische Kohärenztomographie bei Grubenpapille und seröser Makulopathie.

BACKGROUND: Of patients with an optic pit 30% develop an associated maculopathy of unknown origin. We report on 8 patients with an optic pit and associated maculopathy evaluated by optical coherence tomography (OCT) for detection of structural retinal changes and indications for the pathogenesis. PATIENTS AND METHODS: A total of 8 patients (mean age 25 years) suffering from an optic pit and associated maculopathy were evaluated by biomicroscopy, fluorescein angiography (FLA) and OCT and the results were compared. RESULTS: Visual acuity was on average 0.5 (0.05-0.8). Funduscopy revealed a macular elevation. In clinically suspected 'pseudo' macular hole, OCT revealed foveal schisis. OCT demonstrated a retinal detachment with a typical convex schisis of the outer retinal layer (n=6), and three patients showed a neurosensory detachment with (n=2) and without (n=1) intraretinal cystoid formation. CONCLUSION: The typical macular schisis pattern in OCT in optic pit with serous maculopathy helps to differentiate this condition from other macular elevations.

[Testing central retinal function with multifocal electroretinography before and after photodynamic therapy]. / Prüfung der zentralen Netzhautfunktion mit dem multifokalen Elektroretinogramm vor und nach photodynamischer Therapie.

BACKGROUND: Photodynamic therapy (PDT) is applied for certain forms of choroidal neovascular membrane (CNV). The aim of this study was to investigate the effect of PDT on central retinal function as assessed by multifocal electroretinography (ERG). METHODS: 24 patients (25 eyes) with CNV (>50% classic 12 eyes) or occult (9 eyes) in age related macular degeneration (AMD) and CNV with pathological myopia (4 eyes) were treated by PDT using Verteporfin((R)). Before and a median of 6 weeks after therapy, central retinal function was examined using multifocal ERG (RetiScan, 61 hexagons, first-order response). RESULTS: In the area of treatment,we found a tendency of the amplitude of the first positive deflection (P1) to decrease and of the implicit time to increase, but both effects were not statistically significant. These alterations were more pronounced in eyes with occult CNV and in myopia-related CNV. Amplitude reduction and implicit time prolongation could also be found in the areas represented by the multifocal ERG but not treated. There was no significant correlation between change in visual acuity after PDT and amplitude of the multifocal ERG. CONCLUSION: The effects of PDT on retinal function seem to be moderate as assessed by multifocal ERG. An inherent problem of this investigation was the recruitment of nontreated patients as controls. Future goals are investigations of patients with repeated PDT and of long-term alterations in multifocal ERG after PDT.

[Subretinal granuloma, retinal vasculitis and keratouveitis with secondary open-angle glaucoma in schistosomiasis]. / Subretinales Granulom, retinale Vaskulitis und Keratouveitis mit sekundärem Offenwinkelglaukom bei Schistosomiasis.

BACKGROUND: More than 250 million people in Africa and Asia currently suffer from schistosomiasis, however, ocular manifestations of this disease are rare in Germany. PATIENT AND FOLLOW-UP: We present the case of a 32-year-old patient from Gambia who had been resident in Germany for 3 years and suffered from a painful persistent diarrhoea, fever and a reduction of visual acuity (R > L). On admission, the patient reported a schistosomiasis in 1994, which was diagnosed by a skin test and was not adequately treated because of the side-effects of praziquantel. Vision was OD-0.75 sph 0.8, OS sc 1.0, IOD OD 31, OS 18 mmHg. Biomicroscopy: R > L fatty retrocorneal precipitates, especially in the lower circumference (ARLT), large inflammatory cells and Tyndall ++, vitreous with large inflammatory cells, Fundus: OD at 11 o'clock large subretinal granuloma in the periphery. Serum lysozyme was elevated (22.2 mg/l, normal range 10-17 mg/l), a syphilis stage II-III (TPHA 1:5000, VDRL neg.) and an IgG-antibody titre for Schistosoma mansoni of > 30 micrograms/ml was detected by enzyme immunoassay. In the faeces and urine no schistosoma eggs were found. Before the specific treatment for schistosomiasis could be initiated, the patient left the hospital because of reduced ocular pain due to the corticosteroids and fear of the side-effects of the treatment. DISCUSSION: In patients who present a subretinal granuloma and report a painful persistent diarrhoea, schistosomiasis, which is one of the most frequent tropical diseases should be considered, even if they have been living in central Europe for several years. Although the disease cannot become established due to the lack of specific hosts in this area, a curative treatment should be enforced in order to prevent late manifestations of chronic inflammatory organ manifestations.

[Optical coherence tomography in geographic atrophy--a clinicopathologic correlation]. / Optische Kohärenztomographie bei geographischer Atrophie--eine klinisch-pathologische Korrelation.

BACKGROUND: Optical coherence tomography was used for the examination of patients with geographic atrophy in different stages of age-related macular degeneration. Always compared with biomicroscopy and fluorescein angiography [4,7,8,10]. PATIENTS AND METHODS: 37 patients with geographic atrophy (n = 55 eyes) out of 150 with AMD (n = 169 eyes) were examined. The results of biomicroscopy, fluorescein angiography, optical coherence tomography and histological knowledge in age-related macular degeneration were studied. RESULTS: Fluorescein angiography always identified geographic atrophy and in 13.5% the findings additionally were similar to an occult choroidal neovascularisation with circular hyperpigmentation. Geographic atrophy shows a significant thinning of the neurosensory retina of 135 microns as an average in optical coherence tomography (p < 0.0005) which did not correlate to visual acuity. Typically an enhanced vertically sharp demarcated reflectivity of the choroid is found because of the lacking pigment epithelium. 43% of the geographic atrophies were identified by optical coherence tomography. 3 out of 55 eyes (5%) in optical coherence tomography only show macular holes additionally to geographic atrophy. CONCLUSION: A typical pattern of reflectivity is found by optical coherence tomography with enhanced reflectivity of the choroid because of lacking pigment epithelium and significant thinning of the fovea. Atypical macular holes moreover are found in 5% neither appearing in biomicroscopy nor in fluorescein angiography. An occult choroidal neovascularisation can be differentiated by optical coherence tomography from geographic atrophy because there is no spindle-like thickening of the pigment epithelium and no enhanced choroidal reflectivity. In borderline cases optical coherence tomography may be helpful and therapeutically decisive in differentiating geographic atrophy and occult choroidal neovascularisation and in detecting atypical macular holes.

Optical coherence tomography in uveitis patients.

PURPOSE: To evaluate optical coherence tomography in allergy-prone uveitis patients. METHODS: Thirty-four patients (43 eyes) with posterior uveitis (31 eyes) and intermediate uveitis (12 eyes) were evaluated by fluorescein angiography, indocyanine green angiography, and optical coherence tomography. Follow-up examinations used optical coherence tomography in allergy-prone patients. RESULTS: Optical coherence tomography identified epiretinal membranes, which were removed surgically (three eyes); persistent cystoid macular edema, which resolved with cytotoxic treatment (12 eyes); and juxtafoveolar membranes, which were treated by diode laser (six eyes) and excision (two eyes). CONCLUSION: Optical coherence tomography may provide useful information on complications developing in uveitis patients.

[r-tPA in keratoplasty à chaud. Report of 50 patients]. / r-tPA bei der Keratoplastik à chaud. Bericht über 50 Patienten.

BACKGROUND: Fibrinolytic treatment using recombinant plasminogen activator (r-tPA) has been reported in cataract surgery; however, reports are lacking with respect to complex surgical interventions including keratoplasty because of anterior segment infections. PATIENTS AND METHODS: This report deals with a prospective study comprising 50 patients (50 eyes) suffering from a serpent ulcer treated by keratoplasty à chaud. r-tPA (25 micrograms) was instilled intracamerally at the end of surgery in 25 eyes. RESULTS: The 25 eyes treated with r-tPA were subsequently less inflamed than the control population (decrease in inflammatory cells 1.5 days vs 7 days, fibrin reaction 1x vs 12x), had highly significantly better visual acuity and there was significantly reduced inpatient hospitalization (median 9.9 vs 19.3 days). No hemorrhages were observed in either population; medically treated infection recurrences (S. aureus, C. tropicalis, acanthameba) were observed in 3 and primary graft failure or rejection in both populations 3x. CONCLUSIONS: This study showed that perioperative application of r-tPA had a beneficial effect. This therapeutic avenue should be further evaluated in a randomized, double-masked multicenter study.