Stenotrophomonas maltophilia induced post-cataract-surgery endophthalmitis: Outbreak investigation and clinical courses of 26 patients.

BACKGROUND: Stenotrophomonas maltophilia, a microorganism which colonizes plastic material, is a rare causative agent of iatrogenic endophthalmitis. PATIENTS AND METHODS: A cluster of 26 cases of acute post-cataract-surgery endophthalmitis (PE) was identified. An outbreak investigation was performed. Information was abstracted from patients' charts and questionnaires sent to patients and their general practitioners. Vision was examined before, during, as well as one and six months after acute PE. Bacterial isolates were subjected to molecular typing. RESULTS: All patients initially received empiric systemic antibiotic treatment. The source of the infections was identified to be the rinsing solution used during cataract surgery, which was contaminated with two strains of S. maltophilia. Antibiotic therapy was subsequently changed to trimethoprim/sulfamethoxazol and ciprofloxacin for 30 days, complemented with iv fluocortolone and topical treatment with prednisolone, ciprofloxacin, and chloramphenicol. Twenty-one patients (81%) received pars plana vitrectomy and were additionally treated with intravitreal injections of vancomycin, amikacin and dexamethasone, or imipenem and dexamethasone, respectively. In addition, oxacillin, mezlocillin, and prednisolone were applied subconjunctivally after vitrectomy. Six months after acute infection, a final visual acuity of > or = 0.2 was achieved by 21/26 patients (80%), a visual acuity of > or = 0.5 by 14/26 patients (54%). Twenty of 26 patients (77%, 17 of whom had undergone vitrectomy) achieved a higher visual acuity than before surgery. Patients from the vitrectomy group had a median final visual acuity of 0.5 compared to 0.4 in the 5 patients without vitrectomy. There was 1 retinal ablation, 2 intra-retinal bleedings, and relapse of infection in 2/26 patients (8%), with isolation of S. maltophilia in one of the relapsing infection cases. CONCLUSIONS: Empiric antibiotic treatment of PE may not adequately treat rare pathogens such as S. maltophilia. Administration of an effective systemic or intravitreal antibiotic treatment after identification of S. maltophilia may have contributed to the favorable clinical course and relatively low relapse frequency in our patients. Despite the known problem of persistence of S. maltophilia, visual acuity outcome after treatment is comparable to PE induced by other Gram-positive or Gram-negative bacteria.

Immunoimaging of choroidal melanoma: assessment of its diagnostic accuracy and limitations in 101 cases.

Immunoscintigraphy (IS) was performed on 101 patients with space occupying intraocular lesions including choroidal melanomas (85), choroidal naevi (11), non-melanoma metastases (three), and other melanoma simulating lesions (two). Scintigraphic images with conventional and emission computer tomography techniques were obtained after the intravenous injection of 99mTc-labelled F(ab')2 fragments of monoclonal antibody (MoAb) 225.28S directed against the high molecular weight-melanoma associated antigen (HMW-MAA). Immunohistochemistry was performed on sections of four out of 10 melanoma-containing eyes to confirm MoAb binding. IS demonstrated positive scans in 66 out of 85 choroidal melanomas, offering a sensitivity of 78%. Sensitivity was dependent on the lesion size. True negative results were obtained in 15 out of 16 non-melanoma lesions (specificity 94%). False positive antibody accumulation was found in one patient with a post-traumatic subretinal haemorrhage. Immunohistochemistry demonstrated positive MoAb 225.28S binding in all melanoma sections. In summary IS offered substantial sensitivity and specificity in the differentiation of intraocular lesions, particularly choroidal melanomas, naevi, and metastases. In combination with other diagnostic procedures such as ultrasound echography and fluorescein angiography IS proved to be a valuable method in the diagnosis of choroidal melanoma.

Quantitative color Doppler imaging in untreated and irradiated choroidal melanoma.

Histological data indicate the importance of tumor vascularization as a determinant of the biological behavior and the response to radiotherapy in choroidal melanoma. Duplex ultrasound and color Doppler imaging, the combination of B-mode ultrasound and pulse-waved Doppler analysis, were used to measure quantitatively neovascular blood flow in 31 patients with choroidal melanoma. Follow-up studies (20 patients) were performed to investigate the change of tumor blood flow in choroidal melanomas after radiotherapy. Blood flow was detected in 30 out of 31 melanomas (size 3.1-17.8 mm) within the tumor and at the tumor base with a mean peak systolic frequency of 1.0 kHz (range 0.3-2.7 kHz), a mean end diastolic frequency of 0.3 kHz (range 0.1-1.0 kHz), and a mean frequency of 0.7 kHz (range 0.2-1.3 kHz). Two and six months after 106Ru/106Rh beta-ray application, 19 patients showed a significant decrease in peak systolic frequency. This occurred with and in advance of the decrease in the tumor size. In one patient, a rising maximum systolic frequency after radiotherapy marked a recurrent tumor growth. Results indicate that the quantitative measurement of tumor blood flow by duplex ultrasound and color Doppler imaging may be a new diagnostic modality for monitoring the effectiveness of radiotherapy in choroidal melanoma.

Quantitative duplex and color Doppler ultrasound in the follow-up of beta-irradiated (106Ru/106Rh) choroidal melanomas. A prospective study.

The tumor response to radiotherapy depends highly on the local oxygen concentration, which is governed by the tumor's microcirculatory network. The aim of this prospective study was to quantitate the neovascular blood flow in human choroidal melanomas prior to 106Ru/106Rh irradiation and during a 1-year follow-up period. Pulsatile blood flow was elicited by means of duplex and color Doppler ultrasound in 54 of a total of 55 untreated melanomas with a mean peak systolic frequency of 1.0 kHz (range 0.3-2.7 kHz). The neovascular blood flow decreased significantly 4 and 6 months after beta-irradiation. No intrinsic tumor vascularity was detected 8 and 12 months after treatment. In 3 patients, a rising peak systolic frequency occurred following radiotherapy in advance of recurrent tumor growth. Results indicate that the noninvasive quantitation of neovascular blood flow in irradiated choroidal melanomas by pulsed Doppler ultrasound offers a new diagnostic modality for assessing tumor recurrence.

[Duplex sonography in ophthalmology: current approaches to research and perspectives]. / Duplex-sonographie in der Ophthalmologie: aktuelle Forschungsansätze und Perspektiven.

Duplex ultrasound imaging combines the investigation of morphological structures and hemodynamic data analysis. In ophthalmology the technique permits a non-invasive evaluation of retinal and orbital vascular disorders for diagnostic purposes as well as the quantitative measurement of vascularity in intraocular and orbital tumors. We present current approaches to quantitate velocity patterns in the ophthalmic and retinal artery by Duplex ultrasound imaging. Results and clinical applications of Duplex ultrasonography studies designed to characterize the vascular network in intraocular and orbital tumors are reviewed.

[Temporal tarsal strip-plasty for correction of malposition of the lower eyelid]. / Die temporale Tarsalzungenplastik zur Korrektur von Unterlidfehlstellungen.

The lateral tarsal strip procedure has the combined effect of increasing horizontal lid tension and adjusting the level of the lateral canthus. Following a lateral canthotomy a tarsal strip is created from the lateral aspect of the lower lid and sutured to the periosteum at the lateral orbital wall. Indications for this technique include senile and paralytic ectropion, recurrent entropion, congenital malpositions, and lid laxity following trauma or enucleation. The results yielded by this technique in 148 patients at the University Eye Hospital in Munich are presented. These included 53 suffering from paralytic ectropion in whom a medial canthoplasty was added to the lateral tarsal strip procedure. The two techniques combined provided symmetrical adjustment of the level of both lateral and medial canthal angles, a good position of the lacrimal puncta and increased lid tension.

[Ocular side effects of beta-pyridylcarbinol]. / Okuläre Nebenwirkungen von beta-Pyridylcarbinol.

Derivatives of nicotinic acid such as beta-pyridylcarbinol play an important role in the therapy of lipoprotein disorders. In 1973, J.D. Gass reported the development of cystoid macular edema provoking metamorphosia during the course of nicotinic acid treatment. The aim of this study was to determine subtle changes in ocular function induced by beta-pyridylcarbinol. We investigated 16 patients prior to and after 6 months of beta-pyridylcarbinol treatment and compared the results of clinical and color vision tests in 9 patients after 2-25 years of continuous beta-pyridylcarbinol treatment. After 6 months, significant blue-yellow color vision changes (total error scores within normal ranges) were detected by the Farnsworth-Munsell 100 hue tests in all patients. One patient demonstrated macular edema. Fluorescein angiography, however, showed no evidence of fluorescein leakage. Beta-pyridylcarbinol treatment lasting for years led to diffuse color vision disturbances (total error score = 195). To the best of our knowledge neither macular edema nor color vision disturbances following beta-pyridylcarbinol treatment have been reported so far.

Systemic malignant lymphoma presenting as bilateral exudative retinal detachment.

A 52-year-old male patient presented with a sudden painful loss of vision in both eyes. Ophthalmological examination revealed bilateral uveitis and marked bilateral nonrhegmatogenous retinal detachment near the optic disk. Systemic workup demonstrated IgM paraproteinemia. Abdominal ultrasound and computed tomographic studies revealed enlarged adrenal glands and irregular masses in the right hepatic lobe. Immune electrophoresis and multiple biopsy specimens established the diagnosis of systemic polymorphous immunocytoma. Polychemotherapy of this B-cell-derived type of non-Hodgkin's lymphoma led to a rapid remission and fast reduction of serous retinal detachment. We believe this is the first case of bilateral exudative retinal detachment as the initial ocular manifestation of systemic malignant B-cell lymphoma.

[Sub-choroidal implanted Greene melanoma: an animal experiment model for malignant choroid melanoma]. / Das subchorioidal implantierte Greene-Melanom: Ein tierexperimentelles Modell für das maligne Adherhautmelanom.

A modified technique for subchoroidal transplantation of amelanotic Greene melanoma cells and the intraocular growth patterns of this tumor in rabbit eyes are described. Tumor fragments were implanted via a scleral tunnel in 71 rabbit eyes, with 64 successful tumor growths, producing a prominent, circumscribed choroidal mass within 12-14 days of surgery. Choroidal Greene melanoma in rabbits resembles human epithelioid uveal melanoma in both its growth patterns and morphologic characteristics. The authors' implantation technique guarantees reliable growth of choroidal tumors with easily reproducible size and location. The experimental choroidal melanoma model is particularly valuable in clinical studies where a large number of tumors, with limited variation, is necessary for different experimental groups.

Intravitreal silicone oil injection: complications and treatment of 415 consecutive patients.

Silicone oil injection in conjunction with pars plana vitrectomy was carried out by five surgeons in 415 consecutive patients using the same surgical equipment, the same surgical techniques and the same highly purified silicone oil (viscosity, 5000 mPa.s). Indications for silicone oil injection after vitrectomy included advanced stages of proliferative vitreoretinopathy following rhegmatogenous retinal detachment (49%), severe proliferative diabetic retinopathy (38%), and proliferative vitreoretinopathy following retinal detachment due to ocular trauma (13%). Postoperative complications were noted in a 6- to 30-month follow-up period. Cataractous changes of varying degree were seen in all phakic eyes. Silicone oil entered the anterior chamber in 6% of all phakic and pseudophakic eyes. Subretinal silicone oil was noted in 4%. Other complications associated with the use of intravitreal silicone oil included biomicroscopically visible silicone oil emulsification (0.7%), keratopathy (5.5%), glaucoma (6%), closure of the inferior iridectomy (6%), and reproliferation of epiretinal and subretinal fibrous membranes (40%). We anticipate that the physico-chemical characteristics of the highly purified silicone oil (viscosity, 5000 mPa.s) and the routine performance of an inferior iridectomy in all aphakic eyes had a positive impact on the low incidence of silicone-oil-related complications such as emulsification, keratopathy and secondary glaucoma.

[Early ocular symptoms in Wegener's granulomatosis]. / Okuläre Frühsymptome bei Wegener-Granulomatose.

Wegener's granulomatosis is characterized by necrotizing granulomatous vasculitis that initially occurs in a localized form, disseminates in various degrees and particularly involves the respiratory tract and kidneys. Eye manifestations are common (40 to 60%). Both clinical and histopathological findings are described in eight patients with Wegener's granulomatosis. The initial ocular symptoms included conjunctivitis, episcleritis, scleritis, corneoscleral ulceration, uveitis and ocular proptosis. In one patient histological examination of the orbital tissue was consistent with limited Wegener's granulomatosis 6 years before generalized granulomatous vasculitis confirmed the underlying disease. As new diagnostic and therapeutic modalities (detection of antineutrophil cytoplasmatic autoantibodies and therapy with trimethoprim-sulfamethoxazole) exist, a knowledge of the ocular initial symptoms of Wegener's granulomatosis can have considerable significance.

[Oculoplastic therapy in generalized nevus verrucosus]. / Okuloplastische Therapie bei generalisiertem Naevus verrucosus.

The clinical and histopathological picture of a 27-year-old patient with generalized nevus verrucosus is described. The oculoplastic treatment performed in this patient consisted in lid plasties, surgical excision, cauterization and cryotherapy. The different therapeutic techniques were applied over a period of 2 years. Nearly all papillomatous lesions were removed without impairing lid contour or lid function.

[Thermoradiotherapy of malignant choroid melanoma. Development of a new microwave hyperthermia system]. / Thermoradiotherapie bei malignem Aderhautmelanom. Neuentwicklung eines Mikrowellenhyperthermiesystems.

The therapeutic effects of heat (43 degrees C) as an adjunct to irradiation have generated increasing interest in oncology. It was shown that hyperthermia in addition to irradiation may allow for a radiation dose reduction which may be followed by a decreased irradiation - induced ocular morbidity rate. Intraocular malignant tumors offer excellent conditions for heat application since tumor volumes are small and heat can be locally generated to the tumor through the overlying sclera. Additionally, the vascular supply of intraocular melanoma is restricted to the choroid, limiting the blood flow related heat loss. At present, both experimental and clinical thermoradiotherapy for intraocular malignancies is performed by several investigators including Astrahan (Los Angeles), Coleman (New York), Mieler (Milwaukee), Finger and Packer (Manhasset), Swift (San Francisco), Lagendijk (Utrecht), Alberti (Essen) as well as our group in Munich. Both the advantages and disadvantages of the different technical modalities including our newly designed microwave hyperthermia system are discussed and it is emphasized that thermoradiotherapy at present is almost exclusively experimental. However, it is anticipated that future technology of electromagnetic heat induction will increase the existing therapeutic potential of thermoradiotherapy in intraocular malignancies.

Epithelial tumors of the lacrimal gland: clinico-pathologic correlation and management.

Between 1960 and 1987 29 patients underwent surgery at the Munich University Eye Hospital for benign and malignant tumors of the lacrimal gland. Fifteen tumors were classified as pleomorphic adenomas (three of them with malignant transformation), nine as adenoid cystic carcinomas, two as adenocarcinomas, two as oxyphilic adenomas, and one as oxyphilic adenocarcinoma. The clinico-pathologic correlation of these tumors is described. All age groups were involved in both benign and malignant epithelial gland tumors. A fast growing lesion with bone destruction of the lacrimal fossa in association with pain was found to be highly suspicious of a malignant epithelial tumor. Prior to surgery, inflammatory lesions and lymphomas should be ruled out by clinical history, examination, diagnostic imaging techniques, and, occasionally, by a short course of oral corticosteroids. A diagnostic biopsy prior to tumor excision and a transfrontal surgical approach via craniotomy has a negative impact on the prognosis. Thus it is mandatory to remove epithelial lacrimal gland tumors completely at the time of the initial surgical procedure. Craniotomies facilitate recurrences of lacrimal gland tumors by infiltration into the central nervous system. Lateral orbitotomies using the Krönlein technique are the best surgical approach for successful removal of these unusual tumors.

Relapsing poly(peri)chondritis associated with fibrosing alveolar disease and antibodies to pneumocytes type II and Clara cells.

A 62-year-old man with histological confirmed relapsing polychondritis showed chondritis of ears and nose, arthritis, keratitis and a hemolytic anemia. The bronchoalveolar lavage, computed tomography of the thorax and pulmonary function tests disclosed findings compatible with fibrosing alveolar disease. IgG antibodies to alveolar pneumocytes type II and bronchiolar Clara cells were detected by indirect immunofluorescence of human lung tissue. To our knowledge this is the first report of fibrosing alveolar disease in relapsing polychondritis and detection of antibodies to human pneumocytes type II and Clara cells.

Recovery after severe ethambutol intoxication--psychophysical and electrophysiological correlations.

Six patients with severe ocular side effects caused by therapeutical doses of the tuberculostatic drug ethambutol were investigated during the course of recovery with psychophysical and electrophysiological methods. Three patients developed an optic atrophy with permanently reduced vision as a likely consequence of additional risk factors such as diabetes, alcohol abuse, and reduced kidney function. The severity of the neuritis of the optic nerve was not related to the total intake of ethambutol. The likelihood of a permanent ocular damage increased sharply if the visual acuity had dropped below a value of 1/10. permanently prolonged latency of the P-100 component was found in visual evoked potentials even in cases with good recovery from ethambutol-induced damage. The recovery of color vision could be monitored very well with the Farnsworth-Munsell 100-Hue Test which revealed a diffuse impairment of color discrimination with a slight prevalence of the red-green axis. In addition to the known disturbances of the red-green antagonistic neurons, it could be demonstrated by measuring transient tritanopia and spectral sensitivity functions that ethambutol also affects the blue-yellow antagonism at the retinal level.

[Tumor markers in malignant choroid melanoma]. / Tumormarker beim malignen Aderhautmelanom.

Antibodies against tumor-associated antigens ("tumor markers") can be used for the diagnosis of malignant tumors. Eight different monoclonal antibodies, that can recognize tumor-associated antigens of dermal melanomas, were tested in cryostat sections of uveal melanomas. The uveal melanomas showed antigenic differences (e.g., gangliosides) and common antigens (e.g. high molecular weight melanoma-associated antigen) in comparison to dermal melanomas. The implications of these results for diagnosing and even treating uveal melanomas are discussed.

[Digital subtraction phlebography of the orbit. Technic and diagnostic value]. / Die digitale Subtraktionsphlebographie der Orbita. Technik und diagnostischer Stellenwert.

Orbital venography in the diagnostic assessment of vascular and extravascular expanding lesions of the orbit has been almost abandoned during the last decade due to the rapid development of computed tomography, ultrasound echography, and magnetic resonance imaging. Digital subtraction angiography (DSA) is a new angiographic modality that has recently replaced conventional techniques. DSA saves time and contrast media while facilitating vascular imaging and processing; this decreases the invasiveness of angiographic procedures. We describe the technique used for orbital phlebography via puncture of a frontal vein and injection of a contrast medium during manual compression of the infraorbital veins. We present the history and diagnostic findings of a 21-year-old man suffering from an orbital varix and discuss the diagnostic value of digital subtraction phlebography. In summary, the application of digital subtraction techniques is recommended as an additional diagnostic modality, particularly when impaired venous perfusion of the orbit is suspected.

Immunoscintigraphy in intraocular malignant melanoma.

Immunoscintigraphy of malignant tumours has become an encouraging tool in nuclear medicine. Early diagnosis of small lesions is mandatory for successful cancer therapy. The scintigraphic detectability of small lesions (less than 1 cm in diameter) by immunoscintigraphy is shown in 39 patients suffering from ocular tumours (37 malignant choroidal melanoma, two benign choroidal naevi) using 99Tcm-labelled F(ab')2 fragments of the anti-melanoma monoclonal antibody 225.28S; this antibody recognizes the high molecular weight melanoma-associated antigen. No adverse effects were observed. In terms of true-positive results, single photon emission computed tomography (SPECT) proved to be superior to planar scans (73% versus 41% true-positive results).

[Hyperthermic therapy procedures for supplementing radiotherapy of malignant intraocular tumors]. / Hypertherme Therapieverfahren in Ergänzung zur Strahlenbehandlung maligner intraokularer Tumoren.

Since more than a century ago, temperatures above 40 degrees C have been known to be effective in cancer treatment. Since that time numerous studies have documented that hyperthermia alone causes tumor regression and that the therapeutic effect depends on the amount and duration of heat delivered to a malignant tumor. However, after it was shown that heat combined with irradiation or chemotherapy potentiates the effect of hyperthermia, both thermoradiotherapy and thermochemotherapy were applied in experimental and clinical studies in several medical specialties. In ophthalmic oncology both retinoblastoma and uveal melanoma are treated by irradiation combined with local hyperthermia. In the present paper the use of ultrasound and microwave energy as locally applicable heat sources in intraocular malignancies is described and their suitability discussed. As is the case with malignant skin tumors and malignant tumors of the gastrointestinal and urogenital systems, malignant ocular tumors are accessible to externally applied heat and can thus be treated well by ultrasound and microwave hyperthermia. On the basis of experimental and clinical results gained with both ultrasound and microwave energy the advantages and drawbacks of these two technical modalities in intraocular tumor therapy are pointed out.