Inferior rectus muscle recession as a treatment for vertical diplopia following cataract extraction.

BACKGROUND: Persistent vertical diplopia may occur after cataract surgery as a rare complication of retro- or parabulbar anesthesia. This is probably caused by structural changes in the muscles, altering muscular elasticity and function and thus complicating setting of the dosage for corrective strabismus surgery. The aim of our study was to investigate the effect of strabismus surgery in this specific motility disorder. METHODS: The findings from 15 consecutive patients (six women, nine men, median age 76 years), who had undergone initial strabismus surgery in our eye clinic between 2007 and 2010 due to vertical diplopia following cataract surgery, were investigated retrospectively. In all cases, cataract surgery had been performed under retro- or parabulbar anesthesia. RESULTS: Preoperatively, all affected eyes (five right eyes, ten left eyes) showed hypotropia with elevation deficiency and overaction of the inferior rectus muscle and/or superior oblique muscle on down-gaze. The median vertical deviation in primary position was 9.1 deg (min. 4.6, max. 24.7), measured with the alternate prism cover test, and 8 deg (min. 3.5, max.18) at the tangent screen of Harms. In all cases, the inferior rectus muscle was recessed 3 to 6 mm (median 3.5 mm). On the first day after surgery, the median angle of squint in primary position was 2.3 deg (min. 0, max. 10.2), when measured with the alternate prism cover test, with a mean dose-effect relationship of 1.8 ± 0.7 deg angle reduction per millimetre recession (median 1.9 deg/mm). In the postoperative period, eight patients examined after 2 to 20 months (median 3.5 months) showed a median vertical deviation of 5.7 deg (min. 1.7, max. 11.3), with a mean dose-effect relationship of 1.7 ± 1.3 deg/mm (median 1.8 deg/mm), but the values ranged widely. Four patients were not examined but interviewed by telephone. There was no feed-back from three patients. Six of 12 follow-up patients had no complaints, three had prisms to correct a persisting angle, and three patients needed further squint surgery. CONCLUSIONS: The efficacy of inferior rectus muscle recession for correction of hypotropia following cataract surgery with local anesthesia ranged widely. In this condition, operating on one muscle is a good option for correction of squint angles of less than 12 deg. Squint angle enlargement can occur in the postoperative course, and may necessitate further surgery.

[Subconjunctival or general anaesthesia in trabeculectomy--a retrospective analysis of the bleeding risk from a glaucoma surgeon's point of view]. / Subkonjunktivalanästhesie oder Vollnarkose bei der Trabekulektomie--retrospektive Analyse des perioperativen Blutungsrisikos aus Sicht des Glaukomchirurgen.

INTRODUCTION: The aim of this study was to compare the intraoperative and early postoperative outcome of trabeculectomy with mitomycin C in glaucoma patients undergoing general anaesthesia compared to those undergoing subconjunctival anaesthesia. METHODS: The perioperative results of consecutive glaucoma patients receiving a trabeculectomy with mitomycin C either under general anaesthesia (group 1, n = 60) or in subconjunctival anaesthesia (group 2, n = 60) were analysed in a retrospective study. All surgical procedures were performed by one surgeon and only one eye of each patient with no history of previous conjunctival surgery was included in the study. RESULTS: No significant peri- and postoperative differences concerning period of hospitalisation, intraocular pressure, filtration-bleb bleedings, hyphaema, frequency of laser suture lysis, hypotony, chorioidal detachment or revision surgery could be shown between the two groups. Considering all patients together, there was a significant correlation between the occurrence of postoperative filtering bleb bleedings and the absolute number of topical antiglaucomatous substances used prior to surgery. CONCLUSIONS: The perioperative risk profile of penetrating glaucoma surgery with subconjunctival anaesthesia seems to be similar to that of procedures under general anaesthesia. For prevention of postoperative filtering bleb bleedings, the administration of topical antiglaucomatous drugs should be stopped before surgery.

[Combined phacoemulsification with trabecular aspiration with differing outcomes in pseudoexfoliative glaucoma - a retrospective study]. / Kombinierte Phakoemulsifikation mit Trabekelaspiration bei Pseudoexfoliations-Glaukom mit unterschiedlichem Ausgangsdruck - eine retrospektive Studie.

INTRODUCTION: The aim of this study was to differentiate the pressure-reducing results following trabecular aspiration combined with small incision cataract surgery in eyes with pseudoexfoliation depending on preoperative pressure and medication score. PATIENTS AND METHODS: A retrospective analysis was made of 104 exfoliative eyes of 104 patients who underwent combined phaco/trabecular aspiration. Success was defined as a relative reduction of IOP of at least 20 %, absolute IOP of ≤ 20 mmHg, stable or reduced medication score and a lack of any further pressure-reducing surgery. RESULTS: The success rate was 0.68 and 0.64 after 1 and 2 years. In eyes with medically uncontrolled preoperative IOP (> 20 mmHg) the IOP dropped significantly from 25.4 ± 4.3 mmHg to 17.0 ± 3.4 mmHg after two years. In eyes with preoperative controlled IOP the pressure lowering effect was low (17.1 ± 2.3 to 15.9 ± 2.3 mmHg) with a significant reduction of medication. CONCLUSIONS: Combined cataract surgery and trabecular aspiration is a reasonable option in exfoliative eyes with IOP values in the low twenties in order to achieve a reduction of topical medications and to reach a stable IOP level.

[Quantification of subjective visual quality of life in glaucoma patients : first results of a German version of the GQL-15 questionnaire]. / Quantifizierung der subjektiven visuellen Lebensqualität bei Glaukompatienten : Erste Ergebnisse mit der deutschen Version des GQL-15.

BACKGROUND: There is an increasing interest in assessing the quality of life as an additional guide for therapeutic choices, especially in patients with chronic diseases, e.g. glaucoma. Most standardized questionnaires are available in English making them inapplicable for daily use in non-English-speaking environments. The "Glaucoma Quality of Life 15 Questionnaire" (GQL-15) is a test designed for glaucoma patients in English and was translated into German in order to analyze its practicability in a daily clinical setting. PATIENTS AND METHODS: The GQL-15 was handed out to glaucoma patients during the hospital stay. The questionnaires were analyzed retrospectively and correlated to clinical indices, such as age, visual acuity, visual field, parametric mean deviation (MD) and frequency of pharmacologic treatment. RESULTS: A total of 31 patients were evaluated. It could be demonstrated that the quality of life summary scores correlated with visual field loss. Evaluation of subscale scores of visual function revealed that glare and dark adaptation were correlated with glaucoma severity especially in the early stages of the disease. CONCLUSIONS: The German translation of the GQL-15 was well accepted by glaucoma patients. In our analysis disability of vision-related activities as expressed in the translated GQL-15 correlated with glaucoma severity. This first use of the translated GQL-15 encourages further studies in German glaucoma patients and their quality of life.

[Factors influencing applanation tonometry - a practical approach]. / Einflussgrößen auf die Applanationstonometrie - ein praxisorientierter Überblick.

Applanation tonometry has been the gold standard in clinical ophthalmology for more than fifty years. The most popular factor is central corneal thickness that is now routinely considered in glaucoma management. However, other individual features of the cornea can also play a key role for the interpretation of the applanation values. Other factors influencing applanation tonometry that have been well known for decades include tear film, fluorescein illumination etc., and should be kept in mind. According to the available literature the absence of a correct calibration cannot be neglected.

[Rebound tonometry and applanation tonometry during narcosis investigation of pediatric glaucoma]. / Reboundtonometrie und Applanationstonometrie während einer Narkoseuntersuchung beim kindlichen Glaukom.

BACKGROUND: A comparison of intraocular pressure (IOP) in cases of infantile glaucoma during general anesthesia was carried out by measurement with the iCare rebound tonometer (RBT) and a handheld applanation tonometer (Perkins). METHODS: A total of 45 eyes from pediatric patients with childhood glaucoma were included in this prospective trial. Bland-Altman plots and linear regression were used for statistical analysis. RESULTS: In almost two thirds of the eyes the difference between RBT and Perkins was 2 mmHg or less. A systemic bias of 1.96 mmHg and a 95% confidence interval of -3.35 to 7.26 was detected. Linear regression of the Bland-Altman data showed a proportional error (gradient=0.16; r(2)=0.23; p<0.01). CONCLUSIONS: The iCare rebound tonometer is useful during general anesthesia in cases of childhood glaucoma. It provides comparable IOP values to applanation tonometry with a tendency to record higher values.

[Case report on OCT findings in a patient with hereditary optic neuropathy and a patient with autosomal dominant optic atrophy]. / Kasuistik über OCT-Befunde bei einem Patienten mit Leberscher hereditärer Optikusneuropathie und einem Patienten mit autosomal dominanter Optikusatrophie.

BACKGROUND: Hereditary optic neuropathies lead to a decrease in visual acuity corresponding to a reduction of the ganglion cell layer and the nerve fibre layer. The most common neuropathies, Leber hereditary optic neuropathy (LHON) and autosomal dominant optic atrophy (ADOA), are mitochondrial disorders. CASE REPORT: We describe two cases, one with LHON and one with ADOA, and demonstrate the decrease in thickness of the ganglion cell layer using spectral domain OCT (optical coherence tomography). RESULTS: In the case with LHON, the ganglion cell layer and the nerve fibre layer showed a considerable reduction from the initial occurrence of symptoms to the 1? years follow-up examination. In the patient with ADOA, the atrophy of the ganglion cell layer and the nerve fibre layer was clearly visible on OCT corresponding to the poor visual acuity of the patient. CONCLUSIONS: Spectral domain OCT instruments allow for high resolution imaging and quantitative analysis of the various retinal layers. Using this technology, it is possible to distinguish between retinal disorders of the outer retinal layers and disorders of the inner retinal layers, like in our cases with LHON and ADOA.

[Comparison of Rebound tonometry versus Perkins tonometry in the supine glaucoma patient]. / Vergleich zwischen Rebound-Tonometrie und Perkins-Tonometrie am liegenden Glaukompatienten.

BACKGROUND: The aim of this study was to evaluate the concordance of intraocular pressure (IOP) measurements in the supine glaucoma patient using a Perkins applanation tonometer (PAT) compared to the iCare® rebound tonometer (RT), a hand-held device requiring no local anaesthesia. METHODS: 73 left eyes of 73 glaucoma patients were included in this consecutive case study and measured both by supine Perkins applanation tonometry and by right lateral posture rebound tonometry in the supine position (RLP). The patients were divided into three subgroups dependent on IOP (SG-1: 0 - 15 mmHg, SG-2: 16 - 22 mmHg, SG-3: more than 23 mmHg). RESULTS: The mean deviation between RT and PAT was 2.6 ± 4.0 mmHg, the 95 % confidence interval was -5.3 to 10.4 mmHg. 69 % of the measurements showed deviations within 3 mmHg between the two devices. Deviation was smallest in SG-2, and largest in SG-3. CONCLUSIONS: Rebound tonometry is comfortable to use even in supine patients. RT measurement agreed overall significantly with those of Perkins applanation tonometry, generally overestimating PAT measurement. In high IOP values, RT did not correlate as well with PAT as in moderate IOP levels.

[Neuro-ophthalmological and ophthalmological findings in Joubert syndrome]. / Neuroophthalmologische und ophthalmologische Befunde beim Joubert-Syndrom.

BACKGROUND: Joubert syndrome (JS) belongs to the ciliopathies and is a mostly autosomal recessively inherited disease (in the case of OFD1 mutations, JS is an X-linked trait). It is characterised by midbrain-hindbrain malformations with developmental delay, hypotonia and ataxia and a broad spectrum of other facultative findings. The aim of our study was to examine the ophthalmological and neuro-ophthalmological features of JS in our patients and to compare our findings to those of other studies. METHODS: In a retrospective study we evaluated the ophthalmological and neuro-ophthalmological findings of 9 consecutive patients who met the diagnostic criteria of JS. RESULTS: All patients had abnormalities of ocular motility, 4/9 used head thrusts to shift gaze (oculomotor apraxia OMA). In 6/8 patients, the optokinetic reflex (OKN) was absent. Furthermore, 8/9 children showed nystagmus, mostly see-saw nystagmus. Manifest strabismus was found in 8/9 while 3/9 had a retinopathy with either abnormal ERG and/or fundus appearance with or without visual impairment. Chorioretinal colobomata were present in 5/9 cases. Two patients showed a unilateral congenital ptosis, one a facial nerve paresis. CONCLUSIONS: The early neuro-ophthalmological findings in JS are not pathognonomic, but may lead to the diagnosis of JS. The syndrome should be suspected in patients with nystagmus, especially see-saw nystagmus, and abnormal OKN and/or OMA, and/or colobomata of the fundus, and further paediatric examinations should be initiated.

A prospective randomised trial of trabeculectomy using mitomycin C vs an ologen implant in open angle glaucoma.

PURPOSE: The aim of this study is to assess the efficacy and complications of trabeculectomy with a biodegradable implant (ologen implant) vs trabeculectomy using mitomycin C (MMC) in patients with medically uncontrolled open-angle glaucoma in a prospective randomised clinical trial. METHODS: In the MMC group (10 patients), trabeculectomy was performed according to standard protocols. In the ologen group (10 patients) after standard trabeculectomy the implant was positioned on top of the scleral flap and no MMC was applied. Follow-up was continued for 12 months after surgery and included testing of intraocular pressure (IOP), visual acuity, visual field, ultrasound biomicroscopy, and filtering bleb score. RESULTS: The mean preoperative IOP was 24.8+/-8.9 mm Hg for all patients enrolled. At 1 year after surgery, the mean IOP was 15.6+/-2.4mm Hg in the ologen group (P<0.01, 43% reduction) and 11.5+/-4.1 mm Hg in the MMC group (P<0.01, 50% reduction). No anti-glaucomatous medication was necessary in the MMC group in the first year of follow-up, whereas five patients in the ologen group required topical treatment. The absolute success rate was 100% in the MMC group and 50% in the ologen group (P=0.01). After 1 year, filtering blebs developed significantly more avascular areas in the MMC group (score=1.4) than in the ologen group (score=2.8; P<0.01). CONCLUSION: The complete success rate using trabeculectomy with the ologen implant is lower than that achieved by trabeculectomy with MMC. However, the bleb morphology caused more problems in the MMC group (avascularity score).

[Epithelial downgrowth 48 years after penetrating eye trauma]. / Epithelimplantationszysten--48 Jahre nach Bulbuspenetration.

BACKGROUND: Epithelial invasion is a rare but severe complication after penetrating eye trauma or intraocular surgery. Cystic ingrowth can occur even after decades. CASUISTICS: A 53-year-old woman developed two epithelial cysts in the left eye 48 years after penetrating trauma with a dart. After primary wound closure the intraocular status remained stable for 48 years before symptoms appeared. Preoperative diagnostics (e.g. ultrasound biomicroscopy) detected the origin of the epithelial downgrowth from an intracorneal cyst. Histology confirmed the clinical suspicion of a cystic epithelial ingrowth. CONCLUSION: The latency of our case is the longest reported interval between penetrating eye trauma and appearance of epithelial ingrowth to be described in detail. Ultrasound biomicroscopy is able to detect the origin of epithelial ingrowth.

Kestenbaum procedure on the vertical rectus muscles with simultaneous compensation of the induced cyclodeviation for nystagmus patients with chin-up or chin-down head posture.

BACKGROUND: Kestenbaum surgery is performed for nystagmus-related abnormal head posture, and symmetrically changes the position of both eyes to shift the null point to the primary position. Most patients with infantile nystagmus have their null point zone in a lateral gaze position. Less frequently, surgery can be performed to reduce chin-up or chin-down head posture. We report indications for, and the results of eight consecutive interventions performed according to the Kestenbaum principle for the reduction of a chin-up or chin-down head posture. METHODS: In a retrospective study, the clinical findings for eight patients who consecutively underwent treatment in the University Eye Hospital of Cologne between 2001 and 2007 were investigated. The patients were aged 6 to 16 years; median age was 6.5 years. For all patients, surgery was to correct a chin-up or chin-down head posture due to infantile nystagmus. Preoperatively, five patients showed a chin-down, three a chin-up head posture. All vertical rectus muscles were recessed or tucked between 6 and 7 mm; the resulting cyclodeviation was reduced by an intervention on the superior oblique muscles (6 to 8 mm tucking, in the case of chin-down, or recession in the case of chin-up head posture). RESULTS: Surgery was successful in seven of the eight patients, with a reduction of the vertical head posture to less than 10 degrees. In the cases of chin-down posture, head posture was reduced to between 0 degrees and a maximum of 20 degrees in one case postoperatively (before the operation 20 degrees to 35 degrees ); in the cases of chin-up posture, to less than 8 degrees (before the operation 25 degrees to 35 degrees). One case showed no postoperative improvement in chin-down posture but a head turn to the left of up to 20 degrees; another case had a remaining chin-up posture of 8 degrees with a right turn of 15 degrees . Binocular vision was better or the same in all cases after surgery. CONCLUSION: For nystagmus patients with chin-up or chin-down head posture, surgery for bilateral parallel shifting of the eyes can considerably improve the head posture. It is possible to compensate the induced cyclodeviation at the same time by bilateral surgery on the superior oblique muscles.

[Midterm patient satisfaction following mitomycin C-assisted trabeculectomy]. / Patientenzufriedenheit nach filtrierender Glaukomchirurgie mit Mitomycin C.

BACKGROUND: There are few published data on patient satisfaction following glaucoma surgery. The aim of our study was to investigate factors influencing patient satisfaction more than one year after trabeculectomy with mitomycin C. MATERIAL AND METHODS: We sent a two-page questionnaire to 61 female glaucoma patients who had consecutively undergone filtering surgery with MMC at the Department of Ophthalmology, University of Cologne, requesting anonymous replies (mean follow-up 19.2+/-2.5 months). RESULTS: The response rate was 79%. There was no significant inverse correlation between patient satisfaction and recent IOP values, redness of the eye, local irritation or foreign body sensation. There was a significant correlation between patient satisfaction and visual function, a significant inverse correlation between frequency of visits to the ophthalmologist and frequency of eye drop application. A weak, insignificant inverse correlation was found between satisfaction and number of topical medications. CONCLUSIONS: Patient satisfaction seems to correlate primarily with practical impact on everyday life, visual function, frequency of eye drop application and visits to the eye doctor being identified as the major issues. Local symptoms related to the filtering bleb seem to have a minor influence on patient satisfaction.

[Ultrasound biomicroscopic diagnosis of scleral foreign bodies]. / Hilft das Ultraschallbiomikroskop (UBM) in der Diagnostik von intraskleralen Fremdkörpern?

BACKGROUND: Small intrascleral foreign bodies of different materials, especially plastic or organic, can sometimes not easily--or not at all--be detected by routine X-ray examination or computed tomography scan. The aim of our study was to evaluate the usefulness of ultrasound biomicroscopy (UBM) with regard to the detection and localisation of such foreign bodies. METHODS: An in vitro study with the preparation of a scleral tunnel on 12 porcine eyes was performed. Small foreign bodies of different types of material were placed in the tunnel. The UBM was performed with a Humphrey Ultrasound Biomicroscope, Model 840, to evaluate its diagnostic value in detecting and specifying these sclera-covered foreign bodies. RESULTS: Even small foreign bodies of the anterior ocular segment of only 200 microm in size can be detected with the UBM due to the typical ultrasound patterns and artifacts. However, there is no diagnostic specificity for the corresponding material. CONCLUSION: The UBM is a high-frequency ultrasonic device with an imaging depth of 5 mm and a spatial resolution of 100 microm. Therefore it is a useful alternative or, respectively, additional diagnostic tool to common imaging techniques like routine X-ray imaging or CT scans, especially in the detection of non-metallic objects. It can provide important information for the ophthalmic surgeon with regard to pre-operative evaluation of the eye. Furthermore, the UBM might even substitute operative exploration of foreign bodies if they are located in the anterior segment of the eye.