Cilioretinal artery occlusion.

BACKGROUND: The aim of this study was to evaluate characteristic findings and functional outcome of this rare type of retinal vascular occlusion in a large patient series. PATIENTS AND METHODS: A retrospective chart review of all patients with a cilioretinal artery obstruction (CAO) seen at the University Eye Clinic Mainz (Germany) over a ten-year period between 1/1999 and 12/2008 was undertaken. The mean follow-up amounted to 42 months. RESULTS: Thirty-three eyes were diagnosed with CAO. Three distinct groups were differentiated: (i) isolated CAO in 20/33 eyes; visual outcome achieving 20/50 in 17/20 eyes; (ii) CAO combined with central retinal vein occlusion in 9/33 eyes; visual outcome achieving 20/50 in 5/9 eyes; (iii) CAO combined with anterior ischaemic optic neuropathy in 4/33 eyes; associated with giant cell arteriitis in 4/4 eyes; visual outcome achieving 20/160 in 1/4 eyes. CONCLUSIONS: The visual prognosis of CAO is significantly better than for other types of retinal artery occlusions, with the exception of cases associated with giant cell arteriitis.

[Isolated cilioretinal artery occlusion - clinical findings and outcome in 31 cases]. / Isolierter Verschluss einer zilioretinalen Arteriole - Klinik und Verlauf in 31 Fällen.

PURPOSE: The aim of this study was to evaluate the outcome of this rare type of retinal vascular occlusion in a large patient series. PATIENTS AND METHODS: A retrospective chart review of all patients with an isolated cilioretinal artery obstruction seen at the University Eye Clinic Mainz (Germany) between 1/1998 and 12/2009 was performed. Standard treatment was intravenous anticoagulation with heparin. Follow-up mean was 51 months. RESULTS: Included in this study were 31 eyes from 31 patients (mean patient age 49 years, range 25 - 71 years). Significant atherosclerotic carotid artery obstruction in 17/31 cases. All occlusions were located temporally and involved some portion of the fovea (2 × cholesterol emboli). Fluorescein angiography revealed no eye with complete occlusion of the cilioretinal artery, but late retrograde filling in all eyes and associated choroidal filling defects in 10/31 eyes. During follow-up the scotomatous visual field defect (centrocaecal in 25/31 eyes) usually reduced in size, but scotoma was a persisting remnant of this episode in all eyes. Optical coherence tomography during the acute injury revealed intraretinal oedema in the area of the infarct and months afterwards an attenuated retinal thickness, consistent with retinal atrophy. Visual outcome achieved 20/50 (reading vision) in 23/31 eyes, but in only 2 of 10 eyes with associatted choroidal perfusion defects. CONCLUSIONS: The visual prognosis of isolated cilioretinal artery obstructions seems to be significantly better than for other types of retinal artery occlusion, unless the entire perifoveal capillary network is affected and choroidal involvement is shown angiographically.

Position-dependent accommodative shift of retropupillary fixated iris-claw lenses.

PURPOSE: After implantation of retropupillary fixated iris-claw lenses, changes of the objective refraction can occur depending on the patients' position. The purpose of this study was to evaluate and quantify these changes as well as the influencing factors. METHODS: Within a retrospective study, postoperative refraction visual, acuity and anterior chamber depth after implantation of a retropupillary fixated iris-claw lens (Artisan® / Verisyse®) were measured in 51 eyes (49 patients) depending on their head position. These parameters were determined with the assistance of a mobile auto-refractometer, acoustic biometry, IOL-Master, chart projector and accommodometer in primary position, as well as in forward- and backward-tilted head position. RESULTS: The data analysis indicated a position-dependent change of the anterior chamber depth, which was largest in the backward-tilted head position (median: 4.25 mm/min.: 3.39 mm/max.: 5.37 mm). In comparison to the primary position (4.15 mm), it decreased in a forward-tilted position of the head (4.08 mm). A significant difference in anterior chamber depth was verified for backward- and forward-tilted heads (median: 0.155 mm). Refraction showed a significant difference (0.37 D) between forward- and backward-tilted head position. In comparison to the back-tilted head position (mean: -0.065 D), a smaller spherical equivalent could be demonstrated by bending the head forward (mean: -0.438 D). In addition, no correlation was found between lens movement and other continuous attributes. CONCLUSIONS: Significant changes in anterior chamber depth and refraction due to the iris-claw lens shift were found, depending on head position. The phenomenon of pseudophakic accommodation is explained by pseudo-myopia and pseudo-hyperopia. A considerable influence on visual acuity depending on patients´ head position could not be verified.

[Effect of various compositions of riboflavin eye drops on the intraoperative corneal thickness during UVA-cross-linking in keratoconus eyes]. / Entwicklung der Hornhautdicke während der UV-Vernetzungstherapie unter Anwendung verschiedener Kompositionen von Riboflavin-Augentropfen.

BACKGROUND: During the UVA-cross-linking treatment in keratoconus patients, the UVA rays are partially absorbed in the stroma of the riboflavin-loaded cornea. This effect protects the corneal endothelium from UVA irradiation damage. The intensity of UVA light reaching the endothelium is inversely correlated with corneal thickness. The common composition of riboflavin eye drops may lead to a marked reduction in corneal thickness increasing the risk of endothelial damage. PATIENTS AND METHODS: In a retrospective analysis of 23 UVA-cross-linking procedures on 23 patients we collected data about the pre-, intra- and postoperative corneal thickness (measured with ultrasound). Among these patients and depending on the preoperative state, 8 eyes received Medio Cross (TM) eye drops (group 1), 8 eyes received Medio Cross (TM) eye drops combined with riboflavin 0.1 %/methylhydroxypropylcellulose 1,5 %/NaCl 1.1 % (group 2) and 7 eyes received riboflavin 0.2 %/methylhydroxypropylcellulose 0.5 %/NaCl 0.7 % eye drops (group 3) before and during UVA irradiation. Data are presented as means ± standard deviation. A comparison of the data was performed using (one-way) ANOVA. RESULTS: The mean corneal thickness at the end of the UVA cross-linking procedure was 67 ± 9 % (means ± standard deviation) of preoperative thickness in group 1, 118 ± 14 % in group 2 and 140 ± 23 % in group 3. The values in groups 2 and 3 were significantly different from those in the reference group 1. CONCLUSIONS: Our results show a strong variability of the postoperative corneal thickness using different standard compositions of riboflavin eye drops. Further studies are needed to find a composition of riboflavin eye drops ensuring a moderate increase in intraoperative corneal thickness to protect the corneal endothelium.

[Long-term follow-up 10 years after transpupillary thermotherapy (TTT) for small, posterior located malignant melanomas of the choroid]. / Langzeitverlauf 10 Jahre nach transpupillarer Thermotherapie (TTT) kleiner, posteriorer maligner Aderhautmelanome.

BACKGROUND: The aim of this study was to evaluate the long-term results of transpupillary thermotherapy (TTT) for small malignant choroidal melanomas. PATIENTS AND METHODS: In the time period 1/1998 to 10/1999 in a prospective non-randomised analysis 26 eyes with small malignant melanomas (located posterior to the equator with base ≤ 12 and thickness ≤ 4.5 mm) were primary treated with the TTT standard protocol (follow-up over a time span of at least 10 years). RESULTS: Thirteen women and thirteen men (mean age: 64 years) underwent TTT. The mean preoperative tumour thickness was 2.45 mm (0.8 - 4.5 mm). Ten years postoperatively tumour regression without recurrence after 1.4 treatment sessions (mean) was achieved in 16 / 26 eyes, primary regression followed by tumour regrowth in 6 / 26 eyes, and primary failure of tumour regression in 4 / 26 eyes. Two patients died on liver metastasis. Ocular complications (with preference in posterior tumours after multiple TTT sessions) were observed in 14 eyes: macular pucker in 8, macular oedema in 6, choroidal neovascularisation in 4 and posterior synechia with iris atrophy in one eye. CONCLUSIONS: Choroidal melanomas treated with TTT as a stand-alone procedure need a close monitoring since these tumours developed a significant rate of local recurrences and ocular side-effects in the long run.

Pars plana vitrectomy for visually disturbing vitreous floaters in pseudophacic eyes.

BACKGROUND: The aim of this study was to evaluate the role of vitrectomy in patients with visually disturbing vitreous opacities. PATIENTS AND METHODS: A retrospective analysis of the patient characteristics and the outcome of all pseudophacic eyes, which consecutively received in the decade 1996 to 2005 20 G pars plana vitrectomy for visually disturbing floaters, was carried out at the Mainz University Eye Clinic. RESULTS: Forty-one eyes of 32 patients (63 % university graduates, median age: 64 years) were included in the study. The mean axial length of the globe was 25.3 mm (range: 22.8 to 28.9 mm). Additional pathologies having influence on the vitreous condition were history of laser or cryo retinopexy (12 ×), buckle surgery (5 ×), complicated cataract surgery (16 ×) and Nd:YAG laser capsulotomy (4 ×). Vitreous floaters were considered to be the result of posterior vitreous detachment alone in 61 %, of asteroid hyalosis accompanied by posterior vitreous detachment in 17 %, and vitreous syneresis in 15 % of the eyes. Intraoperatively retinopexy with endolaser or cryo was performed in 6 % of cases. A secondary retinal detachment occurred in one eye (2 %). Thirty-one of 32 patients reported to be very satisfied with the postoperative result. Objectively, their visual acuity was better than or equal to preoperative acuity in 95 % of the eyes. CONCLUSION: Pars plana vitrectomy provides a highly effective treatment for visually disturbing vitreous floaters. In an era in which the expectations and demands of individuals on the quality of vision and life have increased significantly, with careful case selection the benefits of the surgical intervention may outweigh the surgical risks.

[Idiopathic macular telangiectasia - follow-up with and without laser photocoagulation]. / Idiopathische makuläre Teleangiektasie (IMT) - Verlaufsbeobachtung mit und ohne Laserphotokoagulation.

PURPOSE: The aim of this study was to evaluate the effectiveness of laser photocoagulation for idiopathic macular telangiectasia (IMT) by using the revised and simplified classification of Yannuzzi 2006. PATIENTS AND METHODS: The Yannuzzi classification was used for a retrospective analysis of the medical records of all patients with idiopathic macular telangiectasia as diagnosed consecutively in the University Eye Clinic of Mainz in the time period from 1 / 02 to 12 / 06. Laser treatment was indicated only in those eyes which presented with a visual acuity below 10 / 20 (follow-up interval in median 37 months, minimum 13 months). RESULTS: 12 patients with unilateral macular telangiectasia (IMT type I) and 30 patients with bilateral macular telangiectasia (IMT type II) were recruited. In type I disease 9 / 12 patients were male with an average age of 41 years (range: 28 to 47). 10 / 12 eyes showed macular oedema. After focal laser photocoagulation in 6 / 10 eyes the macular oedema decreased in 4 / 6 eyes and visual acuity improved in 3 / 6 eyes. In type II disease 17 / 30 patients were male and the average age was 56 years (range: 45 to 63). All 60 eyes showed macular oedema. In 40 eyes, which did not receive a laser photocoagulation, the ocular findings did not change during the follow-up examinations. In 16 / 20 eyes the macular oedema has successfully been reduced by laser photocoagulation, however without significant visual improvement. In 2 of these 16 treated eyes the development of a subfoveal choroidal neovascularisation with central loss of vision was noted. CONCLUSIONS: In IMT type I laser photocoagulation was able to achieve a visual improvement. In IMT type II, however, a laser photocoagulation indication should be considered very carefully because in this group no visual improvement was reached and a secondary induction of subretinal neovascular membranes seems likely.

[Tumor regression in malignant choroidal melanomas after transpupillary thermotherapy (TTT) versus ruthenium brachytherapy and sandwich therapy - a comparative analysis]. / Tumorregression maligner Aderhautmelanome nach Transpupillarer Thermotherapie (TTT) versus Ruthenium-Brachytherapie und Sandwichtherapie - eine vergleichende Analyse.

PURPOSE: The aim of this study was to evaluate tumour regression in a large series of choroidal melanomas, which were treated with three different eye-sparing treatment modalities. PATIENTS AND METHODS: Retrospective review of the treatment results in all eyes with malignant choroidal melanoma, which were treated in the University Eye Clinic of Mainz consecutively in the time span 1.1992 to 12.2000 with transpupillary thermotherapy (TTT, standard protocol Oosterhuis JA 1995), ruthenium brachytherapy (RB, tumor apex dose 150 Gy) or sandwich therapy (ST). One-step ST was defined as TTT followed by RB with 100 Gy tumor apex dose within 48 hours. The treatment of residual prominences with TTT secondary to RB after different time spans was called two-step ST. Follow-up was 2 years. RESULTS: 131 eyes with malignant choroidal melanoma (mean tumour thickness: 4.5 mm) were treated with RB (66 eyes), TTT (26 eyes) or ST (39 eyes). Preservation of the globe was achieved in 109 eyes (81 %). Local tumour control was found in small melanomas (prominence up to 3 mm) in 89 %, in large tumors (prominence 8 mm and higher) in 50 %. In a subgroup of small posterior melanomas (n = 70 eyes, prominence up to 4.5 mm, located posterior to the equator) local tumour control was noted in 91 %. The time span to reach local tumour control (Kaplan-Meier estimates) was the shortest after TTT (median: 20 weeks), compared with RB (48 weeks) and one-step ST (29 weeks). CONCLUSIONS: In choroidal melanomas the chance of local tumour control and preservation of the globe decreases with increase of the tumour prominence. In small choroidal melanomas with posterior location local tumour control was achieved significantly faster after TTT than after RB.

[Eales' disease--10 years experience with a rare disease]. / Morbus Eales--10 Jahre Erfahrung mit einem seltenen Krankheitsbild.

BACKGROUND: Eales' disease is an uncommon vasoproliferative retinal disease affecting otherwise healthy young men. We report on our treatment results in a large patients group with long-term follow-up. PATIENTS AND METHODS: The treatment results in 50 eyes (35 patients) with Eales' disease, that were consecutively treated from May 1995 to August 2005, were analysed retrospectively. Recorded data included age, sex, race, association of systemic disease, medications, laboratory evaluation and the surgical treatment. Mean follow-up was 5.8 years (minimum: 3.2, maximum: 8.6 years). RESULTS: Systemic and laboratory evaluations detected a factor V Leiden mutation (4x), vestibuloauditory problems (1x) and migraine (1x). 10 eyes with peripheral non-perfusion, teleangiectasia and mild neovascularisations were treated by scatter laser photocoagulation alone. 18 eyes with advanced neovascularisations/vitreous haemorrhages received cryocoagulation too. 14 eyes with persistent or recurrent bleedings despite coagulation therapy and/or development of tractional retinal detachment were treated by vitrectomy. 5 of them received a silicone oil endotamponade. All eyes could be stabilised without further bleedings. Visual acuity increased in 25 eyes. Only 5 eyes showed a visual loss. The visual results (rate of improvements and the stages of visual acuity as well) were the best in those eyes that received vitrectomy. CONCLUSIONS: These results suggest that early retinal laser and cryocoagulation and - if necessary - vitrectomy in due time may led to a stabilised retina without further bleedings and visual improvement too. Coagulopathy could play a role in the pathogenesis of Eales' disease.

[Arteriovenous crossing sheathotomy in branch retinal vein occlusion]. / Arteriovenöse Dissektion (AVD) bei retinalen Venolenastverschlüssen.

BACKGROUND: The aim of this study is to report on arteriovenous sheathotomy in branch retinal vein occlusion (BRVO) with a long-term follow-up and examine the visual field effects of this surgical approach. PATIENTS AND METHODS: In a clinical trial 36 eyes with branch retinal vein occlusion (22 eyes with ischaemia, 14 eyes with chronic macular oedema) underwent surgical decompression accompanied by peeling of the membrana limitans interna after prior isovolemic haemodilution for 3 months had been unsuccessful. RESULTS: All eyes showed a significant reduction of macular oedema 3 months after surgery. During follow-up (median: 26.4 months) visual acuity increased in 24/36 eyes and was stabilised in 8/36 eyes. We observed haemorrhages at the dissection site (5x), vitreous haemorrhages (12x) and retinal holes at the vitreous base (2x). Goldmann perimetry revealed paracentral scotomas in 3 eyes, which had been treated by arteriovenous dissection relatively close to the optic disc. In 16/22 eyes with ischaemic thromboses the visual field was narrowed in the affected quadrant. CONCLUSIONS: The results of arteriovenous sheathotomy in BRVO are encouraging because we observed increase of visual acuity in 67% of the eyes in spite of an unsuccessful haemodilution during 3 months before. However, whether its benefits outweigh potential surgical complications as visual field defects remains to be determined.

[Decreased visual acuity and loss of field of vision after inguinal hernia surgery]. / Sehschärfenminderung und Gesichtsfeldausfall nach Leistenhernien-Operation.

A 60-year-old patient reported a slight decrease in visual acuity with loss of field of vision. He also noted a mild sense of vertigo and a feeling of "pressure in his head". He had undergone laparoscopic bilateral hernia repair 3 days before on an outpatient basis. Diagnostic work-up revealed shock-induced anterior ischemic optic neuropathy (AION) of the left eye. Without special treatment measures the head pressure and feeling of weakness subsided considerably in a spontaneous course within 24 h. Three months later partial optic atrophy of the affected eye was observed with stable visual acuity of 0.8 and unchanged loss of field of vision.

[Central serous chorioretinopathy (CSC) and corticosteroids]. / Chorioretinopathia serosa centralis (CSC) und Kortikosteroide.

BACKGROUND: Corticosteroids are under suspicion of playing an important role in the development of central serous chorioretinopathy (CSC). PATIENTS AND METHODS: In a prospective study the course of CSC was evaluated in a consecutive series of 46 patients, who received the diagnosis of CSC in the period 4 / 2004 - 12 / 2005. Data analysis was focused on the complete medical and ocular history and the ocular course of this disease. RESULTS: 27 patients had been taking exogenous corticosteroids (oral, intravenous, inhalative, cutaneous and intraarticular) within 4 weeks before onset of symptoms. Additionally, one case with Cushing's disease and 2 pregnant women were included. These 30 / 46 patients with steroid association presented bilateral involvement in 21 cases (70 %) and angiographically more than one leakage point in 10 cases (33 %). In 16 / 46 patients without history of taking exogenous corticosteroids bilateral involvement was seen in 2 / 16 cases (13 %) and multiple leakages in only one case (6 %). CSC resolved spontaneously in 25 / 46 patients within 2 - 6 months. In 21 / 46 patients recurrences were documented either in the eye, which was primarily affected or in the other one. In this group of recurrent CSC all 8 patients were included who did not discontinue the use of systemic corticosteroids. CONCLUSIONS: These results strongly support the association of steroid use with CSC. Unter systemic treatment with corticosteroids bilateral involvement and multilocular leakages seem to be more likely than without use of steroids. All patients in need of corticosteroids by any systemic route of administration should be informed of the associated risk.

[Laser photocoagulation and photodynamic therapy (PDT) with verteporfin for retinal angiomatous proliferation (RAP) in age-related macular degeneration (AMD)]. / Laserfotokoagulation und photodynamische Therapie (PDT) zur Behandlung der retinalen angiomatösen Proliferation (RAP) bei feuchter altersabhängiger Makuladegeneration (AMD).

BACKGROUND: Retinal angiomatous proliferation (RAP) is a subtype of neovascular age-related macular degeneration (AMD) with particularly bad prognosis. Diverse treatment modalities are performed. PATIENTS AND METHODS: This is a retrospective review on the treatment results of 41 consecutive patients from 1/2003 to 12/2005 with RAP stage 1-3 (Yannuzzi classification), who were treated with laser photocoagulation, photodynamic therapy (PDT) and intravitreal injection of triamcinolone acetonide (IVT). Follow-up was 12 months minimally. RESULTS: In RAP stage I complete closure of the vascular lesion in 14 / 22 eyes was achieved by 1.2 +/- 0.5 sessions of laser photocoagulation (4 x combined with IVT) and in 3/14 eyes with photodynamic therapy (2 +/- 0.5 sessions). In RAP stage II closure of the lesion was achieved by 3.2 +/- 0.6 sessions of photodynamic therapy in 6/14 eyes (4 x combined with IVT). In RAP stage III closure of the lesion was achieved by 3.2 +/- 0.4 sessions of photodynamic therapy in 0 / 5 eyes (3 x combined with IVT). A rip of the retinal pigment epithelium was observed in 2/14 eyes of RAP stage II and 2/5 eyes of RAP stage III. Visual acuity improved in 9/17 eyes with occlusion of RAP stage I. Without closure of the vascular lesion all eyes got legally blind (visual acuity 1/50 or less). CONCLUSIONS: Early detection and subsequent direct treatment of RAP stage I in AMD is recommended. In advanced stages anatomical closure of the vascular complex is rarely achieved and the risk is improved for development of tears in the retinal pigment epithelium and getting legally blind.