[Impact of age on success rate of lacrimal duct irrigation with silicone tube intubation in connatal lacrimal duct stenosis]. / Einfluss des Operationszeitpunktes auf den langfristigen Erfolg von Tränenwegsoperationen mit Schlauchintubation bei kindlicher Tränenwegsstenose.

BACKGROUND: Irrigation of the lacrimal duct with silicone tube intubation (TWS/S) remains the preferred treatment in persisting connatal lacrimal duct stenosis (kTWS). The timepoint of operation is however discussed controversely. On the one hand, it is recommended to wait for spontaneous opening of the lacrimal duct within the first year of life, on the other hand a later operation may trigger inflammatory changes within the lacrimal duct system influencing the success rate of the operation negatively. The aim of this study was to analyze the best time point of operation regarding the long-term success rate of the operation. PATIENTS/MATERIALS AND METHODS: 411 lacrimal ducts of 316 children with kTWS between 0 and 48 months of age (164 male, 156 female), who had undergone TWS with S because of kTWS at a tertiary eye care centre between 2007-2011 were included in this study. The children were divided into 6 groups of age (0-6, 7-12, 13-18, 19-24, 24-36, > 36 months) at the time of operation. The operative success was retrospectively evaluated after 36 months. The groups were compared and differences in late success rate analyzed statistically. RESULTS: The average success of operation of TWS/S in kTWS was 89 % (366 of 411 lacrimal ducts). The success rate of operation differed between the groups. If operated at the age of 0-6 months the operation was successful in 94 %, at the age 7-12 months in 91 %, between 13-18 months in 90.5 %, from 19-24 months in 88 %, and from 25-36 months in only 84.5 %. The success rate was therewith at the age of 25-36 months significantly lower than at the age of 0-6 months (p < 0.05). CONCLUSION: TWS/S in kTWS has overall a very high rate of success. The success of the operation decreases however in correlation with age at time of operation and shows with > 25 months significantly poorer results than at 0-6 months. The choice of the best time point for operation merits further investigation.

[Medical malpractice in ophthalmology]. / Behandlungsfehler in der Augenheilkunde.

BACKGROUND: The increasing number of patients taking action for medical malpractice (MM) is a burden for the medical practitioners accused. After the assessment through an arbitration committee, which is free of cost for the patients,a large number of lawsuits can be avoided. Discussion of patient complaints and analyzing cases of MM is an important concern for the medical community in order to reduce errors in treatment and to contribute to patient safety. MATERIAL AND METHODS: The patient applications to the arbitration committee of the medical association of North-Rhine ("Gutachterkommission Nordrhein") for review of MM in the field of ophthalmology in the years 1999-2010 were analyzed statistically. RESULTS: In the years 1999-2010 a total of 583 cases were related to ophthalmology (3% of all cases) and in 122 cases (21%) MM was recognized by the committee. In 61% of the cases MM was caused by errors in diagnosis, in 24% by errors in processes and in 15% by errors in surgical procedures. CONCLUSIONS: The proportion of ophthalmological cases in the total number of MM cases is low. Most errors in diagnosis are caused by the lack of basic diagnostic on examination procedures. Errors in processes are caused by instrumental errors and deficient communication. An important reason for errors in surgical procedures is a deficient management of complications. A standardized workflow of medical examinations and a quality management can help to avoid MM.

[Fasanella-Servat procedure for the surgical treatment of acquired ptosis of the upper eyelid]. / Das Fasanella-Servat-Verfahren zur Therapie der erworbenen Ptosis.

PURPOSE: The oculoplastic surgeon may choose between several surgical procedures to treat ptosis of the eyelid. One such potential therapeutic option is the Fasanella-Servat procedure. The purpose of our study was to evaluate the postoperative outcome of the Fasanella-Servat procedure in patients with ptosis of the eyelid with regard to objective and subjective criteria. METHODS: The postoperative success of 20 patients (23 eyelids), 11 female and 9 male, with acquired ptosis of the upper eyelid who underwent the Fasanella-Servat procedure between 1995 and 2004 in an eye tertiary care centre, was evaluated. With regard to the type of ptosis, the pre- and postoperative opening of the eyelid, the levator function, and the symmetry between both eyes were analysed statistically. The patients' subjective satisfaction with the functional and cosmetic postoperative outcome was evaluated by means of a nominal questionnaire (scale 1 - 5). The intraoperatively removed tissue was analysed histopathologically for accessory lacrimal glands or levator muscle. RESULTS: The mean preoperative opening of the eyelid was 7.1 mm (min. 4 mm, max. 10 mm) with a mean levator function of 12.6 mm. Postoperatively, the opening of the eyelid improved significantly to 9.3 mm (min. 7 mm; max. 14 mm), while the levator function remained stable. The preoperative asymmetry between both eyes was significantly decreased. 90 % of the patients were satisfied with the cosmetic and functional results. There were no early and late postoperative complications. No side effects were recorded following treatment. The intraoperatively removed tissue showed no evidence of tissue of accessory lacrimal gland or levator muscle. CONCLUSIONS: The Fasanella-Servat procedure remains an effective procedure in treating mild ptosis with few complications and good cosmetic and functional results.

[Microbiological analysis in contact lens-associated keratits]. / Bakterielles Spektrum der kontaktlinsenassoziierten Keratitis.

INTRODUCTION: More than 125 million (2 %) people worldwide wear contact lenses (CL). 0.011 - 0.2 % of the wearers develop keratitis per year. The aim of this study was to explore and analyse the spectrum of germs in different microbiological analysis techniques to optimize the strategy of antiobiotic therapy. PATIENTS AND METHODS: A retrospective study about 65 eyes with CL induced keratitis or corneal ulceration who were treated in our hospital between 2005 - 2010. We analysed and compared the development of best-corrected visual acuity (BCVA) under single and combined antibiotic therapy and microbiological analysis of conjunctiva (CS) and CL and CL-container swabs (CLS). RESULTS: Of the patients 96.9 % were soft contact lenses wearers. 48.8 % had microbiological findings in the CS, 81.3 % in CLS. 19.6 % (n = 9) coagulase-negative Stapyhlococcus and 17.3 (n = 8) Pseudomonas species were found. Different spectra of germs in CS and CLS were found. Gram-positive bacteria in CS (54.5 %) were dominant, whereas Gram-negative bacteria were dominant in CLS. No significant difference of mean BCVA changes between single (0.09 ± 0.2) and double (0.14 ± 0.29) topical antibiotic therapy (p = 0.16) were seen, but significant differences between the groups of "gentamicin & ofloxacin" (0.2 ± 0.2) and "moxifloxacin & tobramycin" (0.1 ± 0.43) (p < 0.05) were found. No significant differences of BCVA change between patients with positive (0.12 ± 0.23) and negative (0.20 ± 0.37) microbiological results of conjunctival swabs were observed (p = 0.5). CONCLUSIONS: A strong association between keratitis among wearers of soft lenses and typical spectra of germs was found. Different microbiological findings in different swabs, a lack of findings in around 51.2 % of CS combined with the comparable clinical outcomes between sterile and "microbial" disease means the findings from CS are less important. No differences in development of BCVA between single and double antibiotical therapy were found. There was a better outcome of BCVA with ofloxacin with gentamicin compared to newer generation agents. To improve current treatment strategies in future we recommend increasing the microbiological analysis of CL and CL containers.

[Bacteriology of occluded nasolacrimal ducts in infants]. / Bakterielles Keimspektrum bei kindlichen Tränenwegsstenosen.

BACKGROUND: Connatal lacrimal duct stenosis (cLDO) commonly causes purulent bacterial dacyrocystitis. The recommended treatment of choice is up to the sixth month of life a conservative antimicrobiological therapy. After the sixth month lacrimal duct irrigation with silicone tube intubation remains the gold standard. Our purpose was to analyse the current bacterial spectrum in cLDO and to compile a bacterial resistogram in order to specify antimicrobiological therapy. METHODS: 66 samples from the lacrimal duct of 6- to 16-month-old children (41 female, 25 male) were obtained by collecting the refluxing liquids with cotton wool swabs after irrigation of the lacrimal drainage system with sterile saline during lacrimal duct surgery. Cultures were incubated aerobically and anaerobically and the infectious agents were isolated. Sensitivity testing was performed for each isolate, testing 8 different commonly used local antibiotics. Data were statistically analysed using SPSS. RESULTS: Cultures were positive in cLDO in 97 %, showing co-colonisation in 87 % with up to five bacterial strains. Gram-positive bacteria were seen in 72 % of the isolates in cLDO with Streptococcus pneumoniae (31 %) being the most abundant strain, followed by Staphylococcus aureus (13 %) and S. epidermidis (13 %). In 85 % of the samples at least one Gram-negative rod was present, most often Branhamella (12 %), followed by Haemophilus influenzae (11 %). Sensitivity testing revealed chloramphenicol, fusidic acid and ciprofloxacin/levofloxacin to be the most effective drugs in cLDO, whereas erythromycin and gentamycin turned out to be insufficient in treating cLDO. CONCLUSION: Bacterial colonisation plays a crucial role in cLDO, showing a positive culture in 97 % with frequent co-colonisation of several bacterial strains (often in combination with at least one Gram-negative strain). The sampling of a microbiological probe of the lacrimal duct is recommended at least in therapy-refractory cases. Current bacteria in cLDO can be effectively treated with chloramphenicol, fusidic acid and ciprofloxacin. The commonly used antibiotics erythromycin and gentamicin are inappropriate as monotherapeutics.

[Factors influencing the long-term success of lacrimal duct surgery and the prognostic value of dacryocystography]. / Einflussfaktoren auf den langfristigen Erfolg von Tränenwegsoperationen und der prognostische Wert der Dakryozystografie.

BACKGROUND: Irrigation of the lacrimal duct with silicone tube intubation, endoscopic microdrill dacryoplasty and external dacryocystorhinostomy (DCR) are commonly used in lacrimal duct surgery. Dacryocystography (DCG) is one of the standard procedures in preoperative imaging. This study evaluates the influence of individual parameters and the prognostic meaning of preoperative DCG on the success rates after lacrimal duct surgery, in order to predict more precisely the long-term outcome after different operative paradigms. MATERIALS AND METHODS: 145 patients (mean age 60 years; 32 % male) with lacrimal stenosis, who underwent lacrimal duct surgery in the University Eye Hospital Münster during 2002 were included in this retrospective study. Individual parameters (age, gender, preoperative duration of symptoms, lacrimal sac area and operative procedures) were recorded. The lacrimal sac area of each patient was calculated from preoperative DCG imaging. The individual parameters and the prognostic relevance of preoperative DCG were statistically analysed with regards to the long-term success rate after different surgical procedures. Criteria for success were an asymptomatic patient and a successful probing and irrigation of the lacrimal duct system at follow-up at 24 to 36 months after lacrimal duct surgery. RESULTS: With a mean success rate of 79 %, DCR was most effective regarding long-term outcome. Particularly in elderly patients DCG was superior to minimal-invasive procedures. The mean area of the lacrimal sac, calculated from DCG imaging, was 18 mm (2). There was a significant correlation (p = 0.001) between the area of the lacrimal sac and long-term success of DCR. CONCLUSION: Endoscopic microdrill dacryoplasty and DCR have the most successful options in the treatment of lacrimal stenosis. DCG was the most effective procedure in elderly patients. An enlargred lacrimal sac proved to be a positive prognostic factor for the long-term success of DCR.

[Ophthalmological symptoms as key findings in neurosyphilis--diagnosis and therapy]. / Ophthalmologische Symptomatik als Schlüsselbefund der Neurosyphilis--Diagnose und Therapie.

BACKGROUND: The incidence of neurosyphilis, one of the late manifestations of syphilis, is reemerging. Affection of the eye is often associated with the disease. It may present with various clinical symptoms, leading to diagnostic difficulties. In cases of early diagnosis and adequate treatment the prognosis of the disease is good. PURPOSE: The purposes of this study are 1. to analyse clinical manifestations of patients with neurosyphilis on ophthalmological symptoms and 2. to demonstrate the course of the disease and the visual outcome in patients with optic nerve affection in neurosyphilis treated with standard therapy (penicillin G) or adjunct steroids. METHODS: We performed 1. a retrospective analysis of all 23 patients who were treated for neurosyphilis between 2000-2008 at this centre and 2. evaluated a case series of 4 patients with optic nerve affection in neurosyphilis who were treated with penicillin and adjunct methylprednisolone. RESULTS: 91% of the patients with neurosyphilis showed ocular affection in various presentations. The optic nerve was affected in 78%. In 43% ocular symptoms were the exclusive sign of the neurosyphilis. In all patients who were treated with penicillin, visual acuity improved. Adjunct treatment with methylprednisolone resulted in complete visual recovery in two cases. CONCLUSION: Ocular symptoms serve as the key diagnostic findings in neurosyphilis. Treatment of choice is penicillin G. Adjunct treatment with methylprednisolone may improve the visual outcome in patients with optic nerve involvement.

[Long-term results of iridocyclectomy for iris tumours]. / Langzeitergebnisse nach Iridozyklektomie bei Iristumoren.

BACKGROUND: The aim of this study was to evaluate the long-term survival rate and functional results after iridocyclectomy. PATIENTS AND METHOD: Between 1980 and 2002 39 patients (26 female and 13 male) ranging in age from 20 to 79 years (median m = 58 years) underwent iridocyclectomy for a tumour of periphery iris by means of a lamellar technique or by trepanating. Follow-up time ranged from 3 months to 24 years (m = 11.2 years). RESULTS: In 21 cases (54 %) there was a malignant tumour including 20 melanomas (mostly spindle-cell and mixed-cell melanomas) and one filiae of a bronchial carcinoma. There was a variety of histopathological entities in the 18 benign lesions (46 %). Naevi were the most frequent. The outcome was satisfactory: 57 % of the patients kept a visual acuity of > 0.5. Three eyes had to be enucleated. The rate of recurrence was 10 % (4 cases). The Kaplan-Meyer estimate for the 10-year-survival of the patients with a malignant iris tumour was 77 %. Two patients died of metastic melanoma following spindle-cell and mixed-cell melanoma. CONCLUSION: The long-term functional results after Iridocyclectomy are good, whereas complications and recurrences are rare. The 10-year-survival is high. Over a long period iridocyclectomy is a recommendable surgical procedure for removal of progredient tumours of the anterior uvea.

Implantable visual prostheses.

Visual impairment and blindness is primarily caused by optic neuropathies like injuries and glaucomas, as well as retinopathies like agerelated macular degeneration (MD), systemic diseases like diabetes, hypertonia and hereditary retinitis pigmentosa (RP). These pathological conditions may affect retinal photoreceptors, or retinal pigment epithelium, or particular subsets of retinal neurons, and in particular retinal ganglion cells (RGCs). The RGCs which connect the retina with the brain are unique cells with extremely long axons bridging the distance from the retina to visual relays within the thalamus and midbrain, being therefore vulnerable to heterogeneous pathological conditions along this pathway. When becoming mature, RGCs loose the ability to divide and to regenerate their accidentally or experimentally injured axons. Consequently, any loss of RGCs is irreversible and results to loss of visual function. The advent of micro- and nanotechnology, and the construction of artificial implants prompted to create visual prostheses which aimed at compensating for the loss of visual function in particular cases. The purpose of the present contribution is to review the considerable engineering expertise that is essential to fabricate current visual prostheses in connection with their functional features and applicability to the animal and human eye. In this chapter, 1) Retinal and cortical implants are introduced, with particular emphasis given to the requirements they have to fulfil in order to replace very complex functions like vision. 2) Advanced work on material research is presented both from the technological and from the biocompatibility aspect as prerequisites of any perspectives for implantation. 3) Ultimately, experimental studies are presented showing the shaping of implants, the procedures of testing their biocompatibility and essential modifications to improve the interfaces between technical devices and the biological environment. The review ends by pointing to future perspectives in the rapidly accelerating process of visual prosthetics and in the increasing hope that restoration of the visual system becomes reality.

Can lenticular factors improve the posttrauma fate of neurons?

The intraocular lens has recently been recognized as a potential source for neuroprotective and neurite-promoting activities. The lens is ontogenetically and functionally a peculiar intraocular tissue with the unique feature of performing incomplete cellular apoptosis throughout the lifetime. The ectodermally derived epithelial cells permanently divide to produce the nuclei- and organelle-free lens fibre cells that allow for the optical transparency. The underlying extremely specific physical, biochemical, metabolic and structural mechanism lead to efficient protection from photo-oxidative stress caused by exposure to short-wavelength light. The fact that fibre cells undergo incomplete apoptosis is also of crucial importance to other cellular systems. In particular, injured nerve cells such as axotomized retinal ganglion cells may profit from the apoptosis-blocking mechanisms operating within the lens fibres. In this review we first discuss some factors involved in the lens differentiation and partial apoptosis as a basic principle of long-term survival. We then present recent experimental evidence that lenticular factors also operate outside the lens, and in particular within the retina to contribute to axonal regeneration, e.g. after a trauma. In turn, factors such as GAP-43 that were thought to be exclusively expressed within nervous tissue have now also been discovered within the lenticular tissue. Experiments of the direct confrontation of lenticular epithelial and fibre cells with regenerating ganglion cell axons in vitro are presented. It is concluded that survival factors supplied by the lens might be used to facilitate survival within neuronal tissue.

[Examination of preschool children for refractive errors. First experience using a handheld autorefractor]. / Untersuchung von Kindergartenkindern auf Refraktionsanomalien. Erste Erfahrungen mit einem handgehaltenen Autorefraktometer.

BACKGROUND: Since ametropia is a leading cause of amblyopia refractive screening of preschool children is recommended. Measurement of refraction using tabletop autorefractors can be difficult or impossible due to lack of cooperation in this age group. The intention of the present study is to evaluate the use of a new handheld autorefractor for screening in kindergartens. METHODS: A total of 216 children aged 3.5-4.5 years were examined without cycloplegia using the handheld autorefractor (SureSight, Welch Allyn) in their kindergartens. RESULTS: Using the test device the majority of the examined eyes showed mild hyperopia (on average +1.18+/-0.87 dpt spherical equivalent) and mild astigmatism (on average 0.60+/-0.46 dpt cylinder power). The reproducibility of repeated autorefractor readings was higher for cylinder power and axis than for the spherical equivalent. Autorefractor readings of 55 eyes could be compared with the results of cycloplegic retinoscopy. The results were similar between the two measurements with differences of no more than 0.5 dpt in 18.2% for the spherical equivalent, in 82.1% for cylinder power, and in 66.6% for axis (weighted axis difference). There was adequate cooperation in 99.5% of the children. CONCLUSION: The handheld autorefractor proved an accuracy of measurement comparable to that of conventional tabletop autorefractors for cylinder power and axis with limitations in accuracy for the spherical equivalent. Validity and threshold values for relevant abnormalities are to be evaluated in further studies. By the high cooperation rate the instrument proved useful for screening examinations in preschool children.