Changes in the occlusal function of orthognathic patients with vertical malformations after combined orthodontic surgical therapy: a prospective clinical study.

The aim of this study was to assess the changes in occlusal patterns during combined surgical and orthodontic therapy in patients with vertical jaw malformations. Twenty-six orthognathic patients (18 female, eight male; median age 25 years, interquartile range 11.5 years) and 10 control patients (five female, five male; median age 29.8 years, interquartile range 13.5 years) recruited from neutral configured patients attending the Department of Orthodontics, were investigated. Based on cephalometry, the patients were grouped into vertical skeletal configurations of either open, deep, or natural bite cases. Registrations of the occlusal contacts were taken using a digital occlusal sensor immediately before surgery and at 9 months after the surgical intervention. Before the intervention, open and deep bite patients showed significantly less efficient occlusal patterns than the untreated controls regarding total tooth contact (P < 0.001), time of occlusion (P = 0.002), occlusal asymmetry (P = 0.001), anterior tooth contact (P < 0.001), and posterior tooth contact (P < 0.001). After surgery, the parameters in the deep bite patients were similar to those in the controls; however, in open bite patients, total tooth contact (P = 0.003), occlusal asymmetry (P = 0.011), and posterior tooth contact (P = 0.035) differed significantly. In conclusion, combined orthodontic and surgical correction of vertical malocclusions was found to improve occlusal function in patients with deep bite to the level of controls.

[Surgical treatment of eyelid tumors]. / Operative Therapie von Lidtumoren.

Eyelid tumors are often periocular skin lesions but can also be derived from adnexal structures or the conjunctiva. Treatment is primarily surgical, especially for malignant tumors, whereby complete excision is strived for to minimize the local rate of recurrence. Adjuvant therapy and conservative alternative methods (e.g. radiotherapy, cryotherapy and immunomodulation) are reserved for specific cases. The main goal for reconstruction of the eyelids is the functional and aesthetic rehabilitation. This article focuses on the principles and underlying techniques for the reconstruction of the periocular region.

[Botulinum toxin A induced protective ptosis for the treatment of recurrent epithelial defects in neurotrophic keratopathy]. / Medikamentöse Oberlidptosis in der Therapie der rezidivierenden Epitheldefekte infolge neurotropher Keratopathie.

In this article, a case of recurrent epithelial defects in neurotrophic keratopathy is described. Multiple abrasions of the corneal epithelium with a therapeutic contact lens, corneal stitches, and amniotic membrane transplantation in combination with artificial tears brought only short-term success. However, a botulinum toxin A induced protective ptosis could finally achieve permanent epithelial closure. As this case shows, protective ptosis can be a promising approach in spite of multiple previous ineffective therapeutic efforts.

[Central scotoma after viral prodrome]. / Parazentralskotom nach Erkältung.

CASE REPORT: A 29-year-old female patient presented with a unilateral deterioration of visual acuity, metamorphopsia and a paracentral scotoma. The patient had suffered from a viral rhinitis 1 week prior to the ophthalmological symptoms. DIAGNOSTICS: Fundoscopy revealed parafoveal changes in the retinal pigment epithelium and spectral-domain optical coherence tomography (SD-OCT) disclosed corresponding hyperreflective, subretinal changes with disruption of Bruch's membrane and the outer limiting membrane. In the course of the disease there was a spontaneous regression of these changes. Visual acuity improved and the central scotoma resolved. The patient showed the typical history and clinical findings of unilateral acute idiopathic maculopathy. CONCLUSION: The most probable explanation for the patient's symptoms is an immunologically triggered adverse reaction due to a previous viral rhinitis, with participation of the retina and retinal pigment epithelium. As a rule the disease has a spontaneous and favorable course.

[Traumatic optic nerve neuropathy. Longterm results following microsurgical optic nerve decompression]. / Traumatische Optikusneuropathie. Langzeitergebnisse nach endonasaler mikrochirurgischer Dekompression des N. opticus.

BACKGROUND: Traumatic optic nerve neuropathy (TON) is defined as injury to the optic nerve with subsequent vision loss due to head or craniocerebral trauma. The treatment of this disease is the subject of controversial discussions. The purpose of the present study was to investigate pre- and immediate postoperative visual acuity in patients with unilateral TON and to compare the results with the time interval between trauma and surgical intervention. PATIENTS AND METHODS: A total of 20 patients with unilateral TON and considerable vision loss were examined. All were treated with high dose corticoids and underwent microsurgical optic nerve decompression. Visual acuity was determined pre- and postoperatively. In long-term follow-up visual acuity was determined 3 months postoperatively. RESULTS: Postoperatively, nine patients (45%) achieved an improvement in visual acuity of more than 0.4, and another three patients (15%) an improvement of ≥0.2. At 3 months postoperatively another four patients achieved a further improvement of their visual acuity of >0.2. A decrease in visual acuity was not observed in any case, nor were major surgical complications. CONCLUSIONS: Factors which predict good prognosis for vision recovery include a short time interval between trauma and intervention, edema, and/or hematoma of the optic nerve sheath. Factors which predict a worse prognosis are a fracture line directly through the nerve canal, a time period between trauma and intervention of more than 24 h, and initial complete amaurosis.

[Stem cell therapy for corneal defects]. / Stammzelltherapie bei Korneadefekten.

BACKGROUND: The healing process of corneal defects requires functioning limbus stem cells. Their loss will lead to secondary wound healing problems. Stem cell research offers new treatment options. MATERIAL AND METHODS: A Medline search of the U. S. National Library of Medicine was carried out. RESULTS: The autologous limbus stem cell transplantation is currently the treatment of choice. Amniotic membrane transplantation, previously settled with limbus stem cells, is a clinically proven method. In animal experiments bone marrow-derived mesenchymal stem cells or epidermal stem cells can be used to improve healing of corneal defects. Adipose-derived stem cells may support the regenerative ability of the cornea as well. Moreover, membrane transplantation of epithelial cells from the buccal mucosa cultivated in vitro was clinically tested. DISCUSSION AND CONCLUSIONS: Limbus stem cell failure of both eye is the limiting factor for autologous limbus stem cell transplantation. Epithelial cells, epidermal stem cells, bone marrow- or adipose-derived mesenchymal stem cells promote the regeneration of the cornea and have become established for the treatment of corneal defects. Additionally, mesenchymal stem cells offer the advantage of immunosuppressive and anti-inflammatory effects.

[ITAP - 6-month results of a prospective, randomised phase 3 study for evaluation of the combination therapy of PDT and intravitreal triamcinolone in exudative AMD]. / ITAP - 6-Monats-Ergebnisse einer prospektiven und randomisierten Phase-3-Studie zur Evaluation der Kombinationstherapie aus PDT und intravitrealem Triamcinolon bei der exsudativen AMD.

BACKGROUND: Combination therapy of photodynamic therapy (PDT) with intravitreal triamcinolone (IVTA) for choroidal neovascularisation (CNV) in age-related macular degeneration is thought to improve the prognosis. It is therefore widely used, although results are mostly based upon non-randomised and retrospective studies. Here we present the 6-month results of our prospective, randomised, multicentre ITAP trial (Intravitreal Triamcinolone and PDT) for the evaluation of the combination therapy as compared to PDT alone. PATIENTS: This prospective, randomised, multicentre phase III trial was performed for the evaluation of the efficacy and safety of combination therapy (PDT and IVTA) as compared to PDT alone. Three randomised therapy groups (A: PDT alone, B: IVTA on the same day 1 hour after PDT C: IVTA 1 week before PDT) were monitored over 1 year. The patients included had wet AMD with predominantly classic CNV, minimal classic CNV smaller than 4 papillary diameters or occult CNV with recent disease progression. Re-treatment was performed when persistent leakage of the CNV was visible at follow-up. Primary outcome criteria were the comparison between combination therapy and PDT monotherapy concerning visual acuity, and, second, the comparison between the two groups of combination therapy. RESULTS: 92 patients were included in the study. Before treatment, mean best corrected ETDRS letter score was 52, 53 and 51 in groups A, B and C, respectively. At the 6 months follow-up, mean best corrected letter score was 40, 47 and 47, respectively, with only group A loosing more than 10 letters. This change, however, was not statistically significant between the groups. Mean retinal thickness as measured with optical coherence tomography decreased in all groups, and reached statistical significance in both combination groups. Re-treatment rates did not differ significantly between the three groups at 6 months follow-up, nor was there a significant cataract progression requiring operation. CONCLUSION: At 6 months there was no significant difference between mono- and combination therapy groups concerning visual acuity.

[Pars plana vitrectomy in cystoid macular edema of different forms of chronic uveitis]. / Pars-plana-Vitrektomie bei zystoidem Makulaödem bei verschiedenen Formen der chronischen Uveitis.

BACKGROUND: Cystoid macular edema (CME) is a common complication in different forms of chronic uveitis. In spite of immunosuppressive and anti-inflammatory therapy, chronic or relapsing courses can occur which may have a negative impact on visual prognosis. Pars plana vitrectomy (PPV) is known to positively influence chronic uveitis. This retrospective study was performed to investigate the role of PPV in the therapy refractive uveitic CME. PATIENTS AND METHODS: PPV for CME was performed in eyes with CME in intermediate uveitis (IMU, n=42), chronic iridocyclitis in juvenile rheumatoid arthritis (CIC, n=14) and multifocal chorioretinitis (MFC, n=12). In none of the eyes had immunosuppressive and/or anti-inflammatory therapy or anti-edema treatment (e.g.acetazolamide) led to regression of the CME. After a postoperative follow-up period of 7 and 106 months all patients were re-examined. RESULTS: Postoperative complete or partial regression of CME was observed as follows: IMU: 25/42 (59.5%), CIC: 8/14 (57.1%),MFC: 5/12 (41.7%). A significant increase in visual acuity of 2 lines and more was observed in 50%,71.4% and 41.7% of eyes, respectively. In the long-term follow-up best functional results were achieved in eyes with IMU. CONCLUSIONS: Response to PPV was variable according to the type of underlying form of uveitis. The lowest success rate could be observed in eyes with MFC. Although the postoperative regression rate of CME was satisfactory in eyes with CIC, long-term visual acuity results were disappointing due to secondary complications of CIC in this young age group. Best results were achieved in patients with IMU (statistically not significant). A multicenter study in a larger series of patients is needed to investigate the exact role of PPV in different forms of chronic uveitis.

Pars-plana vitrectomy in cystoid macular edema associated with intermediate uveitis.

BACKGROUND: Cystoid macular edema (CME) is a common complication in the course of intermediate uveitis. In spite of systemic therapy with steroids or carbonic anhydrase inhibitors, persistence of CME is observed. Pars plana vitrectomy (PPV) is known to influence the course of intermediate uveitis positively. The present study was performed to investigate the role of PPV in the therapy of CME in intermediate uveitis. MATERIALS AND METHODS: Forty-two eyes of 32 patients were re-examined after PPV for CME. In all eyes fluorescein angiography was performed. Average age at the time of surgery was 31.9 years (range 6-64 years). All patients had received systemic corticosteroid and/or immunosuppressive treatment during the course of their disease. In some patients systemic therapy with carbonic anhydrase inhibitors was performed. The mean duration of postoperative follow-up was 20.2 months (range 6-102 months). RESULTS: Preoperative visual acuity (VA) in all eyes was between 1/10 and 0.5. Total regression of CME after surgery was observed in 18 of 42 eyes (42.8%), partial improvement in 7 eyes (16.7%). In 13 of 42 eyes (30.9%) the CME remained unchanged. Twenty-one of 42 eyes (50.0%) experienced a postoperative improvement of VA of 2 lines or more. In 18 of 42 eyes (42.8%) there was no change; in 3 eyes (7.2%) VA was less. In the long-term follow-up the corresponding results were slightly worse (17/17/8 eyes) due to secondary complications. In the majority of patients systemic medical therapy could be reduced or discontinued. CONCLUSION: Pars-plana vitrectomy led to regression of CME in 59% of cases and to subsequent improvement of VA in 50% of eyes with intermediate uveitis. PPV should be considered soon after medical therapy has been shown to be ineffective.

[Differential diagnosis of sinugenic enophthalmos]. / Differenzialdiagnose des sinugenen Enophthalmus.

BACKGROUND: Spontaneous enophthalmos without recent trauma is a rare condition. Its origin is difficult to evaluate. METHOD: Specific properties of this symptom complex are presented based on a literature review and on case reports. Possible connections between enophthalmos and paranasal sinus diseases as well as differential diagnoses are analysed. PATIENTS: 1. 31 year old female patient with right spontaneous enophthalmos and no history of trauma. CT-imaging disclosed tissue formation in the maxillary sinus, partially destroyed medial orbital wall and floor, descended orbital contents following Caldwell-Luc procedure several years previously. After endonasal surgery of ethmoidal and maxillary sinus with removal of a large cyst good functional and cosmetical result. 2. 25 year old male patient complaining of pain in the periorbital region, presenting with left enophthalmos and superonasal deviation of the eyeball. MRI and CT revealed a tumor in the orbital floor region with total destruction of the roof of the maxillary sinus. Removal of the tumor by a combined lateral rhinotomy and subciliary approach. DIAGNOSIS: Leiomyoma. Orbital reconstruction with PDS-sheet. Postoperatively, improved globe position and motility. No recurrence during three year follow-up. CONCLUSION: When evaluating the causes of enophthalmos, chronic diseases of the paranasal sinuses or their walls must be considered. Surgical therapy is promising.

Iris angiographic changes in multifocal chorioretinitis with panuveitis.

BACKGROUND: Multifocal chorioretinitis with panuveitis (MCP) is a chronic inflammatory disease of the peripheral retina and choroid with typical clinical appearance. Although obvious involvement of the anterior segment is often mild, severe chronic inflammatory reactions can occur after cataract surgery. Explantation of an intraocular lens (IOL) or primary aphakia may be necessary. In this pilot study we therefore examined the iris of patients with MCP by means of fluorescein angiography (IAG) to investigate iris vessel involvement. MATERIALS AND METHODS: Twenty-one eyes of 13 patients with MCP (12 women, 1 man) were examined by IAG. The average age of the patients was 72.5+/-6.2 years, and the average duration of the disease prior to examination was 13 months. In 9 of 21 eyes a pars plana vitrectomy (PPV) was performed because of marked vitreous opacification. IAG was performed before and after surgery. RESULTS: Although clinically unremarkable the iris of 14/21 eyes showed avascular zones in IAG; 13/21 had irregular vessels such as vascular collaterals, and 10/21 exhibited neovascularization. All eyes showed leakage of dye at the pupillary margin, and in 15/21 there was leakage out of peripheral iris vessels. In 2 of 9 eyes angiographic changes such as avascular zones regressed after PPV. CONCLUSION: Irides in patients with MCP that are unremarkable on slit-lamp examination may show marked angiographic changes. Thus IAG in those cases with planned cataract extraction and IOL, if necessary combined with PPV for vitreous opacification, may be warranted in order to better assess the prognosis after surgery.

Primary orbital leiomyoma and leiomyosarcoma.

A case of an extremely rare primary orbital leiomyoma in a 25-year-old male patient is presented who had a lifelong history of deviation of the left eye globe with slight enophthalmos and reduced motility. Because of pain and increasing deviation of the eye the tumor was totally resected. On histologic examination the tumor showed ossification which is extremely rare so that a calcifying fibroma had to be ruled out. In immunohistochemistry, however, this tumor stained with smooth muscle antigen. Less than 2% of cells stained positive for Ki-S1, a proliferation marker. The second case is a rare primary orbital leiomyosarcoma in an 84-year-old female patient that showed massive growth. After exenteration histologic examination showed a dedifferentiated highly malignant soft tissue tumor which expressed desmin and smooth muscle actin but was negative for myoglobin, S-100 and HMB-45.

Quantification of intraocular retained perfluorodecalin after macroscopic complete removal.

BACKGROUND: A study was performed to determine the amount of intraocular retained perfluorodecalin after macroscopic complete removal. MATERIAL AND METHODS: Freshly enucleated pig eyes had the anterior segment removed, vitrectomy was carried out, and the eye cups were placed in 0.9% buffered saline solution. One millilitre of perfluorodecalin was instilled for 30 min, followed by a fluid-air exchange. Perfluorodecalin was macroscopically removed. The retina was rinsed twice with 0.9% buffered saline solution. In a second group no rinsing was done, while in a third group no fluid-air exchange was performed. Finally all eye cups were filled with 2.0 ml of the perfluoropolyether Hostinert 130 to dissolve retained perfluorodecalin. The quantity of perfluorodecalin in perfluoropolyether was determined by gas chromatography. RESULTS: Retained perfluorodecalin was detected in all experiments. The smallest portion of perfluorodecalin retained (range 0.04-0.08, mean 0.058%, SD +/- 0.015%) was observed without fluid-air exchange. After fluid-air exchange the portion with rinsing was 0.11-0.27% (mean 0.21%, SD +/- 0.059%) and that without rinsing was 0.51-0.69% (mean 0.60%, SD +/- 0.065%). CONCLUSIONS: Even after macroscopic complete removal of perfluorodecalin a thin layer remains on the retina. If intraoperative fluid-gas exchange is necessary, multiple rinsing with 0.9% buffered saline solution should be performed to reduce the amount of perfluorocarbon liquid retained.

Experimental intravitreal application of ciprofloxacin in rabbits.

BACKGROUND: Ciprofloxacin (CFLX) is a fluoroquinolone antibiotic with a broad antimicrobial spectrum. This study was performed to examine the retinal toxicity of free and liposome-incorporated CFLX in rabbit eyes after intravitreal injection. MATERIALS AND METHODS: Free CFLX in doses of 100, 250, 500, 1,000 and 2,000 microg was injected into the midvitreous of rabbit eyes (n = 28). To prolong the intravitreal antibacterial level, CFLX was incorporated into multilamellar liposomes: 0.1 ml of this suspension ( wedge 273.6 microg CFLX) was injected into the midvitreous of a second group of rabbit eyes (n = 6). The other eye served as a control and received normal saline solution or empty liposomes, respectively. Before injection and at the end of follow-up an electroretinogram (ERG) was obtained. After a follow-up of 1, 14 and 28 days the animals were perfused with glutaraldehyde and the eyes were examined by light and transmission electron microscopy. RESULTS: Significant reduction of the ERG was observed after 2,000 microg free CFLX in 4 out of 6 eyes after 14 days. Fourteen days after injection of 2,000 microg CFLX the central retina showed pigmentary changes in 4 out of 6 eyes. In the second group the ERG as well as the histologic studies did not reveal any pathologic changes after injection of liposome-incorporated CFLX compared to the control eyes. CONCLUSION: In therapeutic doses of 100-500 microg, free CFLX does not have retinal toxicity in rabbit eyes. No retinal toxicity was observed after intravitreal injection of liposome-incorporated CFLX.

[Severe intra- and postoperative supra-choroid hemorrhage. Risk factors, therapy, results]. / Schwere intra- und postoperative suprachorioidale Blutungen. Risikofaktoren, Therapie, Ergebnisse.

BACKGROUND: The aim of this study was to analyze risk factors, therapeutic strategies, and functional and anatomic results of eyes with severe suprachoroidal hemorrhage. PATIENTS: Eight of 11 bleeding episodes occurred intraoperatively and 3/11 postoperatively. Bleeding was associated with the following surgical procedures: perforating keratoplasty (5x), extracapsular cataract extraction (3x), pars plana vitrectomy (2x), intracapsular cataract extraction (1x). RESULTS: Nine operations were performed with general anesthesia, two after retrobulbar injection. Ocular risk factors (e.g., prior operations, ocular diseases) and general risk factors (e.g., cardiovascular diseases, diabetes) were analyzed. At the end of the follow-up time visual acuity had improved in three eyes, and it was unchanged in one eye and worse in seven eyes. Four eyes were amaurotic; two of them had to be enucleated. CONCLUSIONS: In spite of using state-of-the-art surgical techniques the prognosis of suprachoroidal bleeding remains serious. Patients who have a combination of several ocular and general risk factors almost exclusively are the ones who afflicted by this complication.

Long-term results after scleral buckling surgery in uncomplicated juvenile retinal detachment without proliferative vitreoretinopathy.

PURPOSE: To evaluate long-term anatomic and functional results of scleral buckling surgery in retinal detachment without proliferative vitreoretinopathy in juvenile patients. METHODS: A total of 33 eyes of 31 patients were operated on. Surgical techniques included segmental buckle (23 eyes), radial buckle (5 eyes), encircling band (4 eyes), and temporary balloon buckle (1 eye). The average age at time of surgery was 15.3 years and the average follow-up time was 8.9 years. Retinal detachment was associated with the following risk factors: myopia (14 eyes), blunt trauma (8 eyes), and aphakia (3 eyes). In 9 eyes, no risk factors were present. Fifteen eyes had a detached macula. In addition to anterior and posterior segment examination, binocular functions and ocular motility were evaluated. RESULTS: Retinal reattachment required one operation in 29 eyes, two operations in three eyes, and three operations in one eye. In one eye, pars plana vitrectomy had to be performed to reattach the retina. At the end of follow-up, retinal reattachment was achieved in all eyes. Visual acuity of 20/40 or better was achieved by 39.4% preoperatively and 60.6% postoperatively; in 52.4%, binocular functions were normal. CONCLUSION: Scleral buckling procedures allow favorable anatomic and functional results in juvenile retinal detachment without proliferative vitreoretinopathy.

Ultrasound biomicroscopic imaging in intermediate uveitis.

BACKGROUND: Clinical examination of the region of the eye mainly affected in patients with intermediate uveitis is difficult and often hampered by media opacities. In that perspective ultrasound biomicroscopy (UBM) promises to be a valuable additional diagnostic tool. METHODS: UBM was performed at a sound frequency of 50 MHz on 26 eyes of 13 patients with intermediate uveitis in order to determine configuration of pars plana, peripheral retina, and vitreous. Findings of ophthalmoscopy with scleral indentation and UBM were compared. RESULTS: In 18 of 26 eyes pathological structures such as membraneous or fluffy vitreous condensations were identified by UBM. Among these UBM revealed pathological findings which were not visible on funduscopy in nine eyes. Most importantly, vitreoretinal adhesions with traction on the retina were imaged in four eyes. However, in three eyes vitreous opacities being visible on funduscopy were not identified by UBM. CONCLUSION: UBM seems to be a valuable diagnostic technique for the evaluation of patients with intermediate uveitis. Longitudinal studies will have to determine the relevance of UBM findings for the individual clinical course and their influence on therapeutic decisions.