[Leukoplakia of the lower tarsal conjunctiva]. / Leukoplakie der unteren tarsalen Bindehaut.

The case of a 73-year-old woman with a perforated corneal ulcer in the remaining eye with migrating endophthalmitis is presented. In addition, the affected eye had non-abradable whitish coating (leukoplakia) on the tarsal conjunctiva. The cause of leukoplakia was initially histologically diagnosed after an incisional biopsy as focal invasive sebaceous carcinoma with pagetoid growth. After exenteration of the orbit it was confirmed to be an early invasive, non-keratinizing squamous cell carcinoma (G2) of the conjunctiva, which had emerged from a spinocellular carcinoma in situ. The early histological differentiation of malignant lesions in the conjunctiva can be extremely difficult because the pathological changes in the tissue are very similar due to the cell metaplasia.

[Bilateral anophthalmia and left-sided orbital tumor : case of an eight-month-old infant]. / Beidseitiger Anophthalmus und linksseitiger Orbitatumor : Fall eines acht Monate alten Säuglings.

An 8-month-old infant from Russia with bilateral anophthalmia presented with an expanding orbital tumor. The tumor was extirpated and the histological examination revealed a non-malignant pseudocystic process with residual neuro-ectodermal structures.

[Correction factors for central corneal thickness in Goldmann applanation tonometry]. / Hornhautdickenabhängige Korrekturfaktoren bei der Goldmann-Applanationstonometrie.

BACKGROUND: For many years researchers have discussed which corneal parameters can influence the measurement of intraocular pressure (IOP). As a substantial parameter, the central corneal thickness (CCT) is assumed; however, different measuring methods - including Goldmann applanation tonometry (GAT), dynamic contour tonometry (DCT), and corneal compensated pressure measured with the ocular response analyzer (IOPcc) - may lead to a completely different dependence on corneal thickness. METHOD: In a study approved by the ethics commission, the anterior chamber of 92 eyes of cataract patients and 85 eyes of glaucoma patients with very different CCT measurements was cannulized before surgery (cataract operation or trabeculectomy), and the IOP values were measured simultaneously with a pressure absorber and with GAT (Perkins tonometer) at different pressure values. RESULTS: The individual measurements exhibited an extraordinarily wide dispersion. In both groups, weak correlations of the difference between GAT and IOP values with the CCT were found (correction factors of 0.95 mmHg/100 microm CCT at pressure level 20 mmHg, 1.2 mmHg/100 microm CCT at pressure level 30 mmHg, and 1.7 mmHg/100 microm CCT at pressure level 40 mmHg). CONCLUSIONS: Measurement of CCT is valuable for prognostic assessment of glaucoma, but not for correction factors for corneal thickness.

[Bilateral panuveitis with papillary swelling]. / Beidseitige Panuveitis mit Papillenschwellung.

Lues (syphilis) is a chronic cyclic infectious disease which can continue for decades if untreated. A simultaneous HIV infection can result in false negative results in serological tests for lues. The occurrence of neurolues has frequently been described in HIV positive patients. In the differential diagnosis an early ocular manifestion of lues should be considered. A 40-year-old homosexual patient presented in our hospital with bilateral pain-free increasing loss of vision. The ophthalmological examination revealed an intermediately expressed panuveitis with streaky opacity of the vitreous body and pronounced bilateral papillary swelling. Following systemic anti-inflammatory therapy with cortisone the situation worsened after initial improvement. The serological investigations revealed both HIV and lues infections. Intravenous therapy with mega units of penicillin led to a slow improvement of clinical symptoms and also vision. In cases of uveitis of unclear origin together with a HIV infection and suspected lues, regular serological testing should be carried out because the occurrence of late complications of lues can be avoided by the diagnosis of lues and adequate treatment.

Changes of extracellular matrix of the cornea in diabetes mellitus.

PURPOSE: Differences in corneal viscoelasticity due to diabetes have been reported to have a protective effect on the progression of glaucoma and the development and progression of keratoconus. Due to longterm changes of tissue in diabetes mellitus, biomechanical changes of the cornea because of glycation and modified extracellular matrix may be detectable. The purpose of the study was to determine whether there is a difference in corneal biomechanical properties, characterized by corneal hysteresis (CH) and central corneal thickness (CCT), between diabetic and normal subjects, and relate these to the duration of diabetes. METHOD: In a cross sectional study, a group of 484 eyes including 99 eyes of diabetic individuals was evaluated. CH as measured with the Ocular Response Analyzer, CCT (Orbscan II), Goldmann applanation tonometry (GAT) and slit-lamp examination were obtained from each patient. Linear mixed models were applied for statistical evaluation. RESULTS: CH showed a significant decrease with age (-0.036 mmHg/year, p < 0.01) while CCT increased significantly (+0.7 microm/year, p < 0.001). CH was significantly higher in diabetic eyes with an average difference of +0.55 mmHg (after correcting for age, IOP and CCT). This was not related to the duration of diabetes (mean 12.6 +/- 9.0y, p = 0.522). CCT did not differ with regard to diabetes. Intraclass correlation coefficients were 81% and 50% for CCT and CH respectively. CONCLUSION: CH is assumed to be an indicator for acquired changes of tissue such as diabetes-mediated. CCT is a more characteristic parameter for the individual patient. CH may provide more information about changes of the extracellular matrix in diabetes, and therefore offer a new monitoring parameter.

[Resolution of idiopathic macular holes after cryocoagulation of the vitreous base]. / Verschluss idiopathischer Makulaforamina nach Kryokoagulation der Glaskörperbasis.

BACKGROUND: There are only few reports on the spontaneous resolution of idiopathic macular holes. We report on 9 cases of resolution of idiopathic macular holes after cryocoagulation of the vitreous base. METHODS: We analyzed retrospectively 9 / 201 patients from 2005 - 2007, who were planned for a vitrectomy including peeling of the inner limiting membrane (ILM) due to an idiopathic macular hole. Each patient underwent cryocoagulation of the vitreous base 4 weeks ahead of the planned vitrectomy. At the first visit and the visit after cryocoagulation immediately before PPV was scheduled a complete clinical exam including OCT was performed. RESULTS: In all 9 cases macular hole had resolved within an average of 30 days after cryocoagulation. In 4 of these patients focal vitreoretinal adherences in the macula were detected in OCT before cryocoagulation was performed. These adhences had resolved after cryocoagulation. In 3 of these patients the posterior vitreous seemed still to adhere even after resolution of the macular hole after cryocoagulation. In 2 of these patients vitreous detachment seemed to have taken place before cryocoagulation as shown in the OCT scans, postoperatively an additional vitreous floater was detected by OCT so that a preoperative posterior vitreoschisis is assumed. CONCLUSION: Spontaneous resolution of idiopathic macular holes is very rare. After induction of vitreous detachment by cryocoagulation of the vitreous base, resolution of the macular hole seems to be more frequent. However, we do not recommend to delay vitrectomy due to a macular hole after cryocoagulation.

[Measurement of viscoelastic corneal parameters (corneal hysteresis) in patients with primary open angle glaucoma]. / Bestimmung viskoelastischer Hornhauteigenschaften (korneale Hysterese) bei Patienten mit primärem Offenwinkelglaukom.

BACKGROUND: The ocular response analyzer (ORA) uses an air-pressure-triggered, dynamic, bi-directional corneal applanation method to measure biomechanical parameters of the cornea. Corneal hysteresis (CH) is defined as the difference in intraocular pressure recorded during inward and outward applanation. CH is therefore an indicator for the viscoelastic properties of the cornea. PATIENTS AND METHODS: CH was recorded in non-glaucoma patients (80 eyes) as well as in patients with primary open angle glaucoma (POAG, 82 eyes). The correlation between CH and central corneal thickness (CCT) was analyzed. RESULTS: Mean CH was 10.6+/-2.2 mmHg in the non-glaucoma group and 9.3+/-2.2 mmHg in patients with POAG (p<0.01). CH and CCT showed a positive correlation in non-POAG patients, however no such correlation was found in the POAG group. CONCLUSION: Patients with POAG show an alteration of biomechanical corneal parameters with a significant decrease in corneal hysteresis. A positive correlation between CH and CCT, which was seen in the non-glaucoma group could not be detected in the POAG group.

[Methods of measuring intraocular pressure independently of central corneal thickness]. / Hornhautdickenunabhängige Methoden der Messung des Augeninnendrucks.

INTRODUCTION: Goldmann applanation tonometry (GAT) has been the gold standard for measuring intraocular pressure (IOP) for about 50 years. However, it depends on central corneal thickness (CCT) and is, therefore, prone to being incorrect. Dynamic contour tonometry (DCT) has recently been introduced to measure IOP independently of CCT; however, DCT is costly and difficult. IOP measurement using the ocular response analyzer (ORA) offers noncontact tonometry with declaration of the corneal-compensated IOP (IOPcc), which takes corneal hysteresis (CH) into account and is supposed to be independent of CCT. PATIENTS AND METHODS: Using the ORA instrument, IOPcc was determined in 192 glaucoma eyes and 59 nonglaucoma eyes. Subsequently, measurement by DCT and GAT was performed. IOP measurements were compared and analyzed with respect to CCT and CH. RESULTS: Average values were as follows: IOPcc, 18.38+/-6.3 mmHg; GAT, 14.69+/-4.5 mmHg; DCT, 15.17+/-3.9 mmHg; CH, 9.96+/-2.5 mmHg; CCT, 552+/-57 mum. Neither CCT nor CH differed between the two groups. There was a positive correlation between GAT and CCT that did not exist for IOPcc and DCT values. However, IOPcc and DCT differed significantly in Bland-Altman analysis (p<0.01). Furthermore, these two IOP values differed significantly with respect to CH and the level of IOP. CONCLUSION: Because IOPcc is not a primarily measured variable but also takes CH into account, a direct comparison of DCT and IOPcc values is not acceptable, and a simple correction factor may not be valid.

[The effect of cataract and vitreoretinal surgery on central corneal thickness and corneal hysteresis]. / Einfluss der Katarakt- und Glaskörperchirurgie auf die Hornhautdicke und die Corneale Hysterese.

INTRODUCTION: Intraocular irrigating solutions remain for several hours beyond the actual time of surgery in the eye. The irrigating solution ought to resemble biochemically aqueous humor and vitreous and offer protection for sensitive structures of the eye, such as the corneal endothelium. Impairment of the corneal endothelium may lead to corneal oedema and biomechanical alterations of the cornea. PATIENTS AND METHODS: 54 eyes after pars-plana vitrectomy (PPV) in elective macular surgery were evaluated by measuring corneal thickness (CCT) using ultrasound pachymetry (20 MHz) and corneal hysteresis (CH) using the ocular response analyser (Reichert Ophthalmic Instruments, Buffalo, NY, USA). Measurements were performed not earlier than 2 weeks prior to surgery and 1 to 3 days after surgery. Results were compared to a control group (n = 39) and to 101 eyes after clear cornea cataract extraction (KAT). RESULTS: The two groups (PPV and KAT) did not differ with respect to age (p = 0.555). Corneal thickness has increased significantly in both groups (p

[The influence of corneal hysteresis and corneal resistance factor on the measurement of intraocular pressure]. / Der Einfluss von kornealer Hysterese und kornealem Resistenzfaktor auf die Messung des intraokularen Drucks.

BACKGROUND: The influence of central corneal thickness (CCT) on the measurement of intraocular pressure (IOP) has been discussed extensively in recent years. The problem, however, has not been solved so far. In addition to CCT there are probably further biomechanical properties that play a role in IOP measurement. We wanted to find out whether these properties are related to Goldmann applanation tonometry (GAT), noncontact tonometry (NCT), or CCT. MATERIAL AND METHODS: Biomechanical properties of the cornea such as corneal hysteresis (CH) and corneal resistance factor (CRF) can be measured with the Ocular Response Analyzer (ORA, Reichert Ophthalmic Instruments, Depew, NY, USA). Furthermore, a corneal compensated IOP (IOPcc) is given. We examined 156 normal eyes of 80 patients who did not show corneal pathology nor glaucoma. In each eye GAT, NCT, and ORA data as well as CCT were measured. Data were statistically analyzed with respect to agreement and the influence of CH and CRF on IOP measurement. RESULTS: In our patients the following average values were calculated: GAT 14.8+/-3.0 mmHg, NCT 16.4+/-3.9 mmHg, IOPcc 16.2+/-4.1 mmHg, CH 10.6+/-2.3 mmHg, CRF 10.9+/-2.4 mmHg, and CCT 557+/-36 microm. IOPcc was not related to CCT in normal eyes and the only IOP value related to CH (p<0.01). CRF, however, was related to GAT and NCT values (p<0.01). DISCUSSION: In our group of normal eyes IOPcc, i.e., the value that is adjusted by measurement of viscoelastic properties of the cornea, in contrast to GAT and NCT does not depend on central corneal thickness. Corneal hysteresis and corneal resistance factor provide further information about biomechanical properties of the cornea beyond central corneal thickness.

[Rate of reopening of macular holes following cataract operation]. / Wiedereröffnungsrate von Makulaforamina nach Kataraktoperation.

BACKGROUND: We set up this retrospective study to examine how different the functional and morphological results are following pars plana vitrectomy (ppV) for idiopathic macular holes in phakic eyes with later cataract surgery and in pseudophakic eyes, and to what extent cataract surgery can induce reopening of idiopathic macular holes after ppV. METHODS: A total of 189 eyes were vitrectomized because of idiopathic macular hole (37 pseudophakic, 152 phakic); 120 (22 pseudophakic, 98 phakic) of these eyes were examined at follow-up of an average of 19 months after vitrectomy. Cataract surgery was performed in 65 of the phakic eyes in this period. The functional and morphological results recorded for these 22 pseudophakic and 65 phakic eyes were evaluated. RESULTS: In the pseudophakic eyes preoperative visual acuity was 0.14, increasing to 0.20 postoperatively (p=0.16); in 1 case (4.5%) the macular hole was not closed at the time of the follow-up examination. Cataract extraction was performed in 65 of the phakic eyes an average of 10 months after ppV. The initial VA was 0.19 before ppV and increased to 0.37 (p<0.01) after cataract surgery; in 4 cases (6.2%) the macular hole was not closed by the time of the follow-up examination, but in each case this had already been noted when the cataract extraction was done. Reopening did not occur after cataract extraction in any of these cases. CONCLUSION: With a rate of 5.7% for reopening or persistence of macular holes, our results are comparable to those recorded in other studies. Cataract surgery following ppV does not influence the reopening rate of macular holes.

[Bilateral serous detachment of the neurosensory retina and retinal pigment epithelium with rip of the peripheral pigment epithelium]. / Bilaterale seröse Abhebung der neurosensorischen Retina und des retinalen Pigmentepithels mit Riss des peripheren Pigmentepithels.

HISTORY: A 52-year-old patient with atypical plasmocytoma presented with a bilateral serous detachment of the retina as well as a huge detachment of the pigment epithelium (PE) in the periphery. Shortly thereafter the PE ruptured. In the left eye this led to substantial central macular fibrosis. DIAGNOSIS: The clinically healthy patient showed a nephrotic syndrome; neither typical monoclonality was detectable nor was erythropoiesis or myelopoiesis reduced. THERAPY: To avoid further reduction of VA pars plana vitrectomy (ppV) with silicone oil tamponade and laser coagulation was performed. Clinical findings were reduced significantly and VA was stabilized for 2.5 years. DISCUSSION: PE detachments and serous retinal detachments in patients with nephrotic syndrome are only mentioned in a few cases. However, a peripheral rupture of the PE to this extent seems to be very rare. Early ppV with silicone oil and laser coagulation may prevent further macular fibrosis.

[Intraocular pressure and corneal thickness. A comparison between non-contact tonometry and applanation tonometry]. / Augeninnendruck und Hornhautdicke. Ein Vergleich zwischen Non-Contact-Tonometrie und Applanationstonometrie.

OBJECTIVE: Corneal thickness and deformation seem to have a considerable influence on intraocular pressure measurement. Due to differences in the corneal deformation in either non-contact tonometry or applanation tonometry, both methods should be compared in the same patient group depending on central corneal thickness. METHODS: In 106 eyes of 55 patients (18 males, 37 females, age 17-89 years, mean 63.3 years) with glaucoma and central corneal thickness between 409 and 644 microm (Orbscan II pachymetry) intraocular pressure was measured in each eye with non-contact tonometry (Reichert AT550) and 30 min later with Goldman applanation tonometry. RESULT: Non-contact tonometry as well as applanation tonometry showed a positive correlation between measured intraocular pressure and corneal thickness. The steepness of the line of regression was 0.33 mmHg per 10 microm of corneal thickness in non-contact tonometry and 0.17 mmHg per 10 microm of corneal thickness in applanation tonometry. CONCLUSION: Independently of the large differences in individual pressure measurements between non-contact tonometry and applanation tonometry, we found higher IOP values with non-contact tonometry in thicker corneas as compared with applanation tonometry. In thinner corneas there was a better correspondence between both methods. Thus, it seems very likely that corneal rigidity increases with corneal thickness.

[Theoretical basis of goldmann applanation tonometry]. / Grundlagen der Applanationstonometrie.

For more than 50 years Goldmann applanation tonometry has been the internationally accepted method for measuring intraocular pressure. In Goldmann applanation tonometry, however, some basic physical properties are oversimplified and the method has some flaws and restrictions. This paper is intended to promote the understanding of the methodological basis of Goldmann applanation tonometry and describes the most important factors influencing the measurement of intraocular pressure (e. g., corneal thickness, corneal radius, axial length and corneal morphology). Furthermore, the basic principles of other commonly used tonometer devices will be discussed. New developments are anticipated that will measure the true intraocular pressure more accurately than Goldmann applanation tonometry.

[Corneal pachymetry and intraocular pressure]. / Hornhaut-Pachymetrie und Augeninnendruck.

Just recently studies on glaucoma have emphasised the significance of intraocular pressure in the diagnosis of glaucoma and the importance of intraocular pressure reduction in the management of glaucoma. Central corneal thickness appears to play an important role in the exact measurement of intraocular pressure and in the diagnostic assessment of glaucoma. Numerous studies have verified that corneal thickness shows systematic differences in different forms of glaucoma. Since deviations of corneal thickness from normal can possibly result in an artificial change of Goldmann applanation values, it would be a most important source of error in the diagnosis of glaucoma to ignore central corneal thickness. Corrections of intraocular pressure measured with applanation tonometry can be achieved in various ways but there is considerable divergence in the results. The absence of a generally accepted algorithm for the correction of intraocular pressure measured with applanation tonometry should not prevent us from a wide application of pachymetry, since it delivers valuable additional information on the individual risk of glaucoma.

[Analysis of optical parameters after cataract surgery and implantation of foldable lens]. / Analyse der optisch wirksamen Parameter nach Kataraktoperation mit Faltlinsenimplantation.

PURPOSE: Within the first few weeks after cataract surgery, changes of refraction can occur in patients with "clear cornea" surgery and implantation of foldable lenses. The possible reasons were analyzed. METHOD: In 71 consecutive patients we determined axial length, anterior chamber depth, corneal refraction, and corneal thickness prior to cataract surgery, on the 1st postoperative day, and at a follow-up control after obtaining stable refraction. We divided the patients into three groups: patients with no change of refraction between the 1st postoperative day and the follow-up (group A), patients with hyperopic shift of refraction (group B), and patients with myopic shift of refraction (group C). RESULTS: In all three groups we measured no significant postoperative change of the axial length. Central corneal thickness increased by approximately 37 microm on the 1st postoperative day and had normalized at the time of control. Anterior chamber depth decreased in all groups by approximately 0.44 mm between the 1st postoperative day and the follow-up. Central corneal refraction showed an decrease in groups B and C and an increase in group A. The standard deviation was very high in all groups. CONCLUSIONS: The postoperative change of refraction depends on multiple factors among which changes of the anterior chamber depths, the corneal refraction, the swelling of the cornea, and the axial length can play a role.

[Anatomical and functional results after elective macular surgery]. / Anatomische und funktionelle Ergebnisse nach elektiver Makulachirurgie.

PURPOSE: The purpose of this paper is to assess the anatomical and functional results after macular surgery in a large group of patients. METHODS: Between June 1995 and December 2001, 381 eyes underwent vitreous surgery for macular pucker (n=244) or macular holes (n=137) with a standard pars plana vitrectomy (PPV) with induction of posterior vitreous separation, membrane peeling, peeling of the internal limiting membrane (no ICG staining was used), and gas instillation (SF(6)). RESULTS: A second surgical intervention due to vision-threatening complications after PPV had to be performed in 8 of 381=2.1%. In the macular pucker group, metamorphopsias improved in 46.6% and the median of visual acuity (VA) improved from preoperative 0.3 to postoperative 0.5. Hole closure of macular holes was obtained in 92.2%; the median of VA improved in this group from preoperative 0.2 to postoperative 0.4. CONCLUSION: In our group a second vitreoretinal procedure due to vision-threatening complications had to be performed in 2.1%. Compared to the spontaneous course, PPV for macular pucker or macular hole has a very positive influence on functional parameters.

[Individual postoperative refraction after cataract surgery -- a comparison of optical and acoustical biometry]. / Individuelle Vorhersagbarkeit der postoperativen Refraktion nach Kataraktchirurgie -- ein Vegleich von optischer und akustischer Biometrie.

BACKGROUND: Optical biometry with the IOL-Master is an innovative technique that claims to improve the refractive results of cataract surgery compared to acoustical biometry. METHODS: In 140 consecutive non-selected eyes prior to cataract surgery firstly an optical biometry (IOL-Master, Zeiss, V.2.02) and secondly an ultrasound biometry (Sonomed) were carried out. Cataract surgery was performed using either a PMMA-IOL (n = 56) or an acrylic IOL (n = 84). The PMMA-IOL's were implanted in the capsular bag via a scleral tunnel. The acrylic-IOL's were implanted via a clear cornea incision in the capsular bag. The length of the globe was analysed and the deviations between the postoperative refraction after 3 month and the preoperative planned refraction were compared. RESULTS: The mean axial length difference between optical biometry and acoustical biometry was 0.19 mm in the PMMA-lens group and 0.16 mm in the acrylic-lens group. The deviation of postoperative refraction (spherical mean) from the planned refraction was 0.46 +/- 0.88 D in the PMMA-IOL group and 0.25 +/- 0.77 D in the acrylic IOL group when biometry was performed by ultrasonography. When optical biometry was performed the respective values were 1.15 +/- 0.83 D in the PMMA-IOL group and 0.84 +/- 0.75 D in the acrylic IOL group. The differences in mean postoperative refraction of optical and acoustical biometry can be compensated by adaptation of the A constants. The standard deviation of the difference between the postoperative refraction and the preoperatively planned refraction - that means the individual deviations between postoperative refraction and preoperatively planned refraction - were almost identical in optical and acoustical biometry. CONCLUSION: Optical biometry represents a significant simplification in the course of investigation prior to cataract surgery. The claim of optical biometry, however, to gain a higher precision and thus a significantly better prediction of individual postoperative refraction after cataract surgery is not yet fulfilled.