[Corneal refractive surgery despite systemic diseases?] / Refraktive Hornhautchirurgie trotz systemischer Erkrankungen?

According to the literature there are a large number of potential systemic contraindications for corneal refractive surgery. In cases with relative contraindications, surgery should be performed only after weighing up the individual risks and under controlled disease conditions; however, the "evidence" for many of these contraindications is based only on case reports or series, expert opinions or known complications in non-laser-assisted eye surgery. Randomized clinical trials are therefore required.

[Picosecond infrared laser fiber-assisted sclerostomy (PIRL-FAST) : A first proof of principle analysis]. / Pikosekundenlaser-Faser-assistierte Sklerostomie (PIRL-FAST) : Ein erster Machbarkeitsnachweis.

INTRODUCTION: The aim of this study was an analysis of the feasibility of a picosecond infrared laser fiber-assisted sclerostomy (PIRL-FAST) using a novel sapphire fiber and different energy levels of the picosecond laser. METHOD: The laser-assisted sclerostomy was carried out with a newly generated sapphire fiber of the PIRL-HP2-1064 OPA-3000 (Attodyne, Canada). Immediately after the intervention, the eyes were fixed in phosphate-buffered 3.5% formaldehyde. For subsequent histological analysis the eyes were cut into 4 µm thick sections and stained with hematoxylin and eosin (H&E, Merck, Darmstadt, Germany). All preparations were then scanned and digitalized using the MIRAX SCAN (Carl Zeiss Microimaging GmbH, Jena, Germany). RESULTS: The pulse energies 150 µJ (N = 4), 175 µJ (N = 6), 200 µJ (N = 7) and 250 µJ (N = 6) were selected. Within the framework of this first feasibility analysis 400 µm (10 sequential sections) of the sclerotomies were evaluated. The mean area of PIRL-FAST showed a dependency on the pulse energy applied. The diameter of the collateral damage zone (CDZ) depended on the pulse energy used. The largest CDZ could be measured using the highest pulse energy in this experiment (250 µJ). The environmental scanning electron microscope (ESEM) results revealed circular smooth sclerostomy wall with only minimal change of tissue ultrastructure. CONCLUSION: The PIRL-FAST using sapphire fibers is a new minimally invasive instrument to provide robust stenting from the anterior chamber to the subconjunctival space. Since the PIRL has proven to work efficiently in sectioning several tissues with minimal collateral damage these first proof of principle experiments might pave the way for a new minimally invasive glaucoma surgery strategy. We have already initiated experiments to analyze the wound healing and scar formation in vivo.

'I'm not a real boozer': a qualitative study of primary care patients' views on drinking and its consequences.

BACKGROUND: The public health message around alcohol is complex, with benefits versus harms, the confusing concept of risk and drinking guidance changing over time. This provides a difficult context for alcohol screening in primary care, with established barriers from the practitioner perspective, but less is known about the patients' perspective. This study explores patients' views on drinking. METHODS: Eligible participants were recorded as drinking above low risk levels in primary care. Six practices in North London participated. Interviews were in-depth, semi-structured, transcribed verbatim and underwent detailed thematic analysis. FINDINGS: Interviews were conducted with 8 women and 12 men, aged 26-83 years, mostly educated to undergraduate level and of 'White' ethnicity. UK drinking guidance was viewed as irrelevant for reasons related to life stage, lifestyle and absence of harm. Dependence, loss of functionality and control were perceived as key features of problematic drinking. Healthy lifestyles, in terms of diet, exercise and not smoking, were thought to mitigate potential problems associated with alcohol intake. CONCLUSION: The findings suggest that public health messages and brief advice should focus on harm experienced at different life stages, among people with different lifestyles, to challenge the ubiquitous view that 'I'm not a real boozer'.

The Impact of Alcohol Use on Drop-out and Psychological Treatment Outcomes in Improving Access to Psychological Therapies Services: an Audit.

BACKGROUND: The impact of alcohol use disorders (AUD) on psychological treatments for depression or anxiety in primary care psychological treatment services is unknown. AIMS: To establish levels of alcohol misuse in an Improving Access to Psychological Therapies (IAPT) service, examine the impact of higher risk drinking on IAPT treatment outcomes and drop-out, and to inform good practice in working with alcohol misuse in IAPT services. METHOD: 3643 patients completed a brief questionnaire on alcohol use pre-treatment in addition to measures of depression, anxiety and functioning. Symptom and functioning measures were re-administered at all treatment sessions. RESULTS: Severity of alcohol misuse was not associated with treatment outcomes, although those scoring eight or more on the AUDIT-C were more likely to drop out from treatment. CONCLUSIONS: IAPT services may be well placed to offer psychological therapies to patients with common mental disorders and comorbid AUD. Patients with AUD can have equivalent treatment outcomes to those without AUD, but some higher risk drinkers may find accessing IAPT treatment more difficult as they are more likely to drop out. Alcohol misuse on its own should not be used as an exclusion criterion from IAPT services. Recommendations are given as to how clinicians can: adjust their assessments to consider the appropriateness of IAPT treatment for patients that misuse alcohol, consider the potential impact of alcohol misuse on treatment, and improve engagement in treatment for higher risk drinkers.

[Multifocal intraocular lens (MIOL) surgery in young non-presbyopic ametropes : Reasonable and safe?] / Multifokale Intraokularlinsen (MIOL) bei jungen, nicht-presbyopen Patienten : Sinnvoll und sicher?

BACKGROUND: Refractive lens exchange and implantation of a multifocal intraocular lens (MIOL) is mainly advised for ametropes with presbyopia. Non-presbyopic young ametropes who wish spectacle-independence are usually treated with corneal refractive surgery or phakic lenses. OBJECTIVES: This retrospective case series aimed to analyse the refractive and subjective satisfaction outcome after MIOL surgery in both eyes of non-presbyopic ametropes where other treatment options were not possible. MATERIALS AND METHODS: This retrospective case series comprised consecutively treated 32 eyes of 16 patients (5 myopic, 11 hyperopic patients; mean age 31 ± 6 years) who wished spectacle-independence and thus received an aspheric bifocal biconvex refractive-diffractive single-piece MIOL (Acri.Lisa 366/809, Carl Zeiss Meditec AG). Refractive data prior to and after surgery as well as subjective satisfaction at the 1­year follow-up examination were assessed. RESULTS: Related to distance corrected near visual acuity myopic eyes had a median efficacy index (EI) of 0.92 (±0.20) and hyperopes of 0.91 (±0.12) (P = 0.415). For intermediate vision, in both groups a lower EI (<0.5; P = 0.188) resulted in lower subjective satisfaction, which was higher for near and distance vision. Some of hyperopic patients reported limitations in near and distance vision, only one hyperopic patient would not have chosen this surgery again. None had a related complication during the follow-up. CONCLUSIONS: When neither laser refractive surgery nor implantation of a phakic lens is possible, young non-presbyopic ametropes do profit from MIOL surgery with an aspheric bifocal biconvex refractive-diffractive MIOL.

The relationships among physical activity, sedentary behaviour, obesity and quitting behaviours within a cohort of smokers in California.

BACKGROUND: Smoking, insufficient physical activity (PA), sedentary behaviour (SB) and obesity are leading risk factors for morbidity and premature mortality. Few studies examining the relationship between these behavioural risk factors and quitting behaviours among cohorts of smokers have been published. PURPOSE: The goals of this study are to examine the cross-sectional relationships among behavioural health risk factors (insufficient PA, SB and obesity) and past year quitting behaviours within a sample of smokers. METHODS: The California Smokers Cohort, conducted from 2011 through 2013, is a population-based survey of adult smokers in California. Using follow-up data (n = 1050), participants' self-reported health behaviours and past year quitting behaviours were examined in univariate analyses and multivariate logistic regression analyses controlling for demographic covariates. RESULTS: In univariate analyses examining health behaviours among smokers, all three health behaviours examined (PA, SB and obesity) were related, and significantly more obese smokers with high PA and low SB reported a ≥20% smoking rate reduction than smokers with other combinations of health behaviours (48.8%, Chi-squared = 4.765, P = 0.045). In multivariate models adjusted for sociodemographic characteristics, obese smokers (odds ratio [OR] = 1.450, 95% confidence interval [CI]: 1.088-1.932, P = 0.011) and smokers with higher levels of PA (OR = 1.448, 95% CI: 1.111-1.887, P = 0.006) were more likely to report a past year ≥24-hour quit attempt regardless of SB, and obese smokers (OR = 1.760, 95% CI: 1.095-2.828, P = 0.019) were more likely to report being quit for ≥30 days regardless of PA and SB. CONCLUSIONS: Overall, the results demonstrated that more physically active and obese smokers were more likely to report positive strides towards quitting. These findings support the potential positive effect of addressing multiple health behaviours along with smoking.

Recurrence rate and subjective symptoms after standardized (Hamburg protocol) phototherapeutic keratectomy on recurrent corneal erosions.

PURPOSE: To evaluate the objective and subjective outcome after phototherapeutic keratectomy (PTK) on recurrent corneal erosions (Hamburg protocol). METHODS: For the standardized PTK according to Hamburg protocol a manual abrasio corneae performed with 20 % alcohol is followed by an excimer ablation depth of ≥15 µm (group1 15 µm; group 2 > 15 µm ablation depth) and 7 mm optical zone. All patients (N = 48) were invited for follow-up examinations and the evaluation of changes concerning subjective symptoms. RESULTS: A significantly reduced subjective impairment of night vision, significantly less pain and less foreign body sensations (for all p < 0.05) were noted in 48 patients that met the inclusion criteria (26 women, 22 men). In the follow-up period an improvement of corrected distance visual acuities (cdva) from 0.80 to 1.08 (group 1) and from 0.58 to 0.99 (group 2) was demonstrated. CONCLUSION: PTK (Hamburg Schema) is a safe and effective procedure to reduce subjective symptoms and improve discomfort in recurrent corneal erosion.

[Unilateral Solar Maculopathy after Gazing at Solar Eclipse]. / Einseitige solare Makulopathie nach Sonnenfinsternis.

A 43-year-old male patient with unilateral metamorphosia presented after gazing at an eclipse with only one eye. Damage of the macula was demonstrated funduscopically, with OCT and angiography. Six weeks after initial presentation and oral methylprednisolone therapy (40 mg/d for 10 days), the symptoms and the morphological changes decreased. Solar retinopathy is a photochemical alteration of the retina, usually seen after sun gazing. In younger patients, it mostly presents as bilateral solar maculopathy. Some patients exhibit partial or total recovery.

[Corneal biomechanics: Corvis® ST parameters after LASIK]. / Korneale Biomechanik : Corvis® ST-Parameter nach Laser-in-situ-Keratomileusis.

BACKGROUND: Corneal refractive surgery alters the biomechanical properties of the cornea. OBJECTIVES: This study was initiated to evaluate corneal biomechanical parameters after LASIK using a Corvis® ST tonometer (CST). METHODS: This retrospective study included 51 eyes of 32 myopic patients. All CST measurements were performed 1 day before surgery and at the 1-month follow-up examination. The LASIK procedure included mechanical flap preparation using a Moria SBK microkeratome and an Allegretto excimer laser platform. RESULTS: Statistically significant differences were observed for mean second applanation length, mean first and second deflection lengths, mean first and second deflection amplitudes, peak distance and radius of curvature. Statistically significant positive correlations were found between the change (Δ) in radius of curvature and Δ in manifest refraction spherical equivalent (MRSE), between the ablation depth and the Δ in intraocular pressure. Applying multiple regression models also revealed statistically significant differences in parameters obtained by CST measurements. CONCLUSION: Several CST parameters were statistically significantly altered by LASIK thereby indicating that flap creation, ablation or both, significantly change the ability of the cornea to absorb or dissipate energy.

Intravenous lidocaine increases the depth of anaesthesia of propofol for skin incision--a randomised controlled trial.

BACKGROUND: The anaesthetic potency of intravenous propofol is quantified by its Cp50 value, which is defined as the plasma concentration required to prevent movement response in 50% of patients to surgical stimuli. We hypothesised that, in addition to propofol anaesthesia, an intravenous bolus of lidocaine 1.5 mg/kg will decrease the Cp50 value of propofol during anaesthesia. METHODS: We enrolled 54 elective surgical patients undergoing propofol-based anaesthesia, and randomised them to either lidocaine 1.5 mg/kg, lidocaine 0.5 mg/kg or placebo (NaCl 0.9%) 3 min before skin incision. The propofol Cp50 value was then calculated using the 'up-and-down' method of Dixon and Massey. RESULTS: There was no significant reduction in propofol requirements after the administration of 0.5 mg/kg lidocaine from 8.5 µg/ml [confidence interval (CI) 6.0-11.625] to 8.25 µg/ml (CI 6.75-9.76); however, a bolus of 1.5 mg/kg lidocaine decreased the Cp50 value of propofol by 42% from 8.5 µg/ml (CI 6.0-11.625) to 4.92 µg/ml (CI 4.5-5.78) (P < 0.05). CONCLUSION: An intravenous bolus injection of 1.5 mg/kg lidocaine 2% caused a significant reduction of the propofol Cp50 value.

[Pachymetry and intraocular pressure measurement by corneal visualization Scheimpflug technology (Corvis ST): A clinical comparison to the gold standard]. / Pachymetrie und Augeninnendruckmessung mittels Corneal-Visualization-Scheimpflug-Technologie (Corvis ST) : Ein klinischer Vergleich zum Goldstandard.

BACKGROUND: Analyses regarding accuracy and reproducibility of intraocular pressure (IOP) measurements and pachymetry with corneal visualization Scheimpflug technology (Corvis ST®, CST). MATERIAL UND METHODS: Retrospective analysis of 72 eyes with primary open angle glaucoma (POAG) and ocular hypertension (OHT) with no prior surgery or other pathology. The results of Goldmann applanation tonometry (GAT), non-contact tonometry (NCT) and ultrasound pachymetry (USP) were compared with repeat measurements with CST. For statistical analyses the t-test and Bland-Altman plots were applied. RESULTS: The mean IOP was 15.5 ± 4.4 mmHg (CST), 14.8 ± 4.4 mmHg (GAT) and 15.6 ± 4.8 mmHg (NCT). The results of GAT and CST as well as GAT and NCT demonstrated statistically significant differences (p < 0.001) whereas NCT and CST displayed no significant differences in IOP (p = 0.72). The mean differences between the repeat measurements were 0.35 ± 1.7 mmHg (CST) and 0.04 ± 0.85 mmHg (GAT). The mean CST pachymetry results showed 551.3 ± 46.5 µm and the USP 526.5 ± 46.4 µm (p < 0.001). The mean difference between the repeated CST measurements was 24.8 ± 21 µm. No repeat measurement data were available for USP. CONCLUSION: The CST is a new device for simultaneously measuring the IOP, pachymetry and biomechanical properties of the cornea. Whether the deviations in the IOP measured by CST and CST pachymetry from the manually performed gold standard has to be evaluated as deficient, tolerable or maybe as an improvement, has to be evaluated in further studies. Because of the automated and contact-free measurement method as well as the potential for simultaneously analyzing biomechanical properties of the cornea, the CST is a device that might help the quest for measuring the 'true' IOP.

[Perspectives of laser-assisted keratoplasty: current overview and first preliminary results with the picosecond infrared laser (λ = 3 µm)]. / Perspektiven der laserassistierten Keratoplastik: Eine aktuelle Übersicht und erste experimentelle Erfahrungen mit dem Pikosekundeninfrarotlaser (λ = 3 µm).

BACKGROUND: This article provides a review of the current state of laser-assisted keratoplasty and describes a first proof of concept study to test the feasibility of a new mid-infrared (MIR) picosecond laser to perform applanation-free corneal trephination. METHODS: The procedure is based on a specially adapted laser system (PIRL-HP2-1064 OPA-3000, Attodyne, Canada) which works with a wavelength of 3,000 ± 90 nm, a pulse duration of 300 ps and a repetition rate of 1 kHz. The picosecond infrared laser (PIRL) beam is delivered to the sample by a custom-made optics system with an implemented scanning mechanism. Corneal specimens were mounted on an artificial anterior chamber and subsequent trephination was performed with the PIRL under stable intraocular pressure conditions. RESULTS: A defined corneal ablation pattern, e.g. circular, linear, rectangular or disc-shaped, can be selected and its specific dimensions are defined by the user. Circular and linear ablation patterns were employed for the incisions in this study. Linear and circular penetrating PIRL incisions were examined by macroscopic inspection, histology, confocal microscopy and environmental scanning electron microscopy (ESEM) for characterization of the incisional quality. Using PIRL reproducible and stable incisions could be made in human and porcine corneal samples with minimal damage to the surrounding tissue. CONCLUSION: The PIRL laser radiation in the mid-infrared spectrum with a wavelength of 3 µm is exactly tuned to one of the dominant vibrational excitation bands of the water molecule, serves as an effective tool for applanation-free corneal incision and might broaden the armamentarium of corneal transplant surgery.

[Cross-linking and neurodermitis: prolonged re-epithelisation with severe corneal vascularisation after cross-linking in a patient with neurodermitis and keratoconus]. / Crosslinking bei Neurodermitis: schwerwiegende Wundheilungsstörung nach kornealem Crosslinking bei einem Patienten mit Keratokonus und Neurodermitis.

This case report describes a patient with keratoconus and neurodermitis suffering from a significantly prolonged postoperative time interval to re-epithelisation after corneal cross-linking. The development of corneal calcifications and vascularisations additionally inhibited proper re-epithelisation. Therefore the patient received four subsequent subconjunctival injections of Bevacizumab and an additional keratectomy to remove the calcifications. This therapeutic scheme led to a significant reduction of corneal vascularisation and finally a full rehabilitation of the epithelium.

[Astigmatism after keratoplasty: influence of orthotopic transplantation]. / Astigmatismus nach Keratoplastik: Einfluss der übereinstimmenden Augenseite.

BACKGROUND: Patients undergoing corneal transplantation often suffer from postoperative reduced vision due to high astigmatism. This retrospective study analyzed the influence of heterotopic or orthotopic transplantation on astigmatism and visual outcome. PATIENTS AND METHODS: In this study 373 eyes of 334 patients were analyzed. Group 1 (OT) contained 186 eyes, which underwent orthotopic transplantation (side of recipient and donor corresponded), whereas group 2 (HT) included 187 heterotopic keratoplasties (donor cornea placed in the recipient's contralateral side). After 1, 3, 6, 12 and 24 months the median of keratometric astigmatism, objective astigmatism, topographic astigmatism and best corrected visual acuity (BCVA) were assessed and compared between groups. RESULTS: The long-term results showed no statistically significant differences regarding keratometric and objective astigmatism, whereas topographic astigmatism differed significantly (p = 0.04) after 3 months. We observed a lower astigmatism of 5.7 dpt (range 3.08-7.78 dpt) in group OT than in the group HT with 7.1 dpt (range 3.9-10.7 dpt). No differences were found at the other time points. The BCVA showed a significantly better effect after 1 month (p = 0.01) in the OT group of 0.2 (0.1-0.3) than in HT group of 0.1 (0.05/0.25). In the postoperative course no additional significant dissimilarities were documented. CONCLUSIONS: Heterotopic and orthotopic keratoplasty show no significant long-term differences in astigmatism and visual outcom.