Intravitreal treatment in patients with exudative age-related macular degeneration and visual acuity ≤ 0.05.

BACKGROUND: To investigate intravitreal treatment efficiencies in patients suffering from exudative ARMD with a BCVA ≤ 0.05. METHODS: Retrospective analysis: Analysis parameters were lesion type, BCVA at baseline and at follow-up, the intravitreal drug used, and its application frequency. Patients were divided into: 1) following injections of bevacizumab, triamcinolone, their combination, or ranibizumab regardless of their lesion subtype, 2) or by lesion subtype. Statistical tests were performed using Wilcoxon signed-rank tests, Kruskal-Wallis tests and multivariable logistic regressions. RESULTS: Seventy four eyes of 74 patients were analyzed. Follow-up was at 12.0 to 15.7 weeks. Median difference of BCVA (logMAR) between baseline and follow-up was 0.000 (-0.030, 0.175) in classic (p = 0.105), 0.000 (-1.15, 0.20) in occult (p = 0.005), -0.200 (-1.20, 0.60) in cases with subretinal fluid (p = 0.207), 0.000 (-0.60, 0.30) in pigment epithelial detachment (p = 0.813), and 0.050 (-0.40, 0.70) in Junius Kuhnt maculopathy (p = 0.344). BCVA increased ≥ 0.2 logMAR in 4 (24 %) classic, 9 (47 %) occult, 6 (33 %) pigment epithelial detachment, 6 (55 %) subretinal fluid, in 29 (39 %) eyes regardless of the lesion type, and reached a BCVA ≥ 0.05 in 7 (9 %) of those with a baseline BCVA <0.05. CONCLUSIONS: Results indicate that in patients with ARMD and a BCVA lower 0.05, intravitreal treatment may improve visual acuity, most probably in cases with occult lesions.

Pterygium recurrence, astigmatism and visual acuity following bare-sclera excision and conjunctival autograft with or without additional phototherapeutic keratectomy.

BACKGROUND: Treatment outcome in patients with pterygium following bare-sclera excision and conjunctival autograft (CAG) with and without phototherapeutic keratectomy (PTK). METHODS: Retrospective comparative analysis of 81 eyes, with primary and recurrent pterygia, that were analyzed for recurrence, best-corrected visual acuity (BCVA) and astigmatism in primary (P1 without PTK, P2 with PTK) and recurrent pterygia (R1 without PTK, R2 with PTK). BCVA and astigmatism were compared in patients with simple CAG alone (group I) or in combination with PTK (group II). RESULTS: Recurrence rates were 4.7, 11.6, 16.2, 23.2 and 32.5% at 3, 6, 12, 24 and >24 months (P1), 7.1% at >24 months (P2). Recurrence rates were 5.3, 10.5, 21.1, 21.1 and 26.3% at 3, 6, 12, 24 and >24 months (R1) and 1 recurrence (7.7%) till month 24, and 3 (23.1%) thereafter (R2). BCVA increased from logarithm of the minimal angle of resolution 0.095 ± 0.141 (mean ± SD) at baseline to 0.066 ± 0.09 (group I), and from 0.090 ± 0.164 to 0.054 ± 0.124 (group II). Astigmatism decreased from -1.01 ± 0.90 dpt at baseline to -0.97 ± 1.24 dpt (group I), and from -1.19 ± 1.55 to -0.75 ± 0.87 dpt (group II). CONCLUSION: In comparison to CAG alone, additional excimer smoothing with PTK tends to increase BCVA and reduces recurrence rates in patients with primary pterygia.

Use of fibrin glue in fixation of amniotic membranes in sterile corneal ulceration.

PURPOSE: To describe a method of fibrin glue fixation of single or multilayered amniotic membranes in sterile corneal ulceration. DESIGN: A modified microsurgical procedure. METHODS: The corneal ulcer is cleaned and the components of fibrin glue are applied separately. Amniotic membranes are rotated through the fibrinogen component and subsequently into the site of the ulceration where thrombin is already applied. An overlay membrane is sutured additionally on top. The results for one patient are illustrated as an example. RESULTS: The application technique prevents development of foam and leads to a thin fibrin film, which minimizes any irregularities of the fixed membranes and creates extra time to adjust the membranes' position. CONCLUSIONS: This method presents as an effective procedure for the treatment of sterile corneal ulceration and creates valuable time if any elective corneal graft procedure is required.

Bilateral cataract and corectopia after laser eyebrow [corrected] epilation.

PURPOSE: To report a patient with bilateral cataract and corectopia after laser epilation of the eyebrows. DESIGN: Single interventional case report. METHODS: A 27-year-old woman with a history of bilateral eyebrow laser epilation complained of oval pupils, reduced visual acuity, and photophobia immediately after laser epilation of both upper-eyelid regions. The following examinations were performed: visual acuity, slit-lamp examination, pupillary light reflex, perimetry, tonometry, gonioscopy, and funduscopy with contact lenses. The follow-up period was 9 months. MAIN OUTCOME MEASURES: Visual acuity, intraocular pressure, inflammation, and pupillary distortion. RESULTS: Her best baseline visual acuities were 20/25 (right) and 20/40 (left). Examination showed bilateral corectopia with superior iris atrophy, iris stroma clump at the pupillary margin, and pigment residues in the inferior chamber. A cataract developed in the anterior subcapsular regions of the lenses. CONCLUSIONS: Laser epilation at the eyelid may result in irreversible cataract and iris atrophy.

Long-term efficacy of glycerine-processed amniotic membrane transplantation in patients with corneal ulcer.

PURPOSE: The aim of this study was to determine the long-term treatment efficacy of glycerine-preserved human amniotic membrane transplantation in patients suffering from corneal ulcers. METHODS: This was a retrospective, non-controlled, monocentric analysis. Included were patients with corneal ulcers that were non-responsive to ointment or contact lenses and had been treated by amniotic membrane transplantation with either the overlay or sandwich procedure. Analysis parameters were visual acuity before and following treatment, recurrence rate and subjective comfort at the last follow-up. RESULTS: Of the 371 amniotic membrane transplantations that were conducted, 135 surgical treatments in 108 patients (51.9% male, 48.1% female; mean age 63.7 years) met the inclusion criteria. In total, 99 overlay and 36 multilayer amniotic membrane transplantations were performed. The follow-up period was 47.5 ± 66.7 weeks (mean ± SD). The recurrence rate at the last follow-up was 47.8% with overlay membranes and 51.8% with the sandwich technique. There was no significant change in best-corrected visual acuity following treatment with overlays (p = 0.219) or sandwich procedure (p = 0.703). At the last follow-up, 72.1% (overlay) and 78.3% (sandwich) of the patients reported either no pain or increased comfort. CONCLUSION: The recurrence rates and changes in visual acuity following overlay or sandwich amniotic membrane transplantation in patients suffering from corneal ulcer were lower than reported elsewhere in the literature. More than half of the patients profited from each of the amniotic membrane transplantation techniques with respect to recurrence and postoperative comfort.

Symptomatic cicatrizial occlusion of canaliculi after insertion of Herrick lacrimal plugs.

PURPOSE: To report severe symptomatic complications following bilateral insertion of Herrick lacrimal plugs. DESIGN: Interventional case report. METHODS: Bilateral clinical, surgical, and histologic findings in a patient with surgical revision of canaliculi after plug insertion. RESULTS: A 55-year-old patient presented with recurrent inflammation, discharge, and epiphora 24 months after insertion of lacrimal plugs; surgical intervention and partial resection of the cicatrized canaliculi was necessary. Light microscopic histology revealed canaliculi destruction, reactive tissue embedding of the plugs, and dissociated plug material. CONCLUSIONS: The application of Herrick lacrimal plugs may not be reversible and may require invasive surgical intervention.

Presurgical and postsurgical ultrasound assessment of lacrimal drainage dysfunction.

PURPOSE: In addition to the obligatory clinical tests, imaging of the lacrimal drainage system (LDS) is useful in its clinical evaluation. The purpose of this study was to examine the usability and reliability of ultrasonography in the evaluation of the lacrimal drainage system. DESIGN: Observational cohort study. METHODS: A prospective study was conducted at a single institution. We performed ultrasound examinations on 17 patients with epiphora before and after surgery, and on 17 asymptomatic volunteers, to visualize and evaluate the anatomic and functional condition or pathologic abnormalities of the LDS. RESULTS: Echographic evaluation of the LDS was possible in all individuals. Pathologic abnormalities (canaliculitis, diverticulitis, concretion, or dilation of the lacrimal sac, and reduced functionality of the orbicular muscle and/or lacrimal sac pump) could be well demonstrated. In the postsurgical course, functional patency of the dacryocystorhinostomy opening could be verified in all cases. CONCLUSIONS: Sonography of the LDS appears to represent a reliable diagnostic technique supplementary to clinical tests in the presurgical and postsurgical examination of patients with epiphora. Pathologic abnormalities that may not be apparent in routine x-ray dacryocystography can be demonstrated with ultrasound techniques. Patients also benefit from the avoidance of exposure to ionizing radiation. However, ultrasound is not suitable for imaging the lower part of the lacrimal sac and the lacrimal duct because of the presence of overlying bony structures.

Methicillin-resistant Staphylococcus aureus keratitis after excimer laser photorefractive keratectomy1.

A 43-year-old woman in good health was admitted to the hospital 3 days after photorefractive keratectomy (PRK) in the left eye with postoperative bandage contact lens application. She had developed a severe keratitis with ulceration and hypopyon. Upon the patient's admission to the hospital, the contact lens was removed. Ofloxacin eyedrops were prescribed 4 times a day. In the hospital, the patient was successfully treated with immediate thermocautery application, followed by full-thickness keratoplasty the next day and intensive systemic and topical antibiotics. Cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA). Severe MRSA keratitis is a rare cause of infection after PRK.

Examination of preschool children for ametropia: first experiences using a new hand-held autorefractor.

INTRODUCTION: Over the last decades, various methods have been investigated for preschool screening for amblyogenic ametropia. The SureSight is a new hand-held wavefront-analyzing autorefractor designed for screening. METHODS: A total of 338 children (3 1/2 - 4 1/2 years-old) were examined in their kindergartens without cycloplegia using the new instrument. Of these, 56 had a cycloplegic retinoscopy as a reference measurement. Hyperopia > or =3 dpt, myopia > or =1 dpt, astigmatism > or =1 dpt and anisometropia > or =1 dpt were considered amblyogenic ametropia. RESULTS: Testability was 99.4%. Accuracy was high for cylinder power and axis but poor for the spherical equivalent. Sensitivity was 41% for the detection of amblyogenic hyperopia, 95% for astigmatism and 75% for anisometropia, with specificity values of 92, 79 and 73%. CONCLUSION: The high testability and accuracy for cylinder power and axis are the strong points. The poor accuracy for the spherical equivalent is probably caused by the lack of cycloplegia. At present, non-cycloplegic autorefractor screening cannot be recommended due to the low specificity. Our findings support the advice that objective refraction in childhood must be performed with cycloplegia.

Efficiencies of Internet-based digital and paper-based scientific surveys and the estimated costs and time for different-sized cohorts.

AIMS: To evaluate the relative efficiencies of five Internet-based digital and three paper-based scientific surveys and to estimate the costs for different-sized cohorts. METHODS: Invitations to participate in a survey were distributed via e-mail to employees of two university hospitals (E1 and E2) and to members of a medical association (E3), as a link placed in a special text on the municipal homepage regularly read by the administrative employees of two cities (H1 and H2), and paper-based to workers at an automobile enterprise (P1) and college (P2) and senior (P3) students. The main parameters analyzed included the numbers of invited and actual participants, and the time and cost to complete the survey. Statistical analysis was descriptive, except for the Kruskal-Wallis-H-test, which was used to compare the three recruitment methods. Cost efficiencies were compared and extrapolated to different-sized cohorts. RESULTS: The ratios of completely answered questionnaires to distributed questionnaires were between 81.5% (E1) and 97.4% (P2). Between 6.4% (P1) and 57.0% (P2) of the invited participants completely answered the questionnaires. The costs per completely answered questionnaire were $0.57-$1.41 (E1-3), $1.70 and $0.80 for H1 and H2, respectively, and $3.36-$4.21 (P1-3). Based on our results, electronic surveys with 10, 20, 30, or 42 questions would be estimated to be most cost (and time) efficient if more than 101.6-225.9 (128.2-391.7), 139.8-229.2 (93.8-193.6), 165.8-230.6 (68.7-115.7), or 188.2-231.5 (44.4-72.7) participants were required, respectively. CONCLUSIONS: The study efficiency depended on the technical modalities of the survey methods and engagement of the participants. Depending on our study design, our results suggest that in similar projects that will certainly have more than two to three hundred required participants, the most efficient way of conducting a questionnaire-based survey is likely via the Internet with a digital questionnaire, specifically via a centralized e-mail.

Clinical transplantation of individualized recipient serum-adapted cornea reduces the risk of graft rejection after keratoplasty.

Corneal diseases cause severe visual impairment that necessitates corneal transplantation and frequently repetitive procedures due to graft rejection. We tested the hypothesis that exposure of donor corneas to recipient serum-derived factors during eye banking triggers a preoperative adaptation that is beneficial for postoperative tolerance. Donor corneas were incubated in a medium containing human serum (HS) obtained in each case from the prospective graft recipient in order to individually expose the donor cornea to the recipient's serum. All recipient serum-adapted corneas (RSACs) fulfilled the clinical criteria required by the national law and were transplanted successfully. The postoperative ophthalmological examination extended up to 8 years. All RSACs were tolerated by their recipients and did not cause postoperative complications and no rejection. Proteomic analysis of corneas cultivated in culture medium containing either fetal calf serum (FCS) that is routinely used for cornea banking or HS revealed different patterns of proteins. HS-cultured corneas showed a greater proteomic similarity with native human corneas than did the FCS-cultured corneas, indicating a differential nutrification of the cultured corneal tissue by HS-derived factors. The clinical results show for the first time that postoperative complications such as tissue intolerance and graft rejection might be managed if the corneal tissue is individually adapted to the recipient's serum trophic factors. This new donor tissue treatment procedure offers incontrovertible advantages and could be adapted for low-risk eyes as well as other transplantable tissues.

Development and evaluation of a device for sutureless and repeated application of amniotic membrane overlays.

PURPOSE: To develop a prototype device for sutureless and repeated ocular surface treatments with overlay amniotic membranes and to describe the main results of various prototype modifications. METHODS: In this experimental, descriptive study, various modifications of a ring-like device were designed and manufactured. The different variants were tested for comfort, local stability, and corneal contact. The final prototype was photographed during different ocular deviations and investigated at a slit lamp for the fit of the device within the fornices and the integrity of the membrane on the ocular surface. Ultrasound was performed with the final prototype to document the distance between the corneal surface and the amniotic membrane that was sutured to the device. The main outcome measures were feasibility of the device setting into the regular fornices, corneal contact of the device during different ocular deviations, comfort, and local stability during 7 days of continuous wearing. RESULTS: One prototype with five modifications was manufactured and tested. An amniotic membrane patch was sutured onto the final prototype and laid into the fornices of a human eyeball during 7 days of continuous wearing. On slit-lamp examination, the amniotic membrane always appeared attached to the complete human cornea and limbal region without macroscopically visible wrinkling. No side effects were observed. CONCLUSION: The final ellipsoid device enables sutureless and repeated treatment with amniotic membrane overlays and was comfortable in one patient during 7 days of continuous wearing. Limitations of the device such as in cicatriceal foreshortening and possible therapeutic effects need to be determined in future studies.

Treatment of basal cell carcinoma of the eyelids with 5% topical imiquimod: a 3-year follow-up study.

BACKGROUND: The aim of this study was to determine the efficacy and safety of 5% topical imiquimod, and the long-term results following its use, in the treatment of nodular basal cell carcinoma (BCC) of the eyelid. METHODS: Imiquimod cream (5%) was applied topically to five individuals affected by nodular BCC of the eyelid. The patients were followed up during the 6 weeks of treatment and for another 3 years after treatment. Local side effects and evidence of tumour regression or recurrence were noted. RESULTS: Complete clinical clearance of the tumour was obtained in four patients, with no response in the fifth patient. Therapy was typically accompanied by significant discomfort due to local side effects, which disappeared following completion of the treatment. None of these patients showed any local recurrence after 3 years. CONCLUSIONS: Topical imiquimod applied in the form of a 5% cream proved to be a safe, efficacious and sustainable treatment option for nodular BCC of the eyelid in our selected cases.

Lens epithelium supports axonal regeneration of retinal ganglion cells in a coculture model in vitro.

The purpose of this study was to determine whether the lens epithelium influences the survival or axonal growth of regenerating retinal ganglion cells. The optic nerves of adult albino rats were injured in order to induce axonal regeneration, and axon growth was then studied in retinal explants in the presence of cocultivated lens capsules carrying living epithelial cells. In the first series of experiments, cocultivation of retinal explants with lens epithelium in immediate proximity resulted in penetration of fibers into the lens epithelium, indicating that it supported axonal growth. In the second series of experiments, co-explants were placed 0.5-1.0mm from each other. The numbers of outgrowing retinal axons were determined both with respect to the retinal eccentricity and the topological relationship with the lenticular co-explant. The Wilcoxon matched-pairs signed-rank test was used to determine if the numbers of axons differed significantly between four regions of the explants. Significantly more axons grew out from the retinal edge facing the lenticular explant than from its opposite side, indicating that the lens epithelium supports axon growth. The numbers of surviving retinal ganglion cells in culture were determined after retrograde prelabelling with a neuroanatomical tracer. The number of fluorescent ganglion cells within the retinal explants did not significantly differ between the groups (Mann-Whitney test). These findings indicate that the lens epithelium influences both the amount of axonal regeneration and the direction of growth without affecting the survival rate of retinal ganglion cells in vitro.

Ultrasonic visualization of the effect of blinking on the lacrimal pump mechanism.

BACKGROUND: The role of the lacrimal sac (LS) and the medial canthal tendon in the lacrimal pump mechanism is controversial. This study used ultrasonic visualization to analyze this phenomenon. METHODS: Movements of the LS and the medial canthal tendon during blinking were visualized with sonography. In addition, the maximal profile area of the LS was measured before and after blinking using 15-MHz sonography in 14 individuals with a normal lacrimal drainage system and in six patients with lacrimal duct obstruction. RESULTS: The upper part of the LS could be located as an echolucent structure between the lacrimal bone and the medial canthal tendon. The medial canthal tendon appeared to compress the LS during lid closure and release the LS during lid opening. The measured profile area of the visible normal LS at the compression time decreased by 50%. The dilated LS of patients with obstruction could also be compressed by the orbital muscle on blinking, but the maximum area decrease was only 15.5%. CONCLUSION: The findings imply that the lacrimal part of the orbicularis muscle contracts during blinking, with the medial canthal tendon compressing the LS in a cranial direction. Completion of lid closure then compresses both canaliculi and LS, forcing the intrasacral fluid through the drainage system. The expansion of the LS during the opening phase of the blink causes suction, and after opening of the punctal areas the canaliculi and LS vacuum breaks to reload with tear fluid. These findings demonstrate the importance of the orbicularis muscle and the medial canthal tendon for the lacrimal pump mechanism during blinking.

[Development of ocular motility following modified 3-wall decompression of the orbita in endocrine orbitopathy for functional and rehabilitative indication]. / Motilitätsentwicklung nach modifizierter 3-Wand-Dekompression der Orbita bei endokriner Orbitopathie aus funktioneller und rehabilitativer Indikation.

INTRODUCTION: Permanent visual damage due to an increase in volume of the orbital contents may be the result of the failure of conservative therapeutic concepts in the treatment of endocrine orbitopathy. Considerable progress has been achieved in developing successful orbital decompression techniques with regard to functional and cosmetic outcome. Decompression techniques with resection of the bony orbital walls are adequate tools in restoring visual acuity and reducing exophthalmus. A considerable degree of deterioration of motility disorders has been described in the literature depending on the techniques being used. PURPOSE: The purpose of this study was to investigate whether a modified technique of 3-wall orbital decompression with preservation of a medial part of the periorbital tissue to support the medial rectus muscle, is able to reduce the postoperative risk of diplopia. MATERIAL AND METHODS: A modified technique of orbital 3-wall decompression with resection of the medial orbital wall, the medial orbital floor and the floor of the frontal sinus has been used in patients with compressive optic neuropathy (n = 20) and for cosmetic reasons (n = 7) in cases of uni- or bilateral proptosis. Analysis of the results was performed concerning visual outcome, exophthalmus reduction and development of horizontal and vertical motility changes. RESULTS: In all cases of optic neuropathy improvement of visual function at an average of 4.63 +/- 4.5 lines could be achieved. Exophthalmus reduction was 3.2 +/- 2.4 mm in the functional group and 3.9 +/- 1.7 mm in the rehabilitative group. In this group motility of the medial rectus muscle remained unaffected except in one eye. In the functional group motility deterioration was observed in 62 %. CONCLUSION: The modified 3-wall decompression technique with preservation of a medial periorbital tissue strip is an adequate alternative technique in the therapy of optic neuropathy and exophthalmus reduction in endocrine orbitopathy with a low risk of postoperative motility disorders.