[Multicentric study regarding assessment of the driving ability of LASIK and orthokeratology patients compared with conventionally corrected persons]. / Multizentrische studie zur fahreignungsbegutachtung von LASIK- und orthokeratologie-patienten im vergleich zu konventionell korrigierten personen.

PURPOSE: Corneal optical zone induced by LASIK and orthokeratology (Ortho-K) treatment modifies the refraction of the incoming light bundle in its border area in situations of dawn and darkness. Considering the legal regulations of the driver's license and the recommendations of the German Society of Ophthalmology (DOG) and the American Academy of Ophthalmology (AAO), the vision for driving suitability of ortho-K patients is tested and compared with that of LASIK patients and a reference group (juvenile: < 30 years, adult: > 40 years) under different criterions. The examination of the visual acuity, contrast sensitivity under mesopic conditions and glare contrast sensitivity are main topics of the study. METHODS: This multicentre retrospective study includes 333 eyes of 167 subjects. 65 subjects were habitual wearers of reverse-geometry contact lenses, 60 subjects were treated by LASIK. 42 subjects use glasses, contact lenses or none of them. The follow-up time was 22.8 ± 11.9 months. The measurement of the visual acuity was based on DIN Standard 58220 part 3 and the ISO Standard 8596. The Mesotest II (Oculus Inc.) was used for testing contrast sensitivity under mesopic conditions and glare contrast sensitivity. Detecting the personal evaluation of vision and satisfaction, subjects were instructed to complete a questionnaire (NEI-RQL-42). RESULTS: Relating to the legal requirements in Germany, sufficient visual acuity was found in 76.7 % of the LASIK group, in 73.9 % of the Ortho-K users and in 85.7 % of the reference group (72.7 % in the adult group, 100 % in the juvenile group). Considering the DOG recommendations under inclusion of mesopic vision and glare sensitivity, 71.7 % of the LASIK subjects and 95.7 % of the Ortho-K subjects are suitable for driving a motor vehicle of the German classes A, A1, B, BE, M, S, L and T. With regard to the legal situation in the USA, 100 % of the Ortho-K users, 93.2 % of the LASIK group, 86.4 % of the adult reference group and 100 % of the juvenile reference group are fit to drive. The evaluation of the subjective questionnaire showed very high ratings in the Ortho-K (mean 85 of 100 points) and the LASIK (mean 86 of 100 points) group with no statistically significant differences. CONCLUSION: Considering the legal regulations, the volume of the subjects of Ortho-K and LASIK showed no significant difference of individuals considered fit to drive in comparison to a reference group. Neither LASIK nor Ortho-K patients have any restriction in the ability to drive a vehicle. The requirements of the DOG with regard to contrast sensitivity under mesopic conditions and glare contrast sensitivity for driving a vehicle are better fulfilled in the Ortho-K group compared to the group of LASIK patients. According to the DOG recommendations there are fewer subjects that are suitable for driving a motor vehicle as in the reference group. This fact must be discussed preoperatively.

[LASIK - a new treatment or the standard]. / LASIK - Neulandbehandlung oder medizinischer Standard.

Classification of LASIK in refractive surgery and treatment by health insurance, and education by the physician. Results in clinical studies and case law in Germany 2010.

[Mutational analysis of VSX-1 in one patient with posterior polymorphous corneal dystrophy and in three families with hereditary Fuchs endothelial dystrophy]. / Mutationsanalyse im VSX1-Gen bei einem Patienten mit posteriorer polymorpher Hornhautdystrophie und drei Familien mit autosomal-dominant vererbter Fuchs'scher Hornhautendotheldystrophie.

BACKGROUND: Fuchs endothelial corneal dystrophy is the most common disease of the corneal endothelium. Besides some sporadic cases, an autosomal dominant inheritance is frequently described. Mutations in the VSX-1 gene are identified as the underlying gene defect for a rarer kind of endothelial dystrophy, posterior polymorphous endothelial dystrophy. We report on mutational analysis of the VSX-1 gene in affected and non-affected family members of three families with autosomal dominant inherited Fuchs endothelial corneal dystrophy and one male patient showing posterior polymorphous endothelial dystrophy. PATIENTS/MATERIALS AND METHODS: From one patient with posterior polymorphous endothelial dystrophy and 10 affected and 15 non-affected family members of three families with autosomal dominant inherited Fuchs endothelial corneal dystrophy DNA was extracted from leukocytes of the peripheral blood and mutational analysis was performed by direct sequencing of the VSX-1 gene. RESULTS: Screening of the VSX-1 gene did not reveal sequence variants in any affected or non-affected individuals from the three families with Fuchs endothelial corneal dystrophy or the patient with posterior polymorphous endothelial dystrophy. CONCLUSIONS: The absence of pathogenic mutations in the VSX-1 gene in affected family members of 3 pedigrees indicates that other genetic factors are involved in the development of familial Fuchs endothelial corneal dystrophy. In addition, VSX-1 seems unlikely to be the crucial gene in our patient with posterior polymorphous endothelial dystrophy.

[Results of low-vision rehabilitation in vision impaired patients]. / Ergebnisse der optischen Rehabilitation mit vergrössernden Sehhilfen bei Patienten mit irreversibel visuslimitierenden Erkrankungen.

PURPOSE: Diseases of the retina, the optic nerve and the cornea may lead to a non-treatable loss of central vision. We report on low vision rehabilitation in 100 vision impaired patients. METHODS: Low vision rehabilitation was performed in 100 consecutive patients (61 % AMD, 23 % diabetic retinopathy, 16 % other diseases). Most of the patients were between 70 and 90 years old (78 %). In 62 cases we fitted optic systems for visual rehabilitation of the far distance (Galilei systems 54; Kepler systems 8), in additional 54 of them we fitted optic systems for the reading distance (additional lens 40; others 14; e. g. magnifier, television reader) and in 38 patients we fitted optic systems for visual rehabilitation only of the reading distance (magnifier 21, reading glasses with higher refraction and additional prism system 17). RESULTS: In 62 patients with low vision fitted with a system for the far distance we reached an increase of the visual acuity of more than one line in 95 %. In all 92 patients fitted with a system for the reading distance the reading of newspaper letters was possible. In 8 patients we could not fit a low vision systems due to handling difficulties. CONCLUSIONS: We could reach a satisfactory improvement of visual acuity in more than 90 % of the patients fitted for the far and the reading distance. Especially in elderly, vision impaired patients significant improvements in overall quality of life and specific areas of daily living are possible.

[Corneal topography. Analysis of the corneal surface]. / Korneale Topographie. Oberflächenanalyse der Hornhaut.

Various diagnostic procedures have been developed for analyzing the corneal surface. Corneal topographical measurements can be performed by classic Placido disc topographers and tomographers creating three-dimensional corneal models from cross-sectional images. Using a slit scanning system or the Scheimpflug technique additional information about the anterior segment can be obtained. New systems give us a wide range of diagnostic tools. Beside the measurement of the corneal anterior and posterior surfaces and point-to-point-pachymetry they enable analysis of corneal aberrations and measurement of the whole anterior segment, including the anterior chamber and the position of implants, pupil diameter, horizontal white-to-white and the kappa angle. Densitometry, statistical programs for the evaluation of corneal pathology and assistance with intraocular lens calculation following excimer laser treatment are further options available. This article is intended to give an overview of the principles and limitations of the various diagnostic systems.

[Hazeformation (corneal scarring) after cross-linking therapy in keratoconus]. / Haze-Bildung nach Vernetzungstherapie bei Keratokonus.

The aim of cross-linking therapy is to prevent keratoconus progression and stabilize the present refractive situation. A 41-year-old man was treated with collagen cross-linking in one eye. Postoperatively there were a diffuse subepithelial opacification and a paracentral corneal thinning. This superficial scarring in the sense of a "haze" disappeared only gradually despite intensive therapy.

Pellucid marginal corneal degeneration: evaluation of the corneal surface and contact lens fitting.

AIM: To quantify corneal irregularities, to describe the fitting with contact lenses, and to answer the question whether or not contact lenses with a special back surface design could improve visual acuity in patients with pellucid marginal corneal degeneration (PMCD). METHODS: 13 eyes were fitted with contact lenses with a special back surface. Videokeratographic data were assessed. The patients were followed up for an average period of 22.2 months. Lens tolerance and corrected visual acuity were evaluated. RESULTS: The mean eccentricity did not exceed 0.7 in all patients. Either the superior or the inferior eccentricity, or both, were negative in all patients. Using Fourier analysis all PMCD subjects showed an increased irregular astigmatism of the anterior cornea. Using Zernike coefficients seven eyes (53.8%) had a higher order aberration root mean square error (HOA RMS error) out of the normal range. The visual acuity with contact lenses improved in all eyes with an average increase of 2.7 lines (maximum eight lines). No serious complications were observed. CONCLUSIONS: Quantitative evaluation of videokeratographic data may help to diagnose PMCD and to distinguish PMCD from other ectatic corneal diseases. Contact lenses with a special back surface design can improve visual acuity and lens tolerance.

Molecular genetic and ocular findings in patients with holt-oram syndrome.

PURPOSE: The autosomal dominant Holt-Oram syndrome (HOS) is characterized by upper limb and cardiac septal defects. Mutations of the TBX5 gene have been identified as the underlying gene defect in HOS. Embryonic expression of TBX5 has been found in the human retina. This is the first report of ocular findings in two unrelated families with mutations in the TBX5 gene. METHODS: Six living persons affected with HOS and 10 unaffected family members were subjected to mutation analysis and complete ophthalmological examination, including electrophysiological examinations (EOG and flash ERG). RESULTS: A heterozygous single base-pain substitution in exon 5 (408C --> A) was detected in all affected patients. All examined affected patents were ophthalmological asymptomatic with normal EOG. A scotopic elongated b-wave latency was found in affected family members who were older than 35 years. The ERG was normal in the young patients. CONCLUSIONS: Haploinsufficiency of TBX5 alters the dorsal-ventral polarity in developing eye vesicles without amy detected functional loss in human. Slight ERG abnormalities later in life may be a result of changes induced by the inner ganglion cell layer in the inner nuclear layer.

Contact lenses and special back surface design after penetrating keratoplasty to improve contact lens fit and visual outcome.

AIMS: To describe the fitting of patients with high or irregular astigmatism following penetrating keratoplasty with contact lenses and to answer the question whether or not contact lenses with special back surface design can improve visual acuity in complex cases after penetrating keratoplasty. METHODS: 28 eyes were included. They were fitted with contact lenses with a special back surface that was designed for optical rehabilitation after penetrating keratoplasty. Four different types of these lenses (tricurve, keratoconus, reverse, oblong) were used selectively depending on abnormal eccentricity determined by videokeratoscope. The patients were followed up for an average period of 15.5 months. Lens tolerance and corrected visual acuity were evaluated and compared with that corrected with spectacles. RESULTS: The visual acuity was significantly improved in nearly all eyes with an average increase of 3.6 lines (maximal nine lines) accompanied by good contact lens tolerance and satisfactory contact lens fit. No noticeable complications were observed. CONCLUSION: Contact lenses with special back surface design can improve visual results and lens tolerance, and minimise problems in contact lens fitting. This is in favour of contact lenses as an alternative to surgical procedures for correction of high or irregular astigmatism after penetrating keratoplasty. This procedure is recommended especially in cases of patients who decline further operative interventions.

[Corneal wound healing after hyperopic PRK and LASIK]. / Korneale Wundheilungsreaktionen nach hyperoper PRK und LASIK.

BACKGROUND: The purpose of this study was to investigate the influence of different postoperative treatments on the wound healing reaction in the anterior stroma after PRK and in the interface area after LASIK. METHODS: Seventy-two corneal buttons of refractively treated rabbit eyes underwent different postoperative eyedrop regimens with antibiotics and/or steroids or additional UV-B irradiation. Morphological and immunohistological investigations were performed 6 months postoperatively by light and transmission electron microscopy. RESULTS: PRK eyes showed interdigitations between the epithelia and the anterior stroma. LASIK-treated eyes showed only minor changes between epithelia and stroma in the incisional region. Only a slight increase in deposits of fibrillar extracellular matrix components were detectable in the interface region. CONCLUSIONS: The clinically important problem of haze after PRK is caused by the interdigitations between epithelia and anterior stroma. The delicate wound healing reactions in the interface region in LASIK eyes corresponded to the clinically visible minor changes in these corneas.

[Lamellar keratoplasty. Back to the future?!]. / Lamelläre Keratoplastik. Zurück in die Zukunft?!

In 1840 Mühlbauer was the first to describe a technique for anterior lamellar keratoplasty (LKP). However, in the second half of the twentieth century penetrating keratoplasty (PKP) became the gold standard. Although it is associated with a higher risk for serious complications -- it is technically easier to perform and avoids wound healing reactions in the lamellar interface and thus resulting in better visual acuity. In view of the pathology, replacing all layers of the cornea including healthy parts can be considered therapeutic "overkill" for many corneal graft indications. Several innovative surgical techniques have recently been described which allow the lamellar dissection of recipient and donor cornea with good reproducibility in almost every desired depth. This now allows the recipient endothelium and Descemet's membrane to be selectively replaced or preserved and to avoid formation of an optical barrier in the lamellar interface in eyes undergoing lamellar keratoplasty for optical indications. The most important principal advantage of an anterior LKP -- to minimize the risk of an immune reaction in the graft -- is even more important in tectonic indications. From the large number of variations, the surgical technique, results, and problems with anterior and posterior LKP for optical indications as well as lamellar segment keratoplasty and epikeratoplasty for tectonic indications are discussed.

Early expression of proinflammatory cytokines interleukin-1 and tumor necrosis factor-alpha after corneal transplantation.

This study's aim was to determine the early postoperative expression of proinflammatory cytokines interleukin-1 (IL-1) and tumor necrosis factor-alpha (TNF-alpha) by corneal grafts. BALB/c (n = 90) and C57BL/6 (n = 90) murine recipients were grafted with donor corneas from either syngeneic or allogeneic mice. At 7 and 14 days after surgery, corneal grafts were excised and the recipient rims separated from the donor tissue. Corneal segments were cultured and assayed for cytokines by enzyme-linked immunosorbent assay (ELISA). There was profound upregulation in expression of both IL-1alpha and TNF-alpha after corneal transplantation. Among both low-rejecting BALB/c and high-rejecting C57BL/6 hosts, levels of IL-1alpha were significantly (p < 0.01) more marked in allogeneic as compared to syngeneic grafts. TNF-alpha overexpression was similarly more marked in allogeneic as compared to syngeneic grafts in both BALB/c and C57BL/6 hosts, although the difference was generally more marked among high-rejecting C57BL/6 recipients. In the case of both IL-1alpha and TNF-alpha, the principal source of cytokine expression in the transplanted tissue was the recipient rim. There is significant overexpression of both IL-1alpha and TNF-alpha during the first 2 weeks after transplantation in both syngeneic and allogeneic orthotopic corneal grafts. However, whereas in syngeneic grafts cytokine expression generally decreases after the first postoperative week, significantly elevated cytokine levels are sustained in allogeneic grafts, implicating IL-1 and TNF-alpha as mediators of the alloimmune response in corneal transplantation.

Experimental animal myopia models are applicable to human juvenile-onset myopia.

Landmark explorations by Hubel and Wiesel investigating the importance of visual impressions in postnatal development of the visual system demonstrated that neural connections and eye growth can be affected by the absence of a clear retinal image during a critical period of postnatal development. Fundamental theories on neural plasticity and deprivation have recently been established that presume that a reduced quality of the retinal image during infancy and early childhood triggers an elongation of the posterior chamber of the eye, a so-called form deprivation myopia (FDM). In a retrospective multicenter study of 187 patients who suffered from phlyctenular keratitis with corneal opacification since early childhood, we reviewed data on gender, year and age at onset of the disease, refraction, and ultrasound biometry. Compared with the average refraction of +0.5 diopter (D) found in the general population, the mean refraction of -4.43 D that we found in our study demonstrated a marked shift toward myopia of almost 5 D. Patients with an early onset of phlyctenular keratitis had considerably higher myopia (-6.68 D) than those with a late onset (-1.67 D). Additionally, an axial elongation was confirmed by ultrasound biometry. Our average, axial length was 26.53 mm, compared with the epidemiologic mean of 24.00 mm. This myopic shift of 2.53 mm was caused mainly by an enlarged vitreous cavity. These results support the finding that blur can affect eye growth and lead to FDM not only in animal experiments but also in human beings.