[Surgical treatment of neovascular glaucoma]. / Operative Therapie des Neovaskularisationsglaukoms.

PURPOSE: The neovascular glaucoma is one of the leading causes for an enucleation. The cyclocryocoagulation, the peripheral retinal cryocoagulation and the intravitreal injection of bevacizumab as combined therapy aim at the reduction of the intraocular pressure and of neovascularisation. MATERIALS AND METHODS: This study follows up 135 patients with neovascular glaucoma who underwent the above-mentioned combined therapy consisting of cyclocryocoagulation, peripheral retinal cryocoagulation and intravitreal injection of bevacizumab. RESULTS: The most common causes of neovascular glaucoma in our study are diabetic retinopathy and central retinal vein occlusion. The intraocular pressure was 37.4 mmHg (± 15.8) mmHg preoperatively under maximum antiglaucomatous therapy and was reduced to 19.0 (± 8.5) mmHg direct postoperatively. In the long-term intraocular pressure remained within the normal range in 93.33 % of patients. A successful reduction of the local antiglaucomatous drops of 1.9 substances to 1.7 substances was observed after 3 months. The oral intake of acetazolamide was also statistically significantly reduced. 47.37 % of the patients were normotensive without local therapy and only 3 patients were still on acetazolamide even after 1 year. The most serious complication was a phthisis bulbi in 1.5 % of patients. Overall 98.5 % of patients remained free of pain and maintained visual acuity after the end of the follow-up. CONCLUSION: Long-term pressure regulation and freedom from pain were successfully achieved. For decompensated neovascular glaucoma with poor vision and painful bulb, the combination of retinal cryocoagulation and intravitreal application of bevacizumab is an important therapeutic option.

Ruthenium-106 plaque brachytherapy for symptomatic vasoproliferative tumours of the retina.

AIM: To investigate the safety and efficacy of beta ray brachytherapy in treatment of vasoproliferative tumours of the retina (VTR). METHODS: 35 consecutive patients with symptomatic VTR were treated with a ruthenium-106 ((106)Ru) plaque. Three tumours had been treated previously (two with cryotherapy; one with transpupillary thermotherapy). 32 VTR (91.4%) were located in the lower half of the retina and all of them were found between the mid-periphery and the ora serrata. The mean tumour thickness was 2.8 mm. An exudative retinal detachment was present in 25 eyes (71.4%) and in 15 cases (42.9%) hard exudates were found in the macula. The major symptom was loss of vision (77.1%). RESULTS: Brachytherapy was well tolerated by every patient. The mean applied dose was 416 Gy at the sclera and 108 Gy at the tumour apex. In all but four eyes (88.6%), it was possible to control the VTR activity. The median follow up time was 24 months. Three of the above mentioned four eyes with treatment failure had had secondary glaucoma before therapy. There was no case of radiation induced neuropathy or retinopathy. Cataract surgery was necessary for five patients. The development of epiretinal gliosis was the most common event during follow up (n = 10, 28.6%). The mean visual acuity decreased slightly (0.33 before and 0.29 after brachytherapy). Multivariate analysis showed that the presence of macular pathology before treatment was associated with a 6.1-fold risk of vision of 0.25 or better (p = 0.03). CONCLUSIONS: beta ray brachytherapy with (1106)Ru plaques was able to control the activity of VTR and retain vision. Cases with secondary glaucoma before treatment had a very poor prognosis.

Partial deletions of the long and short arm of chromosome 3 point to two tumor suppressor genes in uveal melanoma.

Uveal melanoma is the most common form of primary eye cancer. Monosomy 3, which is an unusual finding in tumors but is present in approximately 50% of uveal melanomas, is significantly correlated with metastatic disease. To obtain positional information on putative tumor suppressor genes on this chromosome, we have investigated tumors from 333 patients by comparative genomic hybridization, microsatellite analysis, or conventional karyotype analysis. A partial deletion of the long arm was found in eight tumors, and the smallest region of deletion overlap (SRO) spans 3q24-q26. We found six tumors with a partial deletion of the short arm and were able to define a second SRO of about 2.5 Mb in 3p25. This SRO does not overlap with the VHL gene. Our finding suggests a role for two tumor suppressor genes in metastasizing uveal melanoma and may explain the loss of an entire chromosome 3 in these tumors.

[Juvenile idiopathic epiretinal membrane]. / Juvenile idiopathische epiretinale Membran.

Idiopathic epiretinal membrane (iERM) is very rare in adolescent patients. The pathogenesis remains unclear although the role of hyalocytes is of major importance. The clinical features in young patients are different from those in older patients. We describe a case of iERM in a 15-year-old girl who presented with metamorphopsia of the right eye. This case report presents the basis for the decision for surgical treatment as well as the clinical features at follow-up examination 9 months after surgery.

Embryo brain kinase: a novel gene of the eph/elk receptor tyrosine kinase family.

A new gene belonging to the Eph/Eck/Elk receptor tyrosine kinase family has been cloned from mouse brain. The gene maps to mouse chromosome 4. In the adult brain it is expressed exclusively and abundantly in the hippocampus. We propose to name it Ebk (embryo brain kinase), as in situ hybridisation shows expression in many parts of the developing mouse brain. The most abundant expression is in the subcommissural organ, and the earliest expression is in the forebrain neural folds, in rhombomeres 2-6, and in somites and heart. Other regions positive at various stages include the cochlear duct, trigeminal ganglion, lung, first branchial arch, and tooth primordia. Also positive are areas of mesenchyme underlying various epithelia during morphogenesis, especially in the mouth and nose, as well as in the eyelids and toes. We compare these patterns with the available data on the 12 other known members of this gene family. Most of them, like Ebk, are expressed in brain (especially adult hippocampus and embryonic rhombomeres) and in organs rich in epithelia (especially lung), although the spatial and temporal patterns differ. We suggest that combinatorial patterns of these receptors act as labels for the regional identity of neurons and epithelia, and could mediate fine control of neurite pathfinding and epithelial morphogenesis.

Mutations in the VMD2 gene are associated with juvenile-onset vitelliform macular dystrophy (Best disease) and adult vitelliform macular dystrophy but not age-related macular degeneration.

Recently, the VMD2 gene has been identified as the causative gene in juvenile-onset vitelliform macular dystrophy (Best disease), a central retinopathy primarily characterised by an impaired function of the retinal pigment epithelium. In this study we have further characterised the spectrum of VMD2 mutations in a series of 41 unrelated Best disease patients. Furthermore we expanded our analysis to include 32 unrelated patients with adult vitelliform macular dystrophy (AVMD) and 200 patients with age-related macular degeneration (AMD). Both AVMD and AMD share some phenotypic features with Best disease such as abnormal subretinal accumulation of lipofuscin material, progressive geographic atrophy and choroidal neovascularisation, and may be the consequence of a common pathogenic mechanism. In total, we have identified 23 distinct disease-associated mutations in Best disease and four different mutations in AVMD. Two of the mutations found in the AVMD patients were also seen in Best disease suggesting a considerable overlap in the aetiology of these two disorders. There were no mutations found in the AMD group. In addition, four frequent intragenic polymorphisms did not reveal allelic association of the VMD2 locus with AMD. These data exclude a direct role of VMD2 in the predisposition to AMD.

A histologic study (including DNA quantification and Ki-67 labeling index) in uveal melanomas after brachytherapy with ruthenium plaques.

PURPOSE: To investigate the proliferative potential and DNA damage in uveal melanomas treated by brachytherapy. METHODS: Forty-two enucleated eyes that had been treated with 106Ru/106Rh radioactive plaques for uveal melanoma were subgrouped according to the extent of irradiation damage. Cell proliferation was determined by immunoreactivity for the proliferation marker Ki-67 (Mib-1) and ploidy by quantitative DNA image analysis. Thirty globes containing uveal melanomas without prior brachytherapy served as a control group. RESULTS: The values for Ki-67 reactivity and ploidy could be correlated with radiation-induced changes within the tumors. In regions of the tumor where complete exposure to the prescribed radiation dose was assumed from the histologic findings, the Ki-67 index was close to or equal to zero. Hypoploidy was exclusive to irradiated tumors and was most often detected in effectively irradiated regions. Tumor regions classified as partially irradiated or recurrent showed an increase of Ki-67 indices and DNA content. Values obtained in recurrent tumors did not significantly differ from the control group. CONCLUSIONS: Tumor cell proliferation and variations in ploidy status could be detected after brachytherapy, but the response varied markedly both within individual tumors and within the irradiated group. Evidence of persisting proliferative potential could be obtained in ostensibly sterilized tumor tissue, but a negligible Ki-67 index and the presence of hypoploidy were considered to be reliable indicators for radiation-induced loss of proliferative potential.

Expression of VLA-2, VLA-3, and alpha(v) integrin receptors in uveal melanoma: association with microvascular architecture of the tumour and prognostic value.

BACKGROUND: The interaction of the integrin receptors with their ligands (collagen, laminin, fibronectin, and others) has a crucial role during the reorganisation of the extracellular matrix and the metastatic process. The presence of particular vascular patterns in uveal melanoma is associated with the development of metastases. There is some evidence that interactions between the tumour cells and the extracellular matrix are responsible for the shape of these patterns. METHODS: The expression of VLA-2, VLA-3, and alpha(v) integrin receptors was examined by immunohistochemistry on paraffin embedded tumour specimens from 92 uveal melanomas (iris melanomas excluded). Possible correlations between these results and the tumour vascular patterns, the histological features of the tumours as well as the clinical outcome of the patients, were investigated. RESULTS: The expression of VLA-2 in tumours was associated with the presence of vascular networks (p = 0.05). Tumours with less than 25% VLA-3 positive cells infiltrated the sclera more frequently than those with more than 25% VLA-3 cell positivity (p = 0.05). Tumours expressing less than 50% alpha(v) positive cells were associated with the mixed or epithelioid cell type (p = 0.05) and, with less statistical precision, with the presence of extraocular growth (p = 0.07). The univariate logistic regression analysis showed that the risk of developing metastases within the first 5 years after diagnosis did not depend on the expression of the integrin receptors investigated. CONCLUSION: The potential biological importance of the associations between integrin expression and the histopathological features of the tumours found in the present study remains to be elucidated in future experiments. The immunohistochemical detection of VLA-2, VLA-3, and alpha(v) integrins had no prognostic value in our preliminary report.

Long-term results after low dose ocular irradiation for choroidal haemangiomas.

AIM/BACKGROUND: The most common choice of treatment for choroidal haemangiomas (CH) in the past has been the employment of scatter photocoagulation of the surface. This management often requires repetitive treatment or additional invasive management due to massive exudative detachment of the retina. The aim of this retrospective study was to investigate the outcome of the alternative application of low dose external beam irradiation with high energetic photons on these tumours. METHODS: A total absorbed dose of 20 Gy was applied to a total of 51 symptomatic eyes: 36 with a circumscribed CH of the posterior pole and 15 with diffuse CH as part of the Sturge-Weber syndrome. The indication for treatment was an exudative retinal detachment including or threatening the fovea. The mean follow up times in each group were 4.5 and 5.3 years, respectively. Out of a group of 33 patients from whom reliable data could be derived, 17 had symptoms lasting longer than 6 months. RESULTS: In 23 cases (63.8%) with circumscribed CH complete resolution of the subretinal fluid was achieved; the remaining 13 cases (36.2%) showed residual serous detachment distant to the fovea. The visual acuity improved by two or more lines in 14 cases (38.9%), remained stable in 14 cases (38.9%), and decreased in eight cases (22.2%). The functional success was dependent on the lag duration between onset of first subjective symptoms and treatment. The morphological results with diffuse CH were similar to those of the group of circumscribed CH. The visual acuity (VA) at last examination was improved in seven cases (46.6%); in the remaining eight cases, VA was unchanged or had deteriorated. The poor functional outcome in the latter was mainly attributable to secondary glaucoma. CONCLUSION: External beam irradiation is a useful and a low invasive therapeutic option for CH. A successful functional outcome is dependent on the time delay between first onset of symptoms and the beginning of therapy, the formation of subretinal fibrosis, and also on secondary glaucoma in the case of Sturge-Weber syndrome.

Photodynamic therapy using verteporfin in circumscribed choroidal haemangioma.

AIM: To investigate the safety and efficacy of photodynamic therapy with verteporfin in patients with choroidal haemangioma. METHODS: A non-randomised, prospective clinical investigation of 19 patients with symptomatic circumscribed choroidal haemangioma was performed. Unsuccessful pretreatment (external beam irradiation, laser photocoagulation) was performed in four patients. Patients were included when (1) subretinal exudation involving the fovea, (2) a decrease in visual function, and (3) additional symptoms (for example, metamorphopsia) were present. Photodynamic therapy (PDT) was performed with verteporfin at a concentration of 6 mg/m(2) body surface area and a light dose of 100 J/cm(2) at 692 nm. RESULTS: The mean follow up time was 10.6 months (2-24 months). The mean number of treatment sessions was 2.15 (range 1-5). Visual acuity improved by at least one line in 73.3%, by at least two lines in 42.1%, was stable in 21.1%, and decreased by one line in 5.2% of the patients. Exudation was completely resolved in 94.8% of the cases. Regression of tumour height was documented in all 19 tumours. Patients receiving any pretreatment before PDT, a visual acuity of 0.1 and less, a history of more than 30 months, and no significant response after the first PDT session, did not show any significant improvement. Cox regression analysis revealed that the number of PDT treatment sessions was inversely associated with the improvement in visual acuity of at least two lines. No recurrences and no local or systemic side effects were observed during the follow up time. CONCLUSION: PDT using verteporfin is a safe and effective therapy for the treatment of symptomatic choroidal haemangioma even in tumours located beneath the fovea.

[The sonographic image of gallbladder adenomyomatosis]. / Sonographisches Bild der Adenomyomatose der Gallenblase.

Compared with oral or intravenous cholecystography, a diagnosis of adenomyomatosis of the gall bladder is only rarely made by ultrasound. In nine patients this diagnosis was made by sonography and confirmed at operation or by cholecystography. In four patients it was an incidental finding during ERCP. The main feature is localised or generalised thickening of the wall of the gall bladder with a smooth outer contour. In seven cases there were small cysts in the wall and in two echogenic areas in the wall. An important criterion for distinguishing between inflammatory and neoplastic mural thickening is the contractility of the gall bladder.

Continuous ambulatory peritoneal dialysis in high-risk patients: patients with cardiovascular diseases--role of the nurse.

Most patients receiving renal replacement therapy have cardiovascular disease. The most frequent conditions are left ventricular hypertrophy and coronary artery disease. Hemodialysis is associated with a characteristic spectrum of acute complications (such as hypotension, sudden death) that can be explained by typical dialysis-induced effects on the heart. With continuous peritoneal dialysis (CAPD) some of the cardiovascular complications are ameliorated owing to slow ultrafiltration and absence of an arteriovenous fistula. CAPD might be concluded to be the preferable option in patients with cardiovascular disease, but a few disadvantages, such as hyperlipidemia and hyperinsulinemia, also exist. Nurses also play an important role in the therapeutic success and outcomes of these patients.

First in vitro and in vivo experiences with Stay-Safe Balance, a pH-neutral solution in a dual-chambered bag.

In addition to low pH and high osmolarity, glucose degradation products (GDPs) are considered to play a major role in the bioincompatibility of peritoneal dialysis fluids (PDFs). The formation of GDPs can be reduced by separating the glucose component of the solution (kept at very low pH) from the lactate component of the solution (kept at alkaline pH) during sterilization and storage. This development has been achieved by the use of a dual-chambered bag. Immediately before infusion, the seam between the two chambers is opened, and the contents are mixed. The result is a fluid with a more physiologic pH in the range 6.8 - 7.4. Concentrations of 3-deoxyglucosone (3-DG), methylglyoxal (MG), acetaldehyde (AA), and formaldehyde (FA) in Stay-Safe Balance (Fresenius Medical Care, Bad Homburg, Germany) were remarkably reduced when compared to conventional PD solution [conventional PDF (1.5% glucose): 172 micromol/L, 6 microLmol/L, 152 micromol/L, and 7 micromol/L respectively; Stay-Safe Balance (1.5% glucose): 42 micromolL, < 1 micromol/L, < 2 micromol/L, and < 3 micromol/L respectively; conventional PDF (4.25% glucose): 324 micromol/L, 10 micromol/L, 182 micromol/L, and 13 micromol/L respectively; Stay-Safe Balance (4.25% glucose): 60 micromol/L, < 1 micromol/L, < 2 micromol/L, and < 3 micromol/L respectively). Human peritoneal mesothelial cells (HPMCs) were exposed to a control solution, a conventional PDF [CAPD 2, 1.5% glucose (Fresenius Medical Care, Bad Homburg, Germany)], and Stay-Safe Balance, either in a co-incubation model (24-hour PDF exposure) or in a pre-incubation model (30-min PDF exposure), followed by 24-hour recovery in culture medium. Interleukin-1beta (IL-1beta)-stimulated (1 ng/mL) IL-6 secretion from HPMCs was assessed by ELISA. Exposure of HPMCs to conventional PDF resulted in a significant reduction in IL-6 release, which was fully restored following exposure to Stay-Safe Balance. In addition to the short-term investigations, long-term in vitro studies were also carried out. All fluids had near-neutral pH and were changed every second day. After 1, 3, 5, 7, 10, and 13 days of exposure, cell viability was assessed. Whereas exposure to conventional PDF resulted in a significant reduction in HPMC viability after just 3 - 5 days, no significant toxicity of filter-sterilized or dual-chambered fluid was observed for up to 13 days. An observational study with 9 patients suggested that the efficacy of Stay-Safe Balance is equivalent to that of conventional solution. However, even short-term treatment (8+/-1 weeks) with this more biocompatible solution seems to improve mesothelial cell mass as indicated by a rise in cancer antigen 125 (CA125) from a baseline of 47+/-37 U/min to 172+/-90 U/min. Our data indicate that Stay-Safe Balance may help to better preserve peritoneal membrane cell function. An ongoing European multicenter study is expected to confirm these results.

Influence of neutral-pH dialysis solutions on the peritoneal membrane: a long-term investigation in rats.

OBJECTIVE: Glucose degradation products (GDPs) and low pH are potential causes of bioincompatibility of peritoneal dialysis fluids (PDFs). The aim of the present study was to compare the effect of 6 weeks' exposure of the peritoneum in rats to two different PDFs: a standard PDF with a low pH and high level of GDPs (CAPD 3: Fresenius Medical Care, Bad Homburg, Germany), and a modified PDF with a low level of GDPs and a physiologic pH (CAPD 3 Balance: Fresenius Medical Care). METHODS: After catheter implantation, rats were exposed twice daily for 6 weeks to CAPD 3 fluid or to CAPD 3 Balance. At the beginning and at the end of the study, a 4-hour dwell was performed in every rat to evaluate intraperitoneal inflammation and its effect on total collagen synthesis in the in vitro cultured rat mesothelial cells (ex vivo study). Additionally, after 6 weeks' exposure, the peritoneal cavity was opened, and macroscopic changes were evaluated according to a semiquantitative scale. Peritoneal samples were also taken for morphology study. RESULTS: In rats treated with CAPD 3 fluid, intraperitoneal inflammation was comparable at the beginning and at the end of the experiment. In animals exposed to CAPD 3 Balance, the intensity of the intraperitoneal inflammation decreased during the study (cell count, p = 0.0781; neutrophil:macrophage ratio, p < 0.01; nitrite concentration, p < 0.05; hyaluronan level, p < 0.05). The capacity of effluent dialysate from CAPD 3 rats to activate collagen synthesis in in vitro-cultured mesothelial cells was the same at the beginning and at the end of the study. In the CAPD 3 Balance group, this capacity was statistically significantly lower at the end of the study than at the beginning (p < 0.05). The mean thickness of the visceral peritoneum was comparable in both groups of animals, but, macroscopically, more severe fibrosis was found in the peritoneum of rats exposed to CAPD 3 as compared with animals treated with CAPD 3 Balance (p < 0.05). CONCLUSION: We showed that, in the rat model of peritoneal dialysis, chronic exposure of the peritoneum to PDFs with low GDPs and a physiologic pH diminished the intraperitoneal inflammatory reaction induced by dialysis, and reduced peritoneal fibrosis.

High glucose dialysis solutions increase synthesis of vascular endothelial growth factors by peritoneal vascular endothelial cells.

OBJECTIVE: Increased peritoneal vasculature has been reported in long-term peritoneal dialysis (PD), and vascular endothelial growth factors (VEGFs) have been found in dialysate. High concentrations of glucose or lactate, glucose degradation products (GDPs), and low pH of dialysis solutions are all possible factors in increased peritoneal VEGF synthesis. In this study, we investigated the effects of high glucose dialysis solutions on VEGF synthesis by peritoneal vascular endothelial cells (PVECs). METHODS: The PVECs were isolated from rat omentum and were incubated for 4 hours in three different culture media [M199 media (control), conventional dialysis solutions containing 4.25% glucose diluted with an equal volume of M199 media (HGD), and M199 media containing 118 mmol/L mannitol as an osmolar control (mannitol)]. Levels of VEGF protein in the culture supernatant were measured by ELISA, and mRNA expression was determined by Northern blot analysis. Data are presented as percent of control. RESULTS: After incubation for 4 hours, the number of cells did not differ between the 3 groups. Levels of VEGF in culture supernatant were significantly higher in the HGD group (124% +/- 19%, p = 0.006) as compared with the control and mannitol (85% +/- 10%) groups. The mRNA expression of VEGF appeared to be higher in the HGD group (128% +/- 49%) than in the control and mannitol (94% +/- 18%) groups. CONCLUSION: High glucose dialysis solutions increased VEGF synthesis by PVECs. The relationship between VEGF synthesis by PVECs and neovascularization of the peritoneum observed in long-term peritoneal dialysis patients has to be studied further.

[EOG in adult vitelliform macular degeneration, butterfly-shaped pattern dystrophy and Best disease]. / EOG bei adulter vitelliformer Makuladegeneration (AVMD), schmetterlingsförmiger Patterndystrophie und Morbus Best.

OBJECTIVES: We evaluated the EOG in the various stages of foveomacular dystrophy (also called adult-onset vitelliform macular dystrophy) and compared these findings to those in Best's disease and butterfly-shaped dystrophy. PATIENTS AND METHODS: The records of 49 patients (98 eyes) in whom foveomacular dystrophy had been diagnosed by ophthalmoscopy or by fundus photographs and fluorescein angiography were retrospectively reviewed. Fifty-seven eyes were followed up (range 1.1-20 years, mean 10.4 years). EOG was elicited according to the method of Rohde and Täumer. The results were compared to those in Best's disease and butterfly-shaped dystrophy. RESULTS: In foveomacular dystrophy all mean EOG values were within normal ranges. There was no difference between the various stages of the disease. In Best's disease only the dark-adapted steady-state potential was in the normal range. The amplitude and the implicit time of the light peak were significantly different from those in patients with foveomacular dystrophy (P < 0.05 ANOVA). In butterfly-shaped dystrophy all the EOG parameters were normal. The ratio of the light peak to steady-state potential was significantly lower in foveomacular dystrophy than in butterfly-shaped dystrophy. CONCLUSION: In foveomacular dystrophy the mean values of the EOG were normal. Despite the morphological similarity we found more pronounced electrophysiological differences from Best's disease than from butterfly-shaped dystrophy.

[Observations of different presentations of choroid neovascularization in indocyanine green angiography]. / Beobachtungen zur unterschiedlichen Darstellung choroidaler Neovaskularisationen in der Indozyaningrün Angiographie.

The interpretation of choroidal neovascular membranes (CNV) in indocyanine green angiography (ICG-A) is difficult. It is not known whether demarcated hyperfluorescence in the ICG-A reliably reflects the true morphology and the total extent of a CNV. Therefore, in this retrospective study, the patterns of fluorescein and ICG angiograms were evaluated and compared in both occult and well-defined CNV. In 153 out of a total of 168 cases with CNV, age-related macular degeneration (AMD) was the underlying disease. CNV was occult in 114 and well-defined in 39 cases. The angiographic examinations with both dyes were performed with a modified fundus camera combined with a digital imaging system. In the group of AMD patients with occult or ill-defined CNV. 42 cases (36.8%) showed a defined membrane in the ICG stain. The filling patterns of ICG were extremely variable. In the group of AMD patients with classic CNV, ICG-A showed evidence of staining in the early and late phase in 14/39 cases (36%), exclusively in the early phase in 5/39 (13%) cases and only in the late phase in 17/39 cases (44%). Surprisingly, three well-defined membranes in fluorescein angiography (FLA) were not seen in any phase of the ICG-A. Compared with FLA, the 17 CNVs with demarcation only in the late phase of the ICG-A were seen to be larger in 8 and smaller in 9 cases while all CNVs seen in the early phase, or in both early and late phase, were of identical size with the early fluorescein staining. The pattern of ICG staining of CNV is complex. The single finding of a demarcated hyperfluorescence in the late phase of ICG-A should be interpreted with utmost caution, particularly in regard to planning laser therapy.

[Treatment with tissue plasminogen activator (tPA) in risk patients with fibrin reactions after cataract operations]. / Behandlung mit Gewebsplasminogenaktivator (tPA) bei Risikopatienten mit Fibrinreaktionen nach Kataraktoperationen.

The postoperative course after cataract surgery can be complicated by the formation of severe fibrinous membranes, especially in cases with previous goniotrepanation, after syn echiolysis, iridotomy or iris suturing, and in patients with diabetes or uveitis. This study retrospectively analyzes the efficacy of intraocular tissue plasminogen activator (tPA) for fibrinolysis in these conditions commonly considered as contraindications to tPA therapy. When antiinflammatory therapy was unsuccessful in lysing fibrinous membranes, 10 micrograms of tPA (Actilyse) was injected into the anterior chamber following the first postoperative day (n = 15). In addition, topical corticosteroids and cycloplegics were given postoperatively. Lysis of the fibrinous membranes was achieved in all patients. However, in three cases lysis was incomplete or recurred. Complications of intraocular tPA therapy consisted of mild hyphema (n = 1) and transient dysfunction of the corneal endothelial cells (n = 2). In conclusion, the results suggest intraocular low-dose tPA as an effective approach for the treatment of severe fibrinous membranes after cataract surgery even in high-risk patients.

[Late vision loss after focal hemorrhagic chorioretinopathy]. / Später Visusverlust nach fokaler hämorrhagischer Chorioretinopathie.

Prospective clinical studies about photocoagulation of extrafoveolar choroidal neovascularizations in focal hemorrhagic chorioretinopathy (CR) have demonstrated that the risk of visual loss years after successful treatment is related to the development of retinal pigment epithelium (RPE) atrophy around the laser scar. The reason for this event was thought to be late damage of RPE cells due to the laser treatment. However, because RPE atrophy can also be seen in untreated patients, a prospective study was started to test this pathogenetic hypothesis and to analyze the pathogenetic factors and prognostic importance of RPE atrophy in focal hemorrhagic CR. Eighty-eight patients (52 women, 36 men, 15-45 years old; mean follow-up 62 months; 26 patients treated by photocoagulation) with focal hemorrhagic CR were reexamined. Fifty-two patients (15 treated by photocoagulation and 37 untreated) showed clinically visible RPE atrophy. In these 52 patients the initial and final visual acuity, the amount of initial subretinal fluid (34.6% < 500 microns, 50% 500-750 microns, 15.4% > 750 microns) and the amount RPE atrophy (23.2% < 500 microns, 53.6% 500-750 microns, 23.2% > 750 microns) were analyzed. The development of RPE atrophy was dependent on the time of follow-up (36 patients without RPE atrophy, mean follow-up 29 months; 52 patients with RPE atrophy, mean 84 months, P < 0.001). Of the 52 patients with RPE atrophy, 15 were treated by photocoagulation. The distribution of RPE atrophy was similar to what was found in the 37 untreated patients (P = 0.4). With pronounced RPE atrophy, a decrease in final visual acuity was seen (RPE atrophy < 500 microns, mean visual acuity 0.5; 500-750 microns mean visual acuity 0.3; > 750 microns, mean visual acuity 0.1; P = 0.005). Increased RPE atrophy was also associated with a higher incidence of visual loss (p = 0.009). The amount of RPE atrophy was not dependent on the time of follow-up (P = 0.3), but only correlated with the initial amount of subretinal fluid (atrophy < 500 microns: subretinal fluid < 500 microns 15.4%, 500-750 microns 7.7%, > 750 microns 0%; atrophy 500-750 microns: subretinal fluid < 500 microns 19.2%, 500-750 microns 32.7%, < 750 microns 1.9%; atrophy > 750 microns: subretinal fluid < 500 microns 0%, 500-750 microns 9.6%, > 750 microns 13.5%; P < 0.0001). Because RPE atrophy in focal hemorrhagic CR was seen in patients both with and without photocoagulation therapy, laser treatment cannot be the causative factor. With increased follow-up the risk of the development of RPE atrophy increases in all patients. The resulting amount of RPE atrophy was only dependent on the initial amount of subretinal fluid. If the fovea is included in the exudative detachment, there is a higher risk of long-term visual loss.