[Scleral melting after cyclophotocoagulation]

We report on a case of a scleral melting as a rare but severe complication of transscleral cyclophotocoagulation. The tissue defect was successfully repaired by tectonic keratoplasty.

Long-term follow-up of intraocular pressure and pressure-lowering medication in patients after ab-interno trabeculectomy with the Trabectome

BACKGROUND

The minimally invasive ab-interno trabeculectomy (AIT) via electro-ablation with the Trabectome has been on the European market since 2009. Many studies have proven the safety and efficacy of the procedure. Up until now, studies investigating the long-term effect of AIT have been sparse. In this study, we present long-term results of AIT in patients with primary and secondary open-angle glaucoma.

METHODS

In a retrospective monocentric study, the data of all the patients having undergone the procedure in 2010 at our institution were recorded. Data was collected during routine examinations at our institution. In total, 81 eyes of 74 patients (46 patients with primary open-angle glaucoma (POAG), 28 patients with pseudoexfoliative glaucoma (PEXG)) were included. At every examination, the intraocular pressure (IOP) was measured using Goldmann applanation tonometry and the number of IOP-lowering medication was registered. Statistical analysis was done using the Kaplan-Meier analysis or Dunnett's t test, respectively.

RESULTS

For both groups (POAG and PEXG), we found a significant lowering of the IOP (28% for POAG and 26% for PEXG) and a significant reduction of the number of IOP-lowering medication (32% for POAG and 29% for PEXG) after a median follow-up period of 3.5 years.

CONCLUSION

In patients with open-angle glaucoma and especially pseudoexfoliative glaucoma, ab-interno trabeculectomy is an effective surgical procedure to significantly lower the intraocular pressure on a long-term basis.

Bleb-related infections and long-term follow-up after trabeculectomy

PURPOSE

Bleb-related infections are serious complications after trabeculectomy. They can be limited to the bleb or disseminate and lead to endophthalmitis. We herein report on all bleb-related infections that have been diagnosed at the Eye Center of the University of Freiburg, Germany, since 1999.

METHODS

We reviewed a total of 1816 consecutive trabeculectomies that were performed at our hospital between the years 1999 and 2014 (353 without and 1463 with intraoperative application of mitomycin C). All bleb-related infections that were diagnosed at our clinic during the same period were included in the analysis. We fitted a Cox proportional hazards model to characterize risk factors for bleb-related infections.

RESULTS

We diagnosed a total of 19 bleb-related infections in this period. Three patients with bleb-related infections that came to our clinic had their trabeculectomy performed elsewhere. The overall percentage of bleb-related infections was 0.1% after 2 years (Kaplan-Meier estimate at median follow-up). Nine eyes suffered from only localized infection of the bleb. Seven eyes developed endophthalmitis. Four infections occurred during the first postoperative month. The median age on the day of diagnosis was 71 years; the median age at surgery was 69 years. In the Cox model, intraoperative application of mitomycin C and a fornix-based conjunctival flap were identified as significant risk factors (hazard ratio: 79.02, 4.69; p < 0.01, p < 0.01). The whole group showed a reduction of visual acuity in the median from logMAR 0.12 to 0.2. Eyes that suffered from endophthalmitis showed a loss from 0.3 to 0.96, while the localized infections had a reduction from 0.04 to 0.07.

CONCLUSION

Bleb-related infections are a rare complication following trabeculectomy and can be localized on the bleb or can lead to endophthalmitis, thereby threatening visual acuity. The risks and benefits of mitomycin C-augmented trabeculectomies should be taken into consideration.

Intraoperative optical coherence tomography and ab interno trabecular meshwork surgery with the Trabectome

Importance

This study is the first description of the use of the intraoperative optical coherence tomography (iOCT) for trabecular meshwork surgery with the Trabectome in a regular clinical setting.

Background

The aim of this study is to evaluate intraoperatively the immediate success of ab interno trabeculotomy with the Trabectome defined as a removal of the trabecular meshwork.

Design

This is a retrospective clinical study performed in the University Eye Hospital, Medical School Hannover.

Participants

A total of nine consecutive Caucasian patients suffering from primary open angle glaucoma, pigment dispersion glaucoma, or pseudoexfoliation glaucoma took part in the study.

Methods

All patients underwent ab interno trabeculotomy surgery with the Trabectome using a commercially available iOCT to visualize the anterior chamber angle (ACA) before and after the procedure. The visualization was done using a modified Swan-Jacobs lens (all nine patients) or without lens (view from above, five patients).

Main outcome measures

The main outcome of this study is the success of visualization of the ACA on iOCT, especially the postprocedural visualization of the wound gap after removal of the trabecular meshwork.

Results

Using the view from above, the ACA could be visualized before and after the procedure in only two of the five cases. Using the modified Swan-Jacobs lens, the ACA could be visualized before the procedure and the trabecular meshwork opening after the procedure in all nine patients.

Conclusion

The iOCT can be used to objectify the immediate success of the surgical procedure, ie, the removal of the trabecular meshwork, of ab interno trabeculotomy with the Trabectome. The procedure itself cannot be captured sufficiently via iOCT.

[Diaphanoscopy in cyclophotocoagulation]

Transscleral cyclophotocoagulation is not usually considered as the first line surgical therapy for glaucoma. However, it still remains an important tool for lowering intraocular pressure in certain patients. It is quick and easy to perform and acts through an alternative physiological approach compared to filtration surgery. As the ciliary body is not directly visible, an empirical distance from the limbus is often used for placement of the laser probe; however, the anatomical structures can be highly variable. Diaphanoscopy provides a very simple and effective way to visualize the ciliary body before or parallel to the cyclophotocoagulation. It helps to direct the laser beam more precisely to the ciliary body and to prevent a false anterior placement of the beams, that carries a great risk of side effects. This article provides an overview on the concept of diaphanoscopy for cyclophotocoagulation.

[Unilateral periocular angioedema after application of contrast agent]

This article presents a case report of unilateral, periocular angioedema after intravenous application of a contrast agent with a temporary increase of intraocular pressure in an eye in which trabeculectomy had been carried out 5 weeks previously.

Refractive and visual outcomes after combined cataract and trabectome surgery: a report on the possible influences of combining cataract and trabectome surgery on refractive and visual outcomes

PURPOSE

To compare combined trabectome-cataract surgery with cataract-alone surgery regarding their refractive and visual outcomes and complications.

METHODS

In 137 eyes that underwent combined trabectome-cataract surgery, the postoperative refraction error and best visual acuity after at least 2 months postoperatively were compared to those of an in-house control group of 1,704 eyes that underwent outpatient cataract surgery.

RESULTS

Combined trabectome-cataract surgery showed no significant differences regarding the biometry prediction error (BPE, mean 0.53 D vs. 0.48 D, p = 0.24) or visual outcome (BCVA, 0.81 vs. 0.78, p = 0.06). The rate of postoperative cystoid macular edema was slightly higher in the combined surgery group (2.2 % vs. 1.9 %).

CONCLUSIONS

Refractive and visual outcomes were similar in both groups. Despite the slightly higher rate of postoperative macula edema, we were able to observe that the combination of these two procedures is a feasible method in glaucoma and cataract surgeries.

[Minimally invasive glaucoma surgery using the trabectome]

The main barrier reducing outflow of aqueous humor in open angle glaucomas is the juxtacanalicular trabecular meshwork. The trabectome removes this pathophysiologically altered tissue by electroablation, thus allowing for the collector channels draining Schlemm's canal to directly communicate with the anterior chamber. In studies published so far, about 30% decrease of intraocular pressure and a simultaneous 42% reduction of pressure-lowering eyedrops could be achieved in primary and secondary open angle glaucomas. A clear cornea tunnel is used to advance the trabectome to the trabecular meshwork, leaving the conjunctiva unaffected. Hence minimally invasive chamber angle surgery using this device is in particular suitable for patients with an altered ocular surface. Lowering of intraocular pressure and reduction of needed topical medication seems to be distinct in pseudoexfoliative glaucoma. Surgery with the trabectome and phacoemulsification can easily be combined in one procedure. Using a minimally invasive approach, the complication profile of the trabectome is rather advantageous, not exceeding the general risks of globe-opening surgery. Ab-interno trabeculotomy is a safe and effective method for treatment of patients with primary or secondary open angle glaucomas and moderate target pressures.

[Body mass index as an influencing factor for outcome of trabectome surgery?]

BACKGROUND

The aim of this study was to investigate a possible influence of body mass index (BMI) to the outcome of trabectome surgery.

METHODS

131 eyes with primary open angle glaucoma, myopia-associated glaucoma and pseudoexfoliation glaucoma were included into this retrospective study. The data were extracted from the Freiburg trabectome database from June 2009 to April 2013. We fitted a Cox proportional hazards model in order to assess the influence of the BMI on trabectome outcome.

RESULTS

The absolute success after trabectome surgery (20 % pressure reduction without anti-glaucomatous medication) was statistically significantly better in the group with BMI > 25 kg/m(2) (p = 0.047). No statistically significant effect was observed for relative success or the rate of re-operation respectively.

CONCLUSION

In our patient cohort of 131 eyes, a high BMI was associated with a reduced success, as long as an absolute success is required. No difference is seen if additional anti-glaucomatous medication is acceptable (relative success).

[Trauma-related secondary glaucoma in childhood: a therapeutic challenge]

CASE REPORT

We performed a minimally invasive trabeculotomy using a trabectome on a 9-year-old boy with a trauma-related secondary glaucoma where the intraocular pressure (IOP) could not be controlled by conservative approaches. After a 1-year follow-up the patient showed well controlled IOP values without using drugs to reduce pressure.

CONCLUSION

Trabectome surgery seems to be a suitable first step intervention for trauma-related glaucoma in selected cases, even in children.

Trabectome surgery for primary and secondary open angle glaucomas

Purpose

In most forms of open angle glaucoma, the trabecular meshwork is the main barrier for aqueous humor outflow, causing elevated intraocular pressure (IOP). The Trabectome is a minimal invasive device for the surgical treatment of open angle glaucoma, particularly eliminating the juxtacanalicular meshwork. This study was conducted to compare the effectiveness and complication profile among different glaucoma subgroups.

Methods

Single center prospective observational study. There were 557 consecutive eyes of 487 patients included in this study. Trabectome surgery was performed either alone or in combination with cataract surgery. Intraoperative and postoperative complications were documented systematically. Main outcome measures were IOP reduction over time and the preoperative and postoperative number of IOP-lowering medications. Due to subgroup sizes, only data from eyes with primary open angle glaucoma and pseudoexfoliation glaucoma were processed for statistical analysis.

Results

For the 261 eyes classified as primary open angle glaucoma, preoperative IOP was 24 ± 5.5 mmHg (mean ± SD) under 2.1 ± 1.3 IOP-lowering medications. After a mean follow-up of 204 ± 238 days, IOP was reduced to 18 ± 6.1 mmHg, and medication was reduced to 1.2 ± 1.1. For the 173 eyes classified as pseudoexfoliation glaucoma, after a mean follow-up of 200 ± 278 days, IOP was reduced from 25 ± 5.9 mmHg to 18 ± 8.2 mmHg, and medication was reduced from 2.0 ± 1.2 to 1.1 ± 1.1. A Cox proportional hazards model hinted forward superiority of the combined surgery cases (Trabectome + Phaco + intraocular lens) in comparison to Trabectome surgery only in phakic or pseudophakic eyes. No serious complications were observed.

Conclusions

Minimal invasive glaucoma surgery with the Trabectome seems to be safe and effective. The subgroup analysis of different kinds of open angle glaucomas presented in this study may help in first-line patient selection. The lack of ocular surface alterations makes it a valuable addition to glaucoma surgery.

Retrospective analysis of the success and safety of Gold Micro Shunt Implantation in glaucoma

BACKGROUND

To evaluate the success rate and adverse effects of Gold Micro Shunt Plus (GMS+) implantation into the supraciliary space.

METHODS

This retrospective study included 31 eyes of 31 patients diagnosed with severe glaucoma and uncontrolled intraocular pressure (IOP) with implantation of a GMS+ by means of a full-thickness scleral flap. The main outcome measures were surgical failure or success, based on the intraocular pressure and adverse effects. Clinical examination data are reported up to 4 years postoperatively.

RESULTS

Thirty eyes (97%) met one of our criteria for failure. Within a mean of 7.3 ± 7.7 months another surgery was performed because of elevated IOP in 24 of 31 eyes (77%) and because of adverse effects in 2 (6%). The remaining 4 eyes, that met one of our criteria for failure, had an IOP reduction of less than 20% with comparable medication. Six GMS+'s were explanted; because of IOP elevation, 2; rubeosis iridis, 2; and low grade inflammation, 2.

CONCLUSIONS

GMS+ implantation is not an effective method to control IOP in patients with glaucoma, when using our surgical technique. The reason for the found signs of chronic low grade inflammation or rubeosis iridis in 4 eyes (13%) remains unknown and has to be further investigated.

Comparative measurement of intraocular pressure by Icare tonometry and Airpuff tonometry in healthy subjects and patients wearing therapeutic soft contact lenses

BACKGROUND

The aim of the present study was to compare the measurement of intraocular pressure (IOP) through a therapeutic soft contact lens with the "native" measurement. We additionally investigate whether a rebound tonometer (RT) or non-contact tonometer (NCT) is more suitable to measure IOP through a bandage contact lens.

METHODS

The IOP was determined using each of the two methods, three times successively with (lens measurement) and without (native measurement) a soft contact lens. The Icare tonometer (Icare® TA01i, Icare Finland Oy, 23 subjects) and the Airpuff tonometer (Nidek NT 53OP, Nidek CO., LTD, Hiroishi Gamagori, Aichi, Japan, 16 subjects) were used. We compared the mean values (validity parameter) and standard deviation (precision parameter) of the three individual measurements in each case using the paired t-test. In addition, we conducted a power analysis to estimate the maximum error in the measurement caused by the contact lens (power level set to 0.8).

RESULTS

With the Airpuff tonometer we detected no statistically significant between the lens and the native measurement (15.6 ± 2.6 vs. 15.3 ± 2.6 mmHg; p = 0.42). The power analysis revealed that the maximum error caused by the contact lens was 1.2 mmHg. The Icare tonometry, however, trended toward higher values in the contact lens measurements (17.5 ± 4.3 vs. 16.4 ± 3.5 mmHg in the native measurements; p = 0.05). Interestingly, this difference exhibited a statistically significant correlation with the corneal thickness (0.03 mmHg per μm corneal thickness; p = 0.04).

CONCLUSION

The use of NCT and RT for IOP measurement over a soft contact lens is feasible. The accuracy appears to be sufficient for the most common clinical applications.

Light scattering and wavefront aberrations in in vivo imaging of the rat eye: a comparison study

PURPOSE

In vivo imaging of the retina is becoming an increasingly important research method. General anesthesia rapidly compromises the corneal surface, which increases scattering. In addition, wavefront aberrations limit the maximum imaging resolution. Three common methods of stabilizing the air-cornea interface and reducing scattering are the use of a contact lens, a microscopy slide coverslip, or mineral oil. These methods have not yet been analyzed regarding their impact on scattering and wavefront aberrations.

METHODS

Nineteen eyes of 19 rats were analyzed with a custom-made Hartmann-Shack (HS) wavefront sensor. The amount of scattering was determined by analysis of the HS spot width, and the wavefront was reconstructed for the naked eye and each scattering-reducing method. Their effect on optical quality was determined by calculating the modulation transfer function (MTF).

RESULTS

The three methods applied significantly reduced scattering but were differentially effective, with the coverslip performing the best and the mineral oil the worst. The root mean square (RMS) of the wavefront aberration, as well as the intereye variability of the RMS, was significantly smaller with the contact lens than with the coverslip. The MTF was best for the contact lens and worst for the coverslip, which was also illustrated by image simulations.

CONCLUSIONS

The coverslip, contact lens, and mineral oil, when applied to the cornea, all reduced scattering. The best-performing method, the coverslip, increased wavefront aberrations. Overall, the contact lens had the best influence on image quality, and it appears to be the method of choice for high-resolution retinal imaging in rats.

[Endocyclophotocoagulation for the treatment of glaucoma]

Cyclophotocoagulation is the standard cyclodestructive procedure for treating patients with refractory glaucoma. In addition to transscleral cyclophotocoagulation, endoscopically controlled cyclophotocoagulation (ECPC) is a relatively new method, introduced in the 1990s. Its clinical and technical background is outlined in this article. ECPC allows direct visualization of the ciliary body and better control of the applied laser energy. Therefore, ECPC has been described as being more effective and safer than the transscleral approach. Our own retrospective ECPC data, however, do not indicate that this method can sufficiently decrease intraocular pressure. The indication for the invasive procedure of endoscopic cyclophotocoagulation is therefore questionable.

The medical and surgical treatment of glaucoma

BACKGROUND

Ongoing demographic changes in Europe are heightening the importance of adequate treatment for glaucoma, a disorder that is markedly more common in the elderly.

METHOD

A selective search for relevant literature, including Cochrane Reviews and the guidelines of the European Glaucoma Society, regarding the topical and surgical treatment of glaucoma.

RESULTS

It is recommended that the intraocular pressure (IOP) should be lowered by 20% to 50% from its baseline value, depending on the extent of already existing damage, the rate of progression, the baseline IOP, and the age of the patient. Topical monotherapy can lower the IOP by 15% to 30%. The success rate of filtration surgery has risen because of the intraoperative application of topical antimetabolites and currently ranges from 50% to 90%, depending on the study.

CONCLUSIONS

The goal of glaucoma treatment is to protect the patient from blindness and visual impairment while keeping the treatment-related decline in quality of life to a minimum. Any type of glaucoma treatment, be it medical or surgical, must further this aim in consideration of the situation of the individual patient.

[Trabecular meshwork bypass surgery for glaucoma]

The outflow facility of the glaucomatous eye can be significantly enhanced by opening Schlemm's canal to the anterior chamber. Surgical options for this approach include mechanical procedures, laser surgery, microbipolar cauterization and intracanalicular microstents. Especially in the area of combined cataract-glaucoma surgery these procedures are valuable options owing to their limited intraoperative and postoperative risk profiles. However, trabeculectomy with mitomycin C must still be regarded as the superior surgical option for glaucoma, which requires a low target pressure if combined surgery is unnecessary.

Self-application of single-use eyedrop containers in an elderly population: comparisons with standard eyedrop bottle and with younger patients

PURPOSE

To test whether patients aged >or=80 years can safely and successfully apply eyedrops from a single-use eyedrop container without support, and to compare the results with those of younger patients using single-use containers and older patients using standard eyedrop bottles.

METHODS

Patients aged >or=80 years who had no physical or mental conditions hindering self-application of eyedrops and actually did so because of glaucoma or dry eyes were included consecutively in the study group (n = 44) in order to perform self-application of eyedrops from single-use eyedrop containers. Patients were observed meticulously by two investigators, who documented practical problems during the procedure in a checklist. In control group A (n = 22), glaucoma or sicca patients aged between 50 and 65 years applied drops from single-use eyedrop containers; in control group B (n = 28), glaucoma or sicca patients aged >or=80 years used a traditional eyedrop bottle.

RESULTS

Successful application of the drops into the conjunctival sac was achieved by 57% in the study group (95% and 89% in control groups A and B, respectively). Scratching of the eyedrop container along the conjunctiva or cornea was observed in 68% of the study group (41% and 61% in control groups A and B, respectively). Frequency of problems during opening and self-application of single-use eyedrop containers in the study group showed an inverse correlation to visual acuity in the better eye and previous experience with this kind of eyedrop container.

CONCLUSION

Older patients have massive problems in self-administering eyedrops from single-use containers. Factors influencing the success of self-application may include the patient's previous experience with this kind of eyedrop container and the patient's visual acuity.

[Midterm patient satisfaction following mitomycin C-assisted trabeculectomy]

BACKGROUND

There are few published data on patient satisfaction following glaucoma surgery. The aim of our study was to investigate factors influencing patient satisfaction more than one year after trabeculectomy with mitomycin C.

MATERIAL AND METHODS

We sent a two-page questionnaire to 61 female glaucoma patients who had consecutively undergone filtering surgery with MMC at the Department of Ophthalmology, University of Cologne, requesting anonymous replies (mean follow-up 19.2+/-2.5 months).

RESULTS

The response rate was 79%. There was no significant inverse correlation between patient satisfaction and recent IOP values, redness of the eye, local irritation or foreign body sensation. There was a significant correlation between patient satisfaction and visual function, a significant inverse correlation between frequency of visits to the ophthalmologist and frequency of eye drop application. A weak, insignificant inverse correlation was found between satisfaction and number of topical medications.

CONCLUSIONS

Patient satisfaction seems to correlate primarily with practical impact on everyday life, visual function, frequency of eye drop application and visits to the eye doctor being identified as the major issues. Local symptoms related to the filtering bleb seem to have a minor influence on patient satisfaction.

[Ultrasound biomicroscopic diagnosis of scleral foreign bodies]

BACKGROUND

Small intrascleral foreign bodies of different materials, especially plastic or organic, can sometimes not easily--or not at all--be detected by routine X-ray examination or computed tomography scan. The aim of our study was to evaluate the usefulness of ultrasound biomicroscopy (UBM) with regard to the detection and localisation of such foreign bodies.

METHODS

An in vitro study with the preparation of a scleral tunnel on 12 porcine eyes was performed. Small foreign bodies of different types of material were placed in the tunnel. The UBM was performed with a Humphrey Ultrasound Biomicroscope, Model 840, to evaluate its diagnostic value in detecting and specifying these sclera-covered foreign bodies.

RESULTS

Even small foreign bodies of the anterior ocular segment of only 200 microm in size can be detected with the UBM due to the typical ultrasound patterns and artifacts. However, there is no diagnostic specificity for the corresponding material.

CONCLUSION

The UBM is a high-frequency ultrasonic device with an imaging depth of 5 mm and a spatial resolution of 100 microm. Therefore it is a useful alternative or, respectively, additional diagnostic tool to common imaging techniques like routine X-ray imaging or CT scans, especially in the detection of non-metallic objects. It can provide important information for the ophthalmic surgeon with regard to pre-operative evaluation of the eye. Furthermore, the UBM might even substitute operative exploration of foreign bodies if they are located in the anterior segment of the eye.

Cyclodialysis ab interno as a surgical approach to intractable glaucoma

PURPOSE

In glaucoma filtration surgery, the problem of subconjunctival scarring has still not been satisfactorily solved. Suprachoroidal drainage of aqueous humour offers a promising, alternative option for intractable glaucoma. We here present a clinical study on the surgical approach of gonioscopic cyclodialysis ab interno.

PATIENTS AND METHODS

Twenty-eight eyes of 20 patients with intractable glaucoma were included in this prospective, consecutive, case-control study. The eyes had had a mean of 4.4 +/- 2.4 previous antiglaucomatous interventions. Baseline intraocular pressure (IOP) was 34.3 +/- 10.5 mmHg despite maximum therapy. Under gonioscopic control, cyclodialysis ab interno was performed over two clock times to gain access to the suprachoroidal space. No additional trabecular meshwork surgery was performed. Success was defined as a lowering of IOP to below 21 mmHg without the need for further medication or intervention.

RESULTS

Mean postoperative IOP was 14.6 +/- 12.4 mmHg. Mean follow-up (FU) for all eyes was 121.8 days. After a mean of 60 days, 21 eyes (75%) needed further surgical intervention. Qualified success was seen in four eyes (14.3%), with a mean FU of 383.6 days. Three eyes (10.7%) showed absolute success after a mean FU period of 202.7 days. In our series, we obtained the best results for phakic eyes, followed by pseudophakic and aphakic eyes.

CONCLUSION

The results of this study do not provide convincing evidence of the functional efficacy of cyclodialysis ab interno. Nevertheless, the technique is easy to perform and offers safe and atraumatic access to the resorptive capability of the choroid. Conjunctival manipulation is avoided. Contrary to reports in the current literature, in our series, the best results were obtained for phakic eyes, though the small number of eyes included does not allow reliable statistics. Further studies will need to focus on the use of different space-retaining substances or a widening of the cyclodialysis cleft to improve surgical outcome.

A novel approach to suprachoroidal drainage for the surgical treatment of intractable glaucoma

PURPOSE

In glaucoma surgery, scarring of the artificial fistula is the limiting factor for long-term control of intraocular pressure (IOP). Several devices and surgical techniques have been developed for artificial aqueous humor drainage in intractable glaucoma. The authors describe a novel surgical technique that uses a silicone tube as a shunt for aqueous flow from the anterior chamber to the suprachoroidal space.

PATIENTS AND METHODS

Thirty-one eyes of 31 patients with uncontrollable refractory glaucoma were included in this prospective consecutive case-control study. Each eye had undergone an average of 3.5+/-1.9 previous interventions for glaucoma. The baseline IOP was 44.25+/-8.7 mm Hg despite maximum therapy. As in trabeculectomy, a limbus-based scleral flap was prepared. The suprachoroidal space was accessed via a deep posterior scleral flap. The silicone tube was inserted as an intrascleral connection from the anterior chamber to the suprachoroidal space. Cyclodialysis was avoided by this surgical approach. Success was defined as a lowering of IOP to below 21 mm Hg without the need for further medication or intervention.

RESULTS

The mean functional shunt survival was 55.9+/-45.6 weeks. IOP was reduced to 12.9+/-5.2 mm Hg in 70% of all eyes after 30 weeks postoperatively. After 52 weeks, 60% of the eyes could be classified as representing success, and 76 weeks after surgery, 40% of the eyes still showed controlled IOP. In none of the eyes were severe postoperative hypotony or suprachoroidal bleeding observed. No localized or general inflammation or infection was seen in connection with the silicon tube. Two patients needed anterior chamber lavage because of bleeding. In 2 patients the tube had to be removed because of corneal endothelial contact. Shunt failure of the tube was caused in some cases by connective tissue formation at the posterior lumen of the tube.

CONCLUSION

This novel surgical approach and the placement of the silicone tube described here have several advantages. Its intrascleral course minimizes the risk of conjunctival erosion and associated infections. No cyclodialysis is performed. Connection to the suprachoroidal space exploits the resorptive capability of the choroid. It guarantees drainage but also provides a natural counterpressure, avoiding severe postoperative hypotony. The suprachoroidal shunt presented here achieves good follow-up results in terms of IOP control. No serious complications have been observed. This new method promises to be an effective surgical technique and presents a new therapeutic option in intractable glaucoma. Fibroblast reaction obstructing the posterior lumen, seemed to be the only factor limiting drainage. Further studies and experiments will be needed to elucidate the exact physiologic mechanisms underlying the draining, the capacity and duration of the draining effect, and the histologic background of suprachoroidal scarring.

[Bilateral anterior panuveitis as early manifestation of syphilis in a patient with HIV infection]

INTRODUCTION

Syphilis is a dangerous sexually transmitted infection which can be effectively treated with penicillin to avoid late-onset diseases. Even if syphilis is diagnosed an HIV infection should be excluded.

PATIENT

A 32-year-old homosexual man complained about a decreased bilateral visual acuity after a feverish infection with lymphadenitis colli. With slit-lamp biomicroscopy a bilateral panuveitis with papillary edema, endothelial cells and episcleritis was found. After antimycotic and antiviral therapy, his visual acuity decreased and symptoms progressed. In the lab routine we found lues and HIV infections and started an intravenous penicillin therapy immediately. A few days later the symptoms improved and visual acuity increased.

CONCLUSION

Lues serology should be incorporated into routine lab diagnostics to aid the detection and to start the right therapy as soon as possible.

[The effect of brimonidine on the pupillary reflex. A pupillographic study in healthy volunteers]

PURPOSE

The effect of brimonidine in comparison with acetazolamide on pupillary reflex was investigated in 18 volunteers.

METHODS

Infrared pupillography was performed with white diode light of 200 ms duration to measure pupil diameter, constriction latency, reaction time, constriction amplitude, and relative constriction amplitude. The measurements were performed according to a fixed schedule including a phase without medication to determine the baseline level. Data were analyzed by Student's paired t-test.

RESULTS

Application of brimonidine and acetazolamide led to a significantly reduced intraocular pressure as well as static and dynamic differences in the pupillary reflex. The pupil diameter measurements were significantly smaller after both medications in comparison to baseline. The reduction of pupil diameter after brimonidine led to significantly reduced contraction amplitude and prolonged latency.

CONCLUSION

Application of brimonidine leads to significant miosis, which might due to the affinity to alpha(2)-receptors with reduction of noradrenaline release in the synapse. This effect may play a role in a higher decrease of intraocular pressure by increasing aqueous humor outflow in comparison to clonidine and apraclonidine, but further investigations are required.

Central and paracentral corneal pachymetry in patients with normal tension glaucoma and ocular hypertension

PURPOSE

The difference in central corneal thickness among subgroups of glaucoma patients, as well as its influence on Goldmann applanation tonometry, has been well documented in several clinical trials. In the present study, possible similarities and differences between central corneal thickness and corneal thickness of paracentral quadrants in patients with normal tension glaucoma (NTG) and ocular hypertension (OHT) were investigated.

METHODS

Central and paracentral corneal thickness was measured by optical slit scan pachymetry (Orbscan II). Fourteen patients (28 eyes) with NTG and 11 patients (22 eyes) with OHT were included in this study. t-Test was performed for statistical analysis. To evaluate overall corneal topography, the mean and SD values of the differences between the central corneal thickness and each peripheral quadrant were analysed.

RESULTS

The following data was obtained (microm): (central, upper, temporal, nasal, inferior paracentral quadrant): OHT group 617-695-663-687-660. NTG group 568-629-593-612-616. Corneal thickness of all four paracentral quadrants differed significantly between the OHT and NTG groups. There was a more heterogeneous intraindividual pattern of overall corneal topography in the OHT group, and a more heterogeneous pattern of corneal topography among the individuals of the NTG group (interindividual heterogeneity).

CONCLUSIONS

A comparison of central corneal thickness and paracentral corneal thickness revealed clinically relevant differences between the OHT and NTG groups. The presented data underlines the importance of correlating the site of applanation with the corresponding corneal thickness, especially in OHT patients. It further substantiates the necessity to obtain individual pachymetric data for each NTG patient.

Neue Aspekte der Hornhautpachymetrie beim kongenitalen Glaukom und kindlichen Aphakieglaukom

BACKGROUND

Knowledge of individual corneal thickness in individual eyes is proving to be more and more crucial for correcting Goldmann applanation tonometry, as well as to assess its predictive value regarding the possible progression of glaucomatous damage. It has become an important factor in determining appropriate glaucoma therapy. Only few pachymetric data exist about eyes with congenital or secondary pediatric aphakic glaucoma.

METHODS

12 eyes with congenital glaucoma (6 patients, mean age 3.3 years, mean 3.9 previous operations) and 7 eyes with secondary pediatric aphakic glaucoma (4 patients, mean age 14.8 years, mean 3 previous operations) without clinical signs of corneal decompensation were investigated by ultrasound pachymetry.

RESULTS

Eyes with glaucoma due to aphakia had a mean corneal thickness of 708 +/- 77.3 microm. Mean corneal thickness of the eyes with congenital glaucoma was 688.1 +/- 115.9 microm, which is far above the values known from the literature. Two eyes, which had a central corneal thickness of 646 microm and 640 microm, presented with a localised paracentral corneal thickness of only 402 microm and 405 microm, respectively, correlating with microscopic descemet scars.

CONCLUSIONS

Congenital glaucoma and the pediatric aphakic glaucoma present with very heterogeneous clinical pictures. Especially for congenital glaucoma, this is confirmed by the high interindividual, but also intraindividual, variability of corneal pachymetry.

Photodynamic modulation of wound healing in glaucoma filtration surgery

AIM

To report a clinical pilot study investigating photodynamic therapy (PDT) in combination with glaucoma filtration surgery. BCECF-AM was used as the photosensitising substance. The clinical safety and tolerability of BCECF-AM, and its efficacy in controlling postoperative intraocular pressure (IOP) were assessed.

METHODS

Before trabeculectomy (TE), 42 consecutive eyes of 36 glaucoma patients received one subconjunctival injection of 80 micro g BCECF-AM (2,7,-bis- (2-carboxyethyl) -5- (and-6) -carboxy-fluorescein, acetoxymethyl-ester) followed by an intraoperative illumination with blue light (lambda = 450-490 nm) for 8 minutes. Antifibrotic efficacy was established as postoperative IOP reduction of >20% and/or an IOP constantly < 21 mm Hg without antiglaucomatous medication. Follow up of the filtering bleb was documented by slit lamp examination.

RESULTS

Eyes had mean 1.1 preoperative surgical interventions (filtration and non-filtration glaucoma surgery). Mean preoperative IOP was 31.6 (SD 9.7) mm Hg. Patients were followed for mean 496 days (range 3.5-31.8 months). Of the 42 eyes, 25 eyes had an IOP decreased to 15.8 (3.4) mm Hg without medication (complete success: 59.5%; p<0.001; t test). Seven eyes showed good IOP reduction < 21 mm Hg under topical antiglaucomatous medication (qualified success: 16.7%). 10 eyes failed because of scarring within 2-67 weeks (23.8%). Clinical follow up examinations revealed no local toxicity, no uveitis, and no endophthalmitis.

CONCLUSIONS

This method is a new approach in modulating postoperative wound healing in human eyes undergoing glaucoma filtration surgery. The data of the first human eyes combining TE with PDT underline the clinical safety of this method and its possible potential to prolong bleb survival.

Intermediate uveitis in childhood preceding the diagnosis of multiple sclerosis: a 13-year follow-up

PURPOSE

An association between multiple sclerosis during childhood and uveitis is exceptionally rare. This is a report of a female patient who presented at the age of 8 years with bilateral intermediate uveitis and whose final diagnosis of multiple sclerosis was made at age 21 years.

DESIGN

Case report.

METHOD

Retrospective chart review of a 13-year follow-up history.

RESULTS

Over 10 years our patient was treated systemically and underwent bilateral vitrectomy to reduce permanent side effects. Owing to good visual function and low inflammatory signs, systemic therapy was stopped. Multiple sclerosis was diagnosed at the age of 21, after a 13-year history of uveitis and after 3 years without medication.

CONCLUSIONS

In the constellation of uveitis in childhood and later diagnosis of multiple sclerosis, the outlined therapy provided good functional results. Moreover, it may have delayed the manifestation of the underlying disease for 13 years.

Iris pigment epithelial cells transplanted into the vitreous accumulate at the optic nerve head

BACKGROUND

Iris pigment epithelial (IPE) cells have mainly been investigated in the past for their proposed potential to rescue or even replace degenerated retinal pigment epithelial (RPE) cells after subretinal transplantation in patients with age-related macular degeneration (AMD). More recent reports have characterised the IPE cell as a potent source of trophic factors and cytokines. In our study we investigated the spatial distribution of IPE cells that were injected into the vitreous instead of being injected subretinally.

METHODS

IPE cells from Long Evans rats were isolated and injected into the vitreous cavity of Wistar rats without preculturing. Free melanin granules were injected into the vitreous in the same manner. After a period of 2 months, eyes were prepared for histological analysis. Localisation of the injected IPE cells was defined by topographical mapping of the analysed sections.

RESULTS

PVR was not observed in any eye. In 8 of 10 injected eyes, IPE cells had accumulated in the prepapillary region. In 2 of 10 eyes, no IPE cells could be detected. The injected melanin granules also accumulated at the optic nerve head, indicating that this is most likely a passive process. In sections of the papillary region containing retinal vessels, the IPE cells seemed to have migrated into the superficial tissue of the optic nerve head.

CONCLUSION

Our results demonstrate a way to access the optic nerve head easily and securely without the danger of damaging its fragile structure. This could have important implications for new therapeutic strategies in ocular neurodegenerative diseases like glaucoma. New prospects in gene therapy will require further characterisation of the potential of the IPE cell to produce neuroprotective trophic factors at the optic nerve head.

Specific features of apoptosis in human lens epithelial cells induced by mitomycin C in vitro

BACKGROUND

Posterior capsule opacification (PCO) is still one of the major complications following modern cataract surgery. Several attempts have been made to find an appropriate therapeutic concept to significantly lower the rate of PCO. Here, we wanted to focus on the antimetabolic strategy, reducing PCO by using mitomycin C, further characterizing the pathway of apoptosis in human lens epithelial cells (hLECs).

METHODS

Human lens epithelial cells were obtained from anterior lens capsules during cataract surgery. The expression of Fas, TRAMP, TRAIL-R1-R4, Apo-3L and TRAIL mRNA was investigated by means of RT-PCR using specific primers. For investigations on bcl-2, bax, p53 and the active form of caspase 3, cell cultures of hLECs were pretreated with mitomycin C and processed for immunocytochemistry thereafter.

RESULTS

We detected the expression of the receptors Fas, TRAMP, TRAIL-R2 and TRAIL-R3 in hLECs. We further obtained evidence of the upregulation of the intracellular apoptotic signalling cascade, represented by bcl-2 and bax, the transcription factor p53 and the active form of caspase 3, after pretreatment with mitomycin C.

CONCLUSION

We demonstrated the presence of the apoptosis-receptor system in hLECs. Furthermore, we demonstrated the possibility of the induction of key proteins of the apoptotic signalling cascade in these cells by the antimetabolic drug mitomycin C. This could have important implications on the strategies regarding both the prevention and the treatment of PCO after cataract surgery.

An apparatus and behavioral training protocol to conduct positron emission tomography (PET) neuroimaging in conscious rhesus monkeys

Nonhuman primates offer a unique resource in neuroimaging research, providing the opportunity to manipulate appropriate biological and behavioral variables under well-controlled experimental conditions in an animal model that is closely related to humans, both functionally and neuroanatomically. The present report describes the development and standardization of PET neuroimaging protocols in conscious rhesus monkeys and their application to characterize the acute effects of cocaine on cerebral blood flow. Specific attention was devoted to the development of an effective and comfortable head restraint device to be used in the imaging of conscious monkeys. The restraint device was designed to attach to a standard primate chair to facilitate frequent immobilization. Subjects received extensive behavioral training prior to neuroimaging in order to ensure their comfort and minimize potential stress associated with the imaging protocols. Functional changes in cerebral blood flow were characterized in three subjects with the positron-emitting tracer 15O water following acute i.v. administration of cocaine. Regions of interest were defined on MRI scans with a high degree of accuracy. Cocaine caused pronounced increases in cerebral blood flow at 5 min postinjection that diminished markedly within 25 min. The results document the feasibility to conduct PET neuroimaging studies of cerebral blood flow in conscious nonhuman primates. Extension of the methodology to include brain activation during behavioral studies could contribute significantly to the growing discipline of behavioral neuroscience.

Oxidation causes melanin fluorescence

PURPOSE

The goal of this study is the characterization of the strong yellow fluorescence of oxidized melanin in the retinal pigment epithelium (RPE) and the choroid.

METHODS

Naturally occurring melanin in the human retina and choroid was oxidized by exposing fixed and plastic-embedded sections of a human eye to light and hydrogen peroxide. Synthetic melanin was also oxidized in vitro by exposure to light and hydrogen peroxide. The fluorescence of oxidized melanin was examined by absorption spectroscopy, fluorescence spectroscopy, and fluorescence microscopy.

RESULTS

Naturally occurring melanin oxidized in situ exhibited a lipofuscin-like yellow fluorescence. Oxidation of melanin in vitro degraded the melanin polymer, resulting in a fluorescent solution. Fluorescence spectroscopy gave an excitation maximum at approximately 470 nm and an emission maximum at approximately 540 nm for both natural and synthetic melanin. Increasing the time of exposure to light or hydrogen peroxide increased melanin fluorescence.

CONCLUSIONS

The results indicate that the strong yellow fluorescence of melanin in the RPE and choroid in situ is a property of oxidized melanin and is not due to contamination of the melanin by proteinaceous or lipid materials. The data presented allow a reinterpretation of the results obtained from fluorescence investigations of melanin-containing tissue and suggest a link between melanin degradation and lipofuscin formation.

Very long baseline interferometric observations made with an orbiting radio telescope

An orbiting spacecraft and ground observatories have been used to obtain interferometric observations of cosmic radio sources. The Tracking and Data Relay Satellite System (TDRSS) was used as the orbiting observatory in conjunction with two 64- meter radio telescopes at ground observatories, one in Australia and one in Japan. The quasars 1730-130 (NRAO 530), 1510-089, and 1741-038 were observed at a frequency of 2.3 gigahertz, and a maximum projected baseline of 1.4 earth diameters was achieved. All quasar observations for which valid data were acquired resulted in detected fringes. Many of the techniques proposed for a dedicated very long baseline interferometry observatory in space were used successfully in this experiment.

Arcial growth with metallic implants in mandibular growth prediction

The present investigation was undertaken to determine whether the Ricketts theory of arcial growth of the mandible can be put to practical use by the clinician to predict mandibular morphology. Eight subjects (six girls and two boys) were selected from the earliest implant samples at the Orthodontic Department of Emory University School of Dentistry. The initial cephalograms were coded and sent to Ricketts, and a 6-year manual growth forecast using the arcial method was requested. The final cephalograms were traced and compared. The three tracings (initial, prediction, and final) were superimposed over the metallic implants and presented on a case-by-case basis. The forecasts, in form, were clinically acceptable in five of the eight cases. In two of the cases (girls) (Cases 2 and 4) a hand-wrist radiograph to determine skeletal age would have improved their accuracy. The forecast in Case 2 was not acceptable. In view of our results in this small sample, the arcial method appears valid for prediction of amndibular growth; however, hand-wrist radiographs will improve the accuracy of short-range predictions of the amount of growth expected. For this reason, the orthodontist should constantly monitor his patients, watching for each individual to assert himself.

Mariner 9 Celestial Mechanics Experiment: Gravity Field and Pole Direction of Mars

Analysis of the Mariner 9 radio-tracking data shows that the Martian gravity field is rougher than that of Earth or the moon, and that the accepted direction of Mars's rotation axis is in error by about 0.5 degrees . The new value for the pole direction for the epoch 1971.9, referred to the mean equatorial system of 1950.0, is right ascension alpha= 317.3 degrees +/- 0.3 degrees , declination delta = 52.6 degrees +/- 0.2 degrees . The values found for the coefficients of the low-order harmonics of Mars's gravity field are as follows: J(2)=(1.96+/-0.01)x10(-3), referred to an equatorial radius of 3394 kilometers; C(22) = -(5 +/- 1) x 10(-5); and S(22) = (3 +/- 1) x 10(-5). The value for J(2) is in excellent agreement with the result from, Wilkins' analysis of the observations of Phobos. The other two coefficients imply a value of (2.5 +/- 0.5) x 10(-4) for the fractional difference in the principal equatorial moments of inertia; the axis of the minimum moment passes near 105 degrees W.