Presentation of Graves' orbitopathy within European Group On Graves' Orbitopathy (EUGOGO) centres from 2012 to 2019 (PREGO III)

BACKGROUND

Graves' orbitopathy (GO) is subject to epidemiological and care-related changes. Aim of the survey was to identify trends in presentation of GO to the European Group On Graves' Orbitopathy (EUGOGO) tertiary referral centres and initial management over time.

METHODS

Prospective observational multicentre study. All new referrals with diagnosis of GO within September-December 2019 were included. Clinical and demographic characteristics, referral timelines and initial therapeutic decisions were recorded. Data were compared with a similar EUGOGO survey performed in 2012.

RESULTS

Besides age (mean age: 50.5±13 years vs 47.7±14 years; p 0.007), demographic characteristics of 432 patients studied in 2019 were similar to those in 2012. In 2019, there was a decrease of severe cases (9.8% vs 14.9; p<0.001), but no significant change in proportion of active cases (41.3% vs 36.6%; p 0.217). After first diagnosis of GO, median referral time to an EUGOGO tertiary centre was shorter (2 (0-350) vs 6 (0-552) months; p<0.001) in 2019. At the time of first visit, more patients were already on antithyroid medications (80.2% vs 45.0%; p<0.001) or selenium (22.3% vs 3.0%; p<0.001). In 2019, the initial management plans for GO were similar to 2012, except for lid surgery (2.4% vs 13.9%; p<0.001) and prescription of selenium (28.5% vs 21.0%; p 0.027).

CONCLUSION

GO patients are referred to tertiary EUGOGO centres in a less severe stage of the disease than before. We speculate that this might be linked to a broader awareness of the disease and faster and adequate delivered treatment.

Multiple Sulfatase Deficiency from an Ophthalmologist's Perspective-Case Report and Literature Review

Multiple sulfatase deficiency (MSD) is an extremely rare autosomal recessively inherited disease with a prevalence of 1:500.000 caused by mutations on the sulfatase-modifying-Factor 1 gene (SUMF1). MSD is most specifically characterised by a combination of developmentally retarded psychomotoric functions, neurodegeneration that entails the loss of many already acquired abilities, and by ichthyosis. Other symptoms include those associated with mucopolysaccharidosis, i.e., facial dysmorphy, dwarfism, and hepatosplenomegaly. In 50-75% of all MSD-affected patients, functional or structural ocular damage is likely. MSD seldom affects the anterior segment of the eye. The main pathology these patients present is a highly conspicuous tapetoretinal degeneration, similar to severe Retinitis pigmentosa, that leads to blindness at an early age. An initially five-year-old boy with MSD, genetically verified at his first examination in our opthalmology department (SUMF1 mutations c.776A>T, p.Asn259Ile; c.797A>T, p.Pro266Leu; c.836A>T, p.Ala279Val), and a 4, 5 year regular follow-up are described. The patient had some visual potential ("tunnel view"), which deteriorated dramatically after his fifth birthday. We observed no evidence of worsening retinal involvement in this patient in spite of his progressively worsening clinical symptoms, extending to total blindness/no light perception. OCT revealed that the outer retinal layers containing photoreceptors were diseased; the ellipsoid zone was only partially discernible and the outer nuclear layer appeared to be thinned out. The inner nuclear layer, ganglion cell layer, and retinal nerve fibre layer were indistinguishable. These anomalies are indicative of a severe pathology within the retina's inner layers. Characteristic anomalies in the fundus should stimulate clinicians to suspect a case of MSD in their differential diagnosis, and thus to order thorough genetic and paediatric diagnostics.

[Ocular prosthetics in children-Possibilities and challenges]

One of the greatest challenges for ocularists is prosthetic fitting in children, especially in children with congenital anomalies such as clinical anophthalmia or functionless (blind) microphthalmia. The most frequent reason for prosthetic fitting in children is a condition following enucleation for retinoblastoma, followed by trauma and congenital pathologies. The standard treatment after enucleation or evisceration begins intraoperatively with the selection of an suitable implant and the use of a conformer at the end of the operation to shape the prosthetic cavity. An initial prosthesis can be fitted 4 weeks postoperatively, with a final fitting taking place 3 months later. If iatrogenic scarring or scarring due to an infection of the prosthetic cavity occurs, the approach of the ocularist must be appropriately adapted with the use of modified prosthesis shapes and shorter treatment intervals. Surgical options include scar excision and oral mucosa or amniotic membrane transplantation. Congenital anomalies require the shortest treatment intervals and even more so for anophthalmia than for microphthalmia. The strategy is characterized by simultaneous stimulation of the soft tissue of the ocular adnexa as well as the bony orbit. As self-inflating hydrogel expanders are no longer available, conservative prosthetic treatment is the only option. Close cooperation between child/parent, ocularist and ophthalmic plastic surgeon is the best prerequisite for a good long-term treatment outcome.

The use of lyophilized bovine pericardium (Tutopatch®) in the management of third nerve palsy following prior conventional strabismus surgery - a case series

To study the secondary management of strabismus due to third nerve palsy using bovine pericardium (Tutopatch®) when previous conventional surgical therapy had failed. Review of our clinic records of selected patients with third nerve palsy, in whom residual deviation had been managed using Tutopatch® after previous surgical correction. The squint angle was measured preoperatively, and at 1 day, 3 months, and if possible 6 months postoperatively. Nine patients were enrolled in this study. One patient had mainly residual vertical deviation and was corrected with tendon elongation of the contralateral superior rectus. Three patients were operated on with tendon elongation of the lateral rectus muscle with or without medial rectus muscle resection and/or advancement (Group 1). Lateral rectus splitting after tendon elongation in addition to the resection and/or advancement of the medial rectus was performed in five patients with complete third nerve palsy (Group 2). In Group 1, the preoperative median squint angle was -20° (range -17° to -25°), which improved postoperatively to -4.5° (range -12° to +3°). In Group 2, the preoperative horizontal and vertical median squint angles were -27° (range -20° to -40°) and 0.5° (range 0° and 20°), respectively. Postoperatively, they had improved to -12.5° (range-2° to -25°), and 1.5° (range 0° to 7°), respectively. Two patients of Group 2 were re-operated due to residual exotropia. No postoperative complications were observed in any patient. In this small series several complex re-do situations of patients with third nerve palsy were evaluated in which Tutopatch® markedly improved outcomes after an initially ineffective surgical management. For better evaluation of its usefulness a study with more patients is recommended.

Therapeutic Strategies in 103 Children with Congenital Microphthalmos

INTRODUCTION

Congenital microphthalmos can either occur alone (simple microphthalmos) or be associated with other ocular malformations, such as sclerocornea or cataract (complex microphthalmos). As this is a rare condition, there are no uniform recommendations for treatment.

MATERIAL AND METHODS

Retrospective case series of 103 patients or a total of 114 eyes with congenital microphthalmos, with reporting of age, sex, visual acuity, pupil reaction, axial length, horizontal width of the palpebral fissure, type of therapy performed and complications.

RESULTS

All patients would have been able to be fitted with a prosthesis primarily. The size of the palpebral fissure depended on the underlying findings: "bilateral microphthalmos" < "microphthalmos and healthy fellow eye" < "microphthalmos and fellow anophthalmos". In order to assess visual (residual) function in an infant in the first weeks or months of life, the pupillary response is of the upmost importance in deciding on therapy, especially in unilateral disease, and as assessed with the indirect light response of the healthy eye. In about half of the cases, conservative prosthetic treatment was sufficient. After the successful initial fitting of a prosthesis, the prosthesis was enlarged according to the ocularist's instructions. If the eye length difference was so large that symmetry could not be achieved even with a double-walled prosthesis, volume filling with retrobulbar implanted self-swelling pellet expanders (osmed GmbH, Ilmenau) was offered. In almost one third of the patients, no surgical therapy or prosthetic treatment was performed. The reason for this was usually the presence of minimal visual function of the microphthalmos - ranging from light perception to hand movements.

CONCLUSIONS

In the case of visual function of the microphthalmos, surgical measures should not be indicated or only with extreme caution, since the preservation of the existing visual acuity must be regarded as having priority over the cosmetic findings. In cases of asymmetry or underdeveloped palpebral fissure, therapy can be started early in the first year of life without fear of resulting complications.

The Nasolacrimal Drainage System in 143 Children with the Microphthalmos-Anophthalmos Complex

BACKGROUND

Report of clinical findings relating to the lacrimal system in congenital clinical anophthalmos and severe blind microphthalmos (MAC-complex patients).

METHODS

A retrospective study of the notes of 207 consecutive patients treated surgically at least once with highly hydrophilic self-inflating expanders for MAC between 1998 and 2021. The lacrimal drainage system was always probed and irrigated under general anaesthesia before any other procedure was started.

RESULTS

64 patients were excluded due to possible misdiagnosis because of previous lid or orbit surgery elsewhere or due to missing data. The analysis therefore included 67 girls and 76 boys aged between 1 and 126 months (median age: 5 months). 72 patients presented with unilateral and 42 with bilateral anophthalmos, and 24 had unilateral and 5 bilateral microphthalmos; consequently, 286 orbits (of which, 190 with probable pathology) were available for assessment. In unilateral cases the lacrimal system on the normal side was never affected. On the anophthalmic or microphthalmic side the lacrimal system was normal in 68 orbits only (35.8%). The most frequent finding was canalicular stenosis (91 orbits; 48%). Common canaliculus stenosis was observed in 12 orbits (6.3%) and nasolacrimal duct obstruction in 9 orbits (4.7%). There were four cases of punctal aplasia, but no other anomalies. In unilateral MAC pathologic findings during lacrimal probing were found to be associated with anatomical malformation of the contralateral fellow eye. Only in unilateral anophthalmos there was a significant association with cleft lip and palate, which was not found in the three other groups.

CONCLUSIONS

In congenital clinical anophthalmos the lacrimal system is affected in up to 66.5% of cases, mostly due to canalicular stenosis. Even if there is no clear evidence of an embryological connection, this association is certainly not a random finding.

Postoperative Behaviour after Primary Strabismus Surgery in Children: Is There an Influence of Intraoperative Topical Anaesthesia?

INTRODUCTION

The course of the recovery phase after general anaesthesia, during which consciousness and pain gradually return, is essentially determined by the choice of anaesthetic drug, and its total dose or duration of application. This phase is often complicated by more or less severe agitation, especially in children. In the present study we investigated whether the application of a topical anaesthetic to the conjunctiva at the end of a strabismus operation had a positive effect on the recovery behaviour of the child.

PATIENTS/METHODS

This prospective, randomised, blinded study was conducted with 50 healthy, ASA class I or II children, aged 3 to 8 years undergoing their first strabismus operation. Following the surgeon's randomisation two drops of a 0,5% tetracaine-HCl ophthalmic solution were applied to the operated conjunctiva three times at 30-s intervals immediately following wound closure. The postoperative evaluation encompassed heart rate, as well as COMFORT and CHEOPS scores. The first assessment was directly postoperatively with repetitions at 15, 30, 45, 60, 75, 90 and 120 min, as well as on the day after surgery.

RESULTS

The CHEOPS scores did not differ significantly between children with or without topical anaesthesia at any time during the observation period. The COMFORT scores revealed a slight, but non-significant analgesic effect at 15 and 30 min. The 60 min score showed the opposite effect, possibly indicating a slight disadvantage of the topical anaesthesia. There were no significant differences with regard to time to first request for additional systemic analgesia, to the total dose of systemic pain medication, or to when the patient was eligible for discharge to the ward.

CONCLUSION

The application of topical tetracaine-HCl immediately after wound closure had no positive effects on the course of the postoperative recovery period after strabismus surgery in children. There was no evidence of an effect on pain or emergence agitation.

[Diseases of the Lacrimal Gland]

Tear gland diseases are comparatively rare in daily ophthalmological practice. The aim of this article is on the one hand to present the necessary basic knowledge and on the other hand to draw a bow to important current publications on the subject in order to provide the reader with sufficient knowledge for daily practice after reading it.Inflammatory (acute and chronic specific dacryoadenitis, idiopathic dacryoadenitis), neoplastic (epithelial and nonepithelial) and structural (cysts etc.) are presented.Diagnostically, the importance of (open) biopsy has increased again in recent years. Only the pleomorphic adenoma of the lacrimal gland has to be removed in-toto in order to avoid a recurrence or malignant degeneration which is difficult to control curatively. Differential diagnostic aids are explained in detail.

Erkrankungen der Tränendrüse

In der augenärztlichen Praxis sind pathologische Veränderungen der Tränendrüse(n) selten anzutreffen. Es überrascht daher nicht, dass sie in augenärztlichen Standardwerken häufig nicht im Detail dargestellt sind. Anliegen dieses Artikels ist es, kompakt notwendiges Basiswissen zusammenzustellen und den Bogen zu wichtigen aktuellen Publikationen zu spannen, um dem Leser nach der Lektüre eine umfassende Kenntnis für die tägliche Praxis zu vermitteln.

[Atropine for the Prevention of Progression in Myopia - Data, Side Effects, Practical Guidelines]

The prevalence of myopia has increased worldwide in recent decades. In East Asia's metropolises ≥ 80% of young adults are affected. This dramatic increase is mainly caused by changes in lifestyle and behaviour. Atropine has been used for more than 100 years to arrest myopia progression. It has become an evidence-based treatment regimen in the last decade, although the exact mechanism of the effect of treatment is still unknown. Atropine eye drops can slow myopia progression by an average of - 0.54 dioptres (D)/year in Asian children and - 0.35 D/year in Caucasian children. However, a non-response rate of about 10% has been found. Treatment should be established in schoolchildren only (age ≥ 6 years) with myopia ≤ - 2 D (spherical equivalent, cycoplegic refraction) and with documented myopic progression of - 0.5 D in the preceding year. 0.01% eyedrops should be instilled into the lower fornix at bedtime. Atropine 0.01% therapy is well tolerated. Atropine is usually administered for 2 years since efficacy is somewhat better in the second year. During treatment, a 6-month follow-up with cycoplegic refraction and axial length measurement is recommended. After the 2-year period, atropine withdrawal is justified if progression is less than - 0.25 D/year in the second year. Even after atropine has been stopped, follow-up examinations are needed to detect any rebound. Atropine-therapy is resumed if progression is again higher than - 0.5 D/year. Topical atropine is used off-label.

[Alcohol Injection in a Patient with Chronic Orbital Pain after Enucleation - a Case Report and Review of the Literature]

A case is presented of a 54-year old patient who had been treated 10 months previously with enucleation for a painful blind eye. This led to severe and chronic pain in the orbital region that did not respond to conventional pain management. However, a single 1.5 ml injection of 96 % ethanol led to almost complete resolution of pain for the follow-up period of 6 months. Orbital pain after enucleation or evisceration may originate from the implant itself, the prosthesis, the socket or the sinuses. Taking a careful medical history and an examination, including orbital scans, are necessary to decide on the correct differential diagnosis. If any pathology is excluded, one should keep in mind that phantom pain in the orbit seems common after removing an eye, more often when pain originating from the ball and/or headache was present before removal. The management of chronic pain in the orbital region has received little attention. Retrobulbar alcohol injection still has a place in modern ophthalmology, because it delivers effective pain relief in certain chronic conditions.

Alternating Current Stimulation for Vision Restoration after Optic Nerve Damage: A Randomized Clinical Trial

BACKGROUND

Vision loss after optic neuropathy is considered irreversible. Here, repetitive transorbital alternating current stimulation (rtACS) was applied in partially blind patients with the goal of activating their residual vision.

METHODS

We conducted a multicenter, prospective, randomized, double-blind, sham-controlled trial in an ambulatory setting with daily application of rtACS (n = 45) or sham-stimulation (n = 37) for 50 min for a duration of 10 week days. A volunteer sample of patients with optic nerve damage (mean age 59.1 yrs) was recruited. The primary outcome measure for efficacy was super-threshold visual fields with 48 hrs after the last treatment day and at 2-months follow-up. Secondary outcome measures were near-threshold visual fields, reaction time, visual acuity, and resting-state EEGs to assess changes in brain physiology.

RESULTS

The rtACS-treated group had a mean improvement in visual field of 24.0% which was significantly greater than after sham-stimulation (2.5%). This improvement persisted for at least 2 months in terms of both within- and between-group comparisons. Secondary analyses revealed improvements of near-threshold visual fields in the central 5° and increased thresholds in static perimetry after rtACS and improved reaction times, but visual acuity did not change compared to shams. Visual field improvement induced by rtACS was associated with EEG power-spectra and coherence alterations in visual cortical networks which are interpreted as signs of neuromodulation. Current flow simulation indicates current in the frontal cortex, eye, and optic nerve and in the subcortical but not in the cortical regions.

CONCLUSION

rtACS treatment is a safe and effective means to partially restore vision after optic nerve damage probably by modulating brain plasticity. This class 1 evidence suggests that visual fields can be improved in a clinically meaningful way.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01280877.

[Orbital neoplasia. Part I: Introduction, vascular and neurogenic tumors]

Tumors of the orbit are rare but the huge variability of clinical symptoms and findings are challenging for the ophthalmologist who is frequently contacted as the first resort. If the patient history and clinical findings are suspicious for an orbital mass the result of the initial examination should allow a rough estimation of localization (intra/extraconal), type of growth (expansive/infiltrative), dignity (vascular/solid etc.) and threat to visual functions. An adequate initial diagnostic pathway enables a precise question to the radiologist to be formulated and selection of the disciplines required for an interdisciplinary workup and therefore for early treatment.

Dermatofibrosarcoma protuberans with primary orbital manifestation

A 45-year-old, otherwise healthy woman presented with mild epiphora and a palpable mass in the lacrimal sac area. After transcutaneus orbitotomy and complete excision histopathology revealed a primary Dermatofibrosarcoma protuberans invading the orbit. During the 24-months follow-up, no recurrence occurred. To the best of our knowledge this is the first report of a primary DFSP with the orbit involved.

[Development of oculoplastic surgery in Kinshasa (capital of Democratic Republic of Congo)]

The partnership between Saint Joseph Hospital in Kinshasa (Capital city of DRC) and University Eye Clinic Rostock, Germany exists since 2000. The ophthalmologists from Rostock University performed 12 visits of St. Josef Hospital with the aim to perform oculoplastic surgery in complicated cases as well as to teach the local ophthalmologists. There they performed about 150 surgeries (entropion, ectropion, ptosis, repair of lid injuries, eye lid reconstruction and tumour management, lacrimal surgery) in joint teams. The programme of on-site training was established during this time. Meanwhile, the Kinshasa colleagues are able to perform the basic techniques by themselves. Two colleagues have obtained advanced training in oculoplastics in Rostock. The fruitful cooperation enabled the development of oculoplastic surgery in St. Josef Hospital in Kinshasa. The further education and training proccesses will support the continuous advancement in ophthalmological health care in DRC.

Epileptic monocular nystagmus and ictal diplopia as cortical and subcortical dysfunction

We present the case of a patient with ictal monocular nystagmus and ictal diplopia who became seizure-free after resection of a right frontal focal cortical dysplasia (FCD), type 2B. Interictal neuroophthalmological examination showed several beats of a monocular nystagmus and a spasm of the contralateral eye. An exclusively ictal monocular epileptic nystagmus could be an argument for an exclusively cortical involvement in monocular eye movement control. The interictal findings in our patient, however, argue for an irregular ictal activation of both the cortical frontal eye field and the brainstem.

Orbital decompression in thyroid eye disease

Though enlargement of the bony orbit by orbital decompression surgery has been known for about a century, surgical techniques vary all around the world mostly depending on the patient's clinical presentation but also on the institutional habits or the surgeon's skills. Ideally every surgical intervention should be tailored to the patient's specific needs. Therefore the aim of this paper is to review outcomes, hints, trends, and perspectives in orbital decompression surgery in thyroid eye disease regarding different surgical techniques.

[Faden operations - indications beyond esotropia and surgical results]

BACKGROUND

Faden operations is a well-known surgical option for the treatment of esotropia. To the best of our knowledge there are only a few reports available dealing with this particular topic.

PATIENTS AND METHOD

Retrospective series of patients in whom between 2000 and 2011 a faden operation was performed under all indications except esotropia. 23 patients (9 Graves' disease, 9 third nerve palsy, 3 sixth nerve palsy, 1 muscle dystrophy, 2 orbital trauma) were included.

RESULTS

5 out of 7 horizontally disturbed patients were operated unilaterally and the remaining 2 bilaterally. The field of binocular single vision increased from 15-70° preoperatively by 10-25° (unilateral) and 20-35° (bilateral) to 30-80° postoperatively. Out of the 16 vertically disturbed patients only one was operated on superior and inferior rectus simultaneously and all the other on only one muscle. The field of binocular single vision increased from 5-55° preoperatively by 5-45° to 10-80° postoperatively. There were no complications so far and none of the patients worsened with the surgery.

CONCLUSION

A faden operation might help to increase the field of binocular single vision in cases of restrictive squint like Graves' disease or in paralytic strabismus.

[Erdheim-Chester disease of the orbit with compressive optic neuropathy]

A 60-year-old man presented with left exophthalmos and deterioration in visual acuity of slow evolution. Bilateral orbital Erdheim-Chester disease was diagnosed. Systemic evaluation revealed a retroperitoneal fibrosis. Treatment with interferon-alpha followed, but bilateral compressive optic neuropathy with visual acuity deterioration and visual field defects evolved. Bilateral orbital decompression was performed.

[Amyloidosis--a rare differential diagnosis of an orbital tumour]

BACKGROUND

Amyloidosis is a disorder caused by a misfoulding of proteins. The deposition of these proteins in tissues and organs can affect the normal function of those tissues and organs.

MATERIALS AND METHODS

Two patients are presented and an overview over the so far published cases with a localised orbital amyloidosis is given.

RESULTS

The first case is a 50-year-old woman with progressive ptosis since half a year, progressive proptosis since three months and deterioration of motility and deviation of the left globe. The second case is a 68-year-old man with progressive ptosis since four years and with affection of the subtarsal conjunctiva of the right eye. Macroscopically a yellow-brown, gelatinous, easily crumbled material was seen during operation.

CONCLUSION

the histological proof of amyloidosis can be made visually in intense unidirectional polarised light after congo red staining. This should be done in suspected cases every time. The orbita can also be involved in systemic forms of amyloidosis, so a systemic form should be excluded. The localised amyloidosis has no effect on the survival time in contrast to the systemic forms does have an effect. An untreated systemic form may be associuated with a prognosis of only 9 to 13 months.

[Comparing specific disc findings of a European and a Bantu population]

BACKGROUND

Glaucoma is the main cause of irreversible blindness in the world. Because of the increasing mean age, glaucoma is expected to become more common in the developing countries. Besides tonometry and perimetry the appearance of the optic nerve head is a main part of glaucoma diagnosis. Ethnic differences have to be considered. This study compares the appearance of the optic nerve head between blacks and whites.

STUDY DESIGN

This is a retrospective analysis of 225 whites of a Swiss population and 1027 blacks of a Congolese population. Using a matched pairs technique 207 whites and 207 blacks were chosen, regarding age, sex, intraocular pressure and examined eye (right/left). The analysis of the optic nerve head was performed by using the "Heidelberg-Retina-Tomograph II" (HRT).

RESULTS

Among the 207 persons of both groups we found 116 females and 91 males. There were 103 right eyes and 104 left eyes examined. The mean age was 45.6 +/- 15.6 years. Compared with European population in the African population we found a greater disc area (2.56 vs. 1.81 mm(2)) as well as a greater cup area (0.65 vs. 0.41 mm(2)) and a greater rim area (1.91 vs. 1.40 mm(2)). Regarding the cup disc area ratio there was no significant difference between both populations found (Kinshasa: 0.24 vs. Basel: 0.21). Although there was no significant difference of the maximum cup depth of both groups we found a deeper mean cup depth in the African population. Furthermore, we found differences regarding the cup shape measure, the RNFL thickness and the height variation contour.

CONCLUSION

As already described in different studies, there are significant differences in the morphology of the optic nerve head between blacks and whites. Although blacks are expected to have a greater cup disc area ratio, this fact could not be proved in this study. As a new fact we found a different mean cup depth between Africans and Europeans, which might be explained by the different cup shape of both populations.

Systemic and ophthalmological anomalies in congenital anophthalmic or microphthalmic patients

INTRODUCTION

Congenital anophthalmos and microphthalmos are reported to occur in 1-20/100 000 newborn infants. The conditions may be characterised by associated pathology in the fellow eye when unilateral disease is present and/or by complex systemic anomalies.

METHODS

We conducted a review of 75 patients with congenital anophthalmos or blind microphthalmos who were examined in our department from 1997 to 2008. Data on pregnancy, birth and family history were collected. Patients were screened for any pathology in the fellow eye in unilateral disease and for any systemic anomaly.

RESULTS

Sixteen patients had blind unilateral microphthalmos. To date there has been only one case of bilateral microphthalmos. Congenital anophthalmos was unilateral in 38 and bilateral in 20 patients. Only one of the children had a positive family history for anophthalmos. None of the mothers had had problems in pregnancy or during delivery. There were more associated systemic findings in anophthalmic (50%) than in microphthalmic (17.6%) patients. Typically, the pathology was characterised by Goldenhar's syndrome, facial clefts and developmental cerebral anomalies. Four out of 16 patients with unilateral microphthalmos (25%) and 18 out of 38 patients with unilateral anophthalmos (47.4%) had anomalies in the fellow eye, predominantly coloboma, dermoid, sclerocornea and glaucoma. On account of this pathology in a single eye, two (12.5%) of the patients with unilateral microphthalmos and 13 (34.2%) of the patients with unilateral anophthalmos, as well as all 20 patients with bilateral anophthalmos, were classified as legally blind. Therefore the overall blindness rate was 17.6% in microphthalmos and 3.4 times higher (56.9%) in anophthalmos.

CONCLUSIONS

All children born with congenital anophthalmos or microphthalmos require a thorough clinical examination by an experienced ophthalmologist to rule out pathology in the fellow eye in unilateral disease and by a paediatrician to screen for any associated systemic anomalies.

[Childhood blindness. VISION 2020 and experiences in an African city]

The struggle against childhood blindness is being given high priority by the WHO. In regions of the world countries where the income per head is low there are 5 times as many blind children as in wealthy countries (1.5/1000 vs 0.3/1000 children). In developing countries cataract is regarded as the main cause of blindness in both childhood and adulthood. If all cataracts that would lead to blindness were operated on, despite a comparatively smaller number of affected persons a similar number of sighted life-years could be achieved throughout the world to that for patients with senile cataract. The partnership between the Rostock Ophthalmological Department and St. Joseph's Hospital in Kinshasa focuses on the analysis and treatment of avoidable blindness in children. Its main concern is the introduction of appropriate procedures for cataract surgery, in most cases combined with the implantation of injectable synthetic intraocular lenses. In the last 7 years about 600 procedures have been jointly performed, including 400 of congenital cataract, mostly bilateral.

[Comparing applanation and impression tonometry in Central African Bantu people]

BACKGROUND

Glaucoma is the main reason for irreversible blindness in the Central African population. Because of the high prevalence, the rapid progression and the limited possibilities of diagnosis and treatment in Africa, glaucoma leads more often to blindness, compared with other parts of the world. The irreversible character of the glaucoma makes it necessary to recognise this disease as soon as possible. Beside the appearance of the optic nerve and visual field defects, tonometry is considered as an essential part of the diagnosis of glaucoma. This study compares the Shiotz tonometer with applanation tonometry to find out whether the Shiotz tonometer presents similar results in the African population.

STUDY DESIGN

In the time between October 2001 and July 2002 in the Democratic Republic of Congo 2020 eyes of 1027 persons were examined. Beside other ophthalmological examinations the intraocular pressure were taken by applanation (Perkins tonometer) and impression tonometry (Shiotz tonometer).

RESULTS

A difference of more than 2 mmHg between the two methods was found in 26.5 % of the examined eyes. Among the first 1000 eyes this difference was found in 40 % of the eyes, while among the second part of the examined eyes only in 13.2 % did a difference appear. Both methods showed a good correlation with k = 0.96 (p < 0.01). For short- or long-sighted eyes, a difference between both methods was found more often than for normal eyes. Among the long-sighted eyes the impression tonometry found higher values for the intraocular pressure more often than among the short-sighted eyes. But altogether the applanation tonometry showed higher values more often for short- as well as for long-sighted eyes. There were no correlations between the age of the examined persons and the difference between the two methods.

CONCLUSION

Altogether it can be said that for screening impression tonometry shows a satisfactory correlation with applanation tonometry in the hands of a well-trained ophthalmologist, who has done at least 1000 examinations. Differences between the two methods are mainly found for long- or short-sighted eyes.

Results of lacrimal assessment in patients with congenital clinical anophthalmos or blind microphthalmos

AIM

To report clinical findings relating to the lacrimal system in congenital clinical anophthalmos and severe blind microphthalmos.

METHODS

A retrospective (up to 2003) and prospective (2004 onwards) study of the notes of 60 consecutive patients treated surgically with highly hydrophilic self-inflating expanders for congenital anophthalmos or severe blind microphthalmos between 1997 and 2006. The lacrimal drainage system was always probed and irrigated under general anaesthesia before any other procedure was started.

RESULTS

Nine patients were excluded due to possible misdiagnosis because of previous lid or orbit surgery elsewhere or due to missing data. The analysis therefore included 23 girls and 28 boys aged between 1 and 90 months (median age: 4 months). Twenty-three patients presented with unilateral and 18 with bilateral anophthalmos, and 10 had unilateral microphthalmos; consequently, 102 orbits (of which, 69 were with probable pathology) were available for assessment. In unilateral cases, the lacrimal system on the normal side was never affected. On the anophthalmic or microphthalmic side, the lacrimal system was normal in 17 orbits only (24.6%). The most frequent finding was canalicular stenosis (40 orbits; 58%). Common canaliculus stenosis was observed in 5 orbits (7.3%) and nasolacrimal duct obstruction in 7 orbits (10.1%). There were no cases of punctal anomaly.

CONCLUSIONS

In congenital clinical anophthalmos the lacrimal system is affected in up to 78% of cases, mostly due to canalicular stenosis. Even if there is no clear evidence of an embryological connection, this association is certainly not a random finding.

Injectable self inflating hydrogel pellet expanders for the treatment of orbital volume deficiency in congenital microphthalmos: preliminary results with a new therapeutic approach

BACKGROUND/AIM

Children with congenital microphthalmos are usually able to wear an eye prosthesis but the cosmetic aspect is determined by the size of the orbital volume deficiency. Instead of using a ball shaped standard hydrogel expander or a regular orbital implant, which would necessitate enucleation of the microphthalmic eye, this study investigates the feasibility of volume augmentation with injectable pellet expanders, as formerly suggested for acquired anophthalmos in adults only.

METHOD

The pellet expander is made from a self inflating hydrogel that takes up water by osmosis (dry state: length 8 mm, diameter 2 mm, volume 0.025 ml; in vitro hydrated state after around 1 day: length 15 mm, diameter 4 mm, volume 0.24 ml; swelling capacity: 9.6-fold). This report concerns six patients (two girls and four boys) aged between 4 months and 42 months with unilateral microphthalmos who were treated by injection of 4-14 pellet expanders into the retrobulbar orbital tissue. Volume augmentation was 1-3.5 ml. The pellets were injected using a customised trocar and placed behind the microphthalmos directed into the intraconal space.

RESULTS

The increasing orbital volume was noticeable within 2 days and was confirmed by ultrasonography and magnetic resonance imaging. The final result can be anticipated by the volume augmentation effect produced by the amount of saline solution injected in the orbital apex region. All patients were fitted with an artificial eye, which was subsequently enlarged every 3-5 months. Anophthalmic enophthalmos was fully compensated with this technique. No complications have been encountered to date.

CONCLUSIONS

Orbital volume augmentation with injectable self inflating hydrogel expander pellets is apparently a safe, quick, and minimally invasive technique for various indications in orbital reconstructive surgery-for example, to treat an enophthalmic appearance in microphthalmos and congenital or acquired anophthalmos.

Laterale kn�cherne Orbitadekompression bei endokriner Orbitopathie

PURPOSE

In Graves' disease a discrepancy between volume increase of the orbital soft tissues and fixed volume of the orbital cavity leads to exophthalmos. The patients do not only feel cosmetically disfigured, they often complain about more or less painful retroorbital pressure sensation or show symptoms of compressive optic neuropathy or corneal exposure because of a significant lid lag. To solve this problem, different orbital decompression techniques have been developed. This is to report about our results with a modified Dollinger technique for lateral orbital decompression.

PATIENTS AND METHODS

A total of 27 patients aged 19-76 years (mean: 45.1 years) with Grave's ophthalmopathy were recorded who had undergone orbital decompression by a lateral approach between June 1999 and April 2003. The modified Dollinger technique was performed by deepening the osteotomy to the level of the sphenoid wing and by additional resection of intraconal fat.

RESULTS

The reduction of exophthalmos achieved after decompressive surgery averaged 2.9 +/- 1.1 mm. Of the patients whose indication for orbital decompression was a compressive neuropathy, the visual acuity improved postoperatively for 3 lines. Of the 16 patients with preoperative retrobulbar pressure sensation, 12 had no complaints after the operation. Remarkably no significant impairment of the ocular motility resulted after surgery.

CONCLUSIONS

Decompression of the orbit by the modified Dollinger technique is a safe and effective approach to reduce exophthalmos, retrobulbar pressure sensation, and compression neuropathy as a result of diffusely elevated orbital tissue tension. In the case of direct compression of the optic nerve in the orbital apex, additional medial orbital wall decompression has to be considered.

[Treatment of congenital clinical anophthalmos with high hydrophilic hydrogel expanders]

INTRODUCTION

Children presenting with congenital anophthalmos usually develop a smaller bony orbit, a constricted mucosal socket, and a shortened eyelid fissure. This causes problems when fitting these patients with a prosthesis. Clinical evaluation of the Wiese self-inflating hydrogel expanders has demonstrated their ability to expand the socket and eyelid fissure for inserting a more realistic prosthesis in shorter periods of time.

PATIENTS AND METHOD

The study included 13 consecutive anophthalmic patients, eight unilateral and five bilateral. Each patient received a hemispherical osmotic tissue expander in the rudimentary mucosal socket and later a sphere implanted in the deeper soft orbital tissue.

RESULTS

The use of hydrogel expanders enlarged the lid and palpebral fissure in all children, with good cosmetic results. It allowed insertion of custom-made glass prostheses with good cosmetic appearance very early in life. Growth of the bony orbit may be stimulated successfully by these expanders in the soft orbital tissue.

CONCLUSIONS

The enlargement of constricted mucosal sockets and short palpebral fissures using self-inflating hydrogel expanders is a new and successful concept in treating congenital anophthalmos.

[Congenital clinical anophthalmia and blind microphthalmia]

Congenital anophthalmia and blind microphthalmia are very rare conditions and there is no standard treatment available. Various previously reported therapeutical concepts are reviewed. The clinical picture can be divided into three subgroups with different therapeutical options recommended: in microphthalmia the conjunctival sac size is usually normal or slightly decreased. The use of non-expandable conformers is possible with good results. Patients treated with hydrogel expanders can wear a prosthesis earlier and with better cosmetic results. In congenital anophthalmia the conjunctival sac is very small and contracted and patients cannot wear a prosthesis or even a conformer. Hydrogel expander treatment--first for the conjunctival sac and second for the orbit--is the therapeutical option which may lead to good cosmetic results. Children >5 years of age and/or unsuccessful pre-treated cases may benefit from osteotomy to reduce mid-face asymmetry. To attain the main therapeutical goal in this subgroup, the ability to fit a normal prosthesis, a combination of different techniques like hydrogel expanders, dermis fat graft, lid surgery etc. may be necessary.

[Low dosage, fractionated, percutaneous teletherapy of subfoveal choroid neovascularization]

AIM

The effect of low-dose fractionated percutaneous teletherapy on visual acuity and the changes in subfoveal neovascular membranes (SNM) in age-related macular degeneration (ARMD) were studied.

PATIENTS AND METHODS

Forty-four patients (aged from 56 to 86 years) were treated. Best distant and near visual acuity was assessed before (initial visual acuity; IVA) and 5 weeks, 3, 6 and 12 months after teletherapy. Fluorescein angiography was done before and 3 and 12 months after radiation. Patients were divided into different groups by IVA for analysis. Mean follow-up was 9 months. Teletherapy was done by a 9 MeV linear accelerator through a lateral port in the half-beam technique with a single dose of 2 Gy to a total dose of 20 Gy within 20 days.

RESULTS

No severe negative side effects have been observed. Four patients reported epiphora. Visual acuity decreased one line in the group with an IVA of 0.05-0.2. The group with IVA 0.3-0.5 remained unchanged during the observation period. We found a tendency for increased visual acuity in group IVA > or = 0.6.

CONCLUSIONS

Teletherapy seems to have an influence on visual acuity, SNM, and metamorphopsia. IVA and duration of thillness play important roles. We cannot say if there is a persistent effect, as these are preliminary results. The longest follow-up so far has been 12 months. In order to better evaluate the potential of radiotherapy, this study must be pursued and coupled with further studies analyzing the effect on SNM in ARMD.