[Visual rehabilitation in patients with hereditary retinal dystrophy: current data from a Low Vision Department]

BACKGROUND

Especially during adolescence, hereditary retinal dystrophies can cause visual impairment. Because of their high mobility and working activities, these patients represent a great challenge for a Low-Vision Department. This study illustrates the spectrum of appropriate magnifying devices for them, as prescribed in our Low-Vision Department.

PATIENTS AND METHODS

Between January 2003 and October 2004, we took care of 2,500 patients in our Low-Vision Department. 141 (5.6 %) of them suffered from a hereditary retinal dystrophy. After ascertaining the best corrected distance and near visual acuity as well as the magnification demand we prescribed the appropriate optic or electronic magnifying aids.

RESULTS

The preferential age for the first visit was between 15 and 40 years. Within the retinal dystrophies we saw cone-rod dystrophy in 46 (33 %) patients, Stargardt's disease in 38 (27 %), retinitis pigmentosa in 37 (26 %), albinism in 15 (11 %) and achromatopsia in 5 (3 %) patients. The average of the best corrected distance visual acuities of the better eye was 0.142 (SD +/- 3.3 lines), the best corrected visual acuity for reading was 0.124 (SD +/- 6.1 lines). The average magnification demand was 5 x (SD +/- 6.7). The most prescribed optic magnifying aids were distance spectacles and magnifying glasses (each 20 %), monocular telescopes, contrast enhancing filters (each 13 %) and reading glasses (8 %). Electronic magnifying aids were prescribed in only 8 %.

CONCLUSIONS

Fluent reading ability in hereditary retinal dystrophies could be achieved mostly by optic magnifying aids. The high proportion of prescribed distance glasses and magnifying glasses shows that often simple magnifying aids are suitable for these patients. Because of the high photophobia, contrast-enhancing filters should always be considered.

Late-stage, primary open-angle glaucoma in Europe: social and health care maintenance costs and quality of life of patients from 4 countries

OBJECTIVE

The purpose of this study was to estimate costs and quality of life (QoL) of late-stage glaucoma patients in 4 European countries.

METHODS

Retrospective review of medical charts of patients with POAG who were followed in a low-vision or vision rehabilitation center in one of 4 countries for at least 1 year was used to determine patient characteristics, health status, and health care resource use. Visual impairment was measured by best-corrected visual acuity (Snellen score). Patients were also interviewed over the telephone in order to assess their health-related QoL (using EuroQol EQ-5D) and use of resources including: the number of visits to rehabilitation centers, visits to hospital and non-hospital specialists, the use of low-vision devices, medication, tests, and the use of hired home help. The costs associated with resource use were calculated from the perspective of a third-party payer of health and social care based on resource usage and unit costs in each country.

RESULTS

Patients undergoing visual rehabilitation in France (n=21), Denmark (n=59), Germany (n=60), and the United Kingdom (n=22) were identified, interviewed and had their medical charts reviewed. Annual maintenance costs of late-stage glaucoma amounted to euro830 (+/-445) on average. Average home help costs were more than 3 times higher. QoL, on average, was 0.65 (+/-0.28). QoL was positively correlated with the level of visual acuity in the patients' best eye. On the other hand, visual acuity was also positively correlated to health care costs, but negatively correlated to costs of home help.

CONCLUSIONS

The study was limited by its observational, uncontrolled design. The finding that late-stage glaucoma is associated with higher home help costs than health care maintenance costs suggests that potential savings from a better preventive treatment are to be found for social care payers rather than health care payers.

Qualitätskontrolle bei der Rehabilitation sehbehinderter Patienten

BACKGROUND

Not only medical care and prescription of magnifying devices, but also social and professional rehabilitation are part of a complete interdisciplinary low vision service. This study provides quantitative data about the success of rehabilitation and the quality of the Low Vision Department's work.

PATIENTS AND METHODS

A sample of 105 visually disabled patients, who had already been provided with magnifying aids and other rehabilitation measures by the Low Vision Department, answered a questionnaire about quality control during a follow-up visit. The survey was carried out between May and October 2004. Patients were asked to rate the different rehabilitation measures and to comment on how frequently they used the different magnifying devices. Furthermore, they were asked to judge to what degree they coped with different life situations when using or not using the low vision aids.

RESULTS

The most frequently used aids were magnifiers (61%), glasses for near vision (34%), closed circuit television (20%), and monocular telescopes (20%). Of the 105 patients, 85 (81%) reported on frequent use of the devices, with just 3 patients (3%) reporting that they hardly ever used the aids. Only 2% of the patients could read newspaper text without the use of magnifying aids, while 51% were able to do this using the aids; 46% of the patients reported that they had profited from the social and professional rehabilitation measures.

CONCLUSION

Independently from the causal ophthalmologic diagnosis, patients were found to have benefited greatly from the rehabilitation measures provided by the Low Vision Department, enabling them to take part in more activities and participate more fully in social life, thereby greatly improving their quality of life. Frequent use of the low vision aids by the patient was ensured when offered alongside continued professional support.

[Age-related macula degeneration and diabetic retinopathy -- differences in optic rehabilitation]

BACKGROUND

Age-related macular degeneration (AMD) and diabetes mellitus are the major contributing causes of visual impairment in the industrial nations. This study shows how far visual acuity (VA) and magnification demand (MD) influence the selection of suitable low vision aids. Based on this information, differences regarding the spectrum of prescribed magnifying devices between both patient groups will be presented.

MATERIALS AND METHODS

Between January 2003 and October 2004, a total of 2500 patients was seen in our Low Vision Department. Among them were 1198 patients with AMD (48 %) and 296 visually impaired patients because of diabetic ocular involvement (12 %). In every patient, best corrected distance and near VA as well as the required MD were measured. Finally, matching of magnifying aids and discussing aspects of professional and social rehabilitation were the main parts of our interdisciplinary Low Vision Service.

RESULTS

In AMD patients, the average of best corrected distance VA at the better eye was 0.24, the best corrected near VA was 0.19. In diabetes patients, the average of best corrected distance VA at the better eye was 0.28, the best corrected near VA was 0.22. The required mean MD was 4.0 x (related to the reading of newspaper text) compared to 7.6 x in patients with AMD. In 94 % of the visually impaired diabetes patients, optical magnifiers could be prescribed (e. g. magnifying eyeglasses, telescopes, monoculars, Galelean and Keplerian systems), whereas electronic devices were necessary in only 6 %. In comparison, 14.8 % of the patients with AMD had to be provided with electronic systems.

CONCLUSIONS

In 94 % of the visually impaired patients caused by diabetes, reading ability could be restored using optical low vision aids. In AMD patients, this could be achieved in only 85.2 %. This fact can mainly be explained with the negative effect of absolute central scotomas on reading speed in AMD patients which leads, compared to diabetes patients, to elevated magnification factors. Therefore, the choice of certain magnifying devices depends not only on VA, but has mainly to be evaluated based on the individual MD.

[Relative contraindication of latanoprost in iris tumors with secondary glaucoma]

INTRODUCTION

Melanocytic iris tumors are often benign and merely require regular follow-up. Evident growth, increasing pigmentation and secondary glaucoma, however, are possible signs of a malignant transformation.

PATIENT

We present a 34-year-old male patient showing a localized, mildly prominent hyperpigmentation of the right iris expanding over 2 h. The lesion had been known since childhood and increasing intraocular pressure (IOP) was treated with timolole, dipivefrin and finally with latanoprost.

PROGRESSION

The patient was seen for the first time at our hospital 4 years previously, presenting an IOP of 28-30 mmHg of the right eye. The tumor had developed marked heterochromia and a nodular prominent surface, the chamber angle was partly closed and completely hyperpigmented. The ciliary body was not affected by the tumor and standard ultrasound revealed a maximum thickness of 1.2 mm. Over the last 4 years, IOP and heterochromia had increased but without growth of the tumor. An excisional biopsy of the prominent portion was refused by the patient.

DISCUSSION

The melanocytic iris tumor described shows malignant characteristics such as progressive heterochromia and secondary glaucoma. However, increasing iris pigmentation can also be caused by topical application of latanoprost. With the evidence of absent tumor growth, there is no reason to suggest malignant degeneration. Generally, in iris naevi or tumors requiring regular follow-up, application of latanoprost should be avoided in order not to conceal the alteration of pigmentation as possible malignant conversion.

[Ocular involvement in nail-patella syndrome (#161200)]

PURPOSE

The "nail-patella syndrome" (NPS) is an autosomal dominant hereditary systemic disease. The underlying defect of the LMX1B gene is localised on chromosome 9q34 and causes various typical clinical signs such as onychodysplasia, patella hypoplasia, renal involvement and open angle glaucoma.

PATIENTS

A 42-year-old mother and her 4-year-old son were examined in our hospital in order to exclude ocular involvement in a genetically confirmed "nail-patella syndrome". A clinical examination including corneal topography, gonioscopy as well as measurement of intraocular pressure and bulbus length was performed.

RESULTS

The examination of both patients showed NPS-specific symptoms, however the boy revealed no indications of glaucoma. He suffered from marked amblyopia caused by excessive astigmatism of the left eye and a bilateral moderate hyperopia.

CONCLUSION

Because of the co-segregation between the syndrome and open angle glaucoma, NPS patients should undergo regular ophthalmological controls including measurement of intraocular pressure. Experiments on mice have shown that mutations of the LMX1B gene result in alterations of several structures of the anterior segments. Thus, the described refraction abnormality could be the consequence of structural changes at the corneal level due to NPS.

[Bacterial keratitis. Microbiological analysis as a principle for therapeutic recommendations]

PURPOSE

The study presented differentiates between the aetiological agents of bacterial keratitis in patients with and without a history of contact lens wear. Based on these results, recommendations are given for optimal antibiotic primary therapy.

PATIENTS AND METHODS

Swabs and corneal scrapings were taken from 218 patients referred to the University Eye Hospital in Munich with a diagnosis of bacterial keratitis from 1989 to 1997. Ninety-two of these patients had a history of contact lens wear; 126 had none. The germs were isolated and identified by staining and microscopy. Observing polymicrobial growth in 51 patients, a total of 275 germs was isolated.

RESULTS

The most frequent pathogens were Staphylococcus epidermidis (44%), S. aureus (18%), Streptococcus spp. (10%), Propionibacterium acnes (7%) and Pseudomonas aeruginosa (6%). Gram-negative germs were nearly exclusively isolated from contact lens wearers, gram-positive germs were predominant in non-contact lens wearers.

CONCLUSION

Keratitis in patients with a history of contact lens wear is often caused by aggressive gram-negative germs. Those cases should immediately be treated with quinolones and erythromycin. In keratitis caused by gram-positive pathogens, a combination with aminoglycosides and erythromycin is sufficient.

[Bacterial keratitis in patients with and without contact lens anamnesis]

BACKGROUND

The study shows differences between contact lens wearers and patients without history of contact lenses regarding the spectrum of etiological agents in bacterial keratitis. Based on microbiological analysis, there are given recommendations for an optimal initial antibiotic treatment in both groups.

MATERIAL AND METHODS

From 1989 to 1997 smears, scrapings and corneal biopsies were taken from 218 patients with bacterial keratitis. The causing pathogens were isolated on directly inoculated culture media and identified by staining and microscopy. The resistance pattern of a total of 275 germs was analysed for different antibiotics.

RESULTS

The most frequently isolated germs were Staphylococcus epidermidis, Staphylococcus aureus, Streptococcus spp., Propionibacterium acnes and Pseudomonas aeruginosa. Whereas sensitive gram-positive germs were predominating in contact lens wearers as well as in non-contact lens wearers, multiresistant gram-negative germs could nearly exclusively be isolated from contact lens wearers. Frequently administered antibiotics like aminoglycosides and quinolones are effective in infections caused by Staphylococcus spp., but increasing resistance could be seen to Streptococcus spp. In this case, erythromycin is very sensitive. Gram-negative germs like Pseudomonas aeruginosa are sensitive to quinolones and some aminoglycosides (e.g. tobramycin).

CONCLUSION

In contact lens wearers, more aggressive germs have to be considered than in non-contact lens wearers. In such cases, frequently administered antibiotics like amino-glycosides are not effective. To cover problematic gram-negative germs we recommend the application of quinolones alternating with erythromycin. The latter one is more effective than quinolones and aminoglycosides in case of Streptococcus spp. co-involvement.

[Eye involvement in Chagas disease (American trypanosomiasis). 1996/1997 studies in Paraguay]

BACKGROUND

Last year's pilot study, which examined for the first time a representative group of patients with Chagas disease, showed that in this parasitosis changes in the ocular fundus can be expected in the form of defects of the retinal pigment epithelium. Examination of more patients in this study should give further information about the character and extent of the alterations found.

MATERIALS AND METHODS

After serological confirmation of the disease, we performed an ophthalmological examination of the anterior and posterior segments.

RESULTS

In 21 out of 23 patients the fundus was unobtrusive; 1 patient showed fibrae medullares and 1 patient clear pigment dispersion on the posterior pole. Together with the pilot study, a total of 102 chagasic patients were examined. In 8 patients (7.8%) defects of the retinal pigment epithelium were found, which did not cause any significant loss of vision.

CONCLUSIONS

We presume that the described defects are a matter of rare and harmless postinflammatory or immunological changes in the American type of trypanosomiasis.

[Intraocular involvement of Chagas disease (American trypanosomiasis). Studies in Paraguay/South America]

BACKGROUND

In Central and South America, Chagas' disease is of great epidemiologic importance. The epidemiologic agent is represented by Trypanosoma cruzi, a monocellular parasite, instrumental in human infection is the presence of vectors, which are various species of hematophagous bugs. The eye is one of the most important entrance sites of the parasite, and relatively little information about the relationship between Chagas' disease and eye complications is available.

PATIENTS AND METHODS

We examined 79 chagasic patients in order to detect changes in the retina. As a control group, we examined 48 patients with negative serology within the same age range and from the same regions. For every patient we completed a routine ophthalmologic examination, with inspection of the retina using direct and indirect ophthalmoscopy.

RESULTS

In most of the chagasic patients, the ocular fundus was unobtrusive; in only 6 out of 79 cases (7.6%) we did observe small parafoveolar retinal pigment epithelium defects and in 1 case (1.3%) distinct pigment epithelium atrophy of the posterior pole. No comparable findings were observed in the control group.

CONCLUSION

Compared with the examination results of the control group, in the patients with intermediate and chronic Chagas' disease we observed an accumulation of retinal pigment epithelium defects, which, however, did not cause a significant loss of vision.