[Transpupillary thermotherapy in exsudative age-related macular degeneration. Two-years results and findings on the other eye]

The purpose of the prospective randomized study was to analyze long-term results of transpupillary thermotherapy (TTT) in exsudative age-related macular degeneration (ARMD) after 24 months of follow-up and to compare them with findings on the other, not treated eye.

MATERIAL AND METHODS

Seventy-two patients aged 50-93 years (average age 70.6 years) with one eye treated by means of TTT and the other considered as control were in the study. Occult choroidal neovascularization (CNV) was treated in 33 eyes (45.8%), serous ablation of the pigment epithelium (SAPE) in 21 eyes (29.2%), and classical CNV in 18 eyes (25.0%). In all patients, the central visual acuity (VA) on EDTRS chart was specified, the macular findings were observed by means of indirect binocular ophthalmoscope and bio-microscopically with the contact lens on the slit lamp, and fluorescence angiography and optical coherence tomography (OCT) examinations were performed before and 3, 6, 12, 18, and 24 months after the TTT treatment.

RESULTS

The final VA improved or remained unchanged in 27 eyes (37.5%), and worsened in 45 eyes (62.5%), by 5 or more lines the VA worsened in 19 eyes (26.4%). The average VA decreased from initial 0.24 to final 0.13, but the decrease in different forms of ARMD varied. In SAPE the highest initial as well as final average VA was found, in occult and classical CNV the initial and final average VA was almost identical. Exsudative changes observed by means of biomicroscopical, fluoroangiographical, and OCT examinations totally disappeared in 59.7%, 63.9%, and 59.7% respectively. At the end of the follow-up period we observed chorioretinal atrophy of different stage in the macula in all eyes (100%) and subretinal fibrosis in 44 eyes (61.7%). Both these findings represented final stages of natural course of exsudative ARMD. On the contrary, differently pronounced areas of chorioretinal atrophy corresponding with applied laser burns represented scars after the coagulation. It developed in 31 eyes (43.0 %) and pointed to the possible destructive consequence of the TTT. In 33 patients (45.8%), late stages of exsudative ARMD, mostly disciform scars with chorioretinal atrophy were found on the other not treated eye. In these eyes the final average VA was 0.05, e.g. more than one half worse than final average VA in treated eyes.

CONCLUSIONS

Results of TTT treatment after 24 month of follow-up demonstrated full regression of exsudative changes in the macula in 60% of eyes and improved or stable VA in 37.5 % of eyes. Results in SAPE and classical CNV confirmed the efficacy of TTT treatment in those forms of ARMD. The TTT did not prevent the appearance and progress of the chorioretinal atrophy and subretinal fibrosis, causing the main obstacle of better functional results. Extremely unfavorable course of exsudative ARMD in the other (not treated) eye could indirectly confirm the positive influence of the TTT in theARMD treatment. Despite all positives are the possibilities of the TTT limited and determined by the basis and natural course of exsudative ARMD.

[Transpupillary thermotherapy in age-related serous detachment of retinal pigmented epithelium]

The goal of this prospective study was to evaluate results of the transpupillary thermotherapy (TTT) in the age related macular degeneration (ARMD) where the serous detachment of the pigment epithelium (SDPE) was the dominant sign.

MATERIAL AND METHODS

Thirty eyes of 29 patients were treated by TTT. All patients were examined before and 3, 6, 9, 12, 18, and 24 months after TTT in terms of visual acuity (VA), indirect binocular ophthalmoscopy, and indirect slitlamp biomicroscopy, fluorescein angiography, and optic coherent tomography (OCT) of the macular region. In 25 eyes (83,3%) signs of choroidal neovascularization (CNV) were present (vascular SDPE). TTT was performed with a standard technique by diode laser (wavelength 810 nm). In 14 eyes (46.7%) the TTT procedure was repeated after 3 to 38 weeks. The follow-up period was 7 to 28 month (mean 15.2 months).

RESULTS

After TTT, VA improved in 6 eyes (20.0%), remained stable in 8 eyes (26.7%), and deteriorated in 16 eyes (53.3%). Indirect slitlamp biomicroscopy revealed, that the SDPE re-attached in 13 eyes (43.3%), decreased in size in 12 eyes (40.0%); fluorescein leakage disappeared in 16 eyes (53.3%) and was reduced in 10 eyes (33.3%). By OCT, the re-attachment of SDPE was confirmed in 14 eyes (46.7%) and it's reduction in 13 eyes (43.3%). The leading cause of the same or worse VA after diminishing of SDPE was chorioretinal atrophy, with or without subretinal fibrosis.

CONCLUSION

In the long term, the TTT led to the decline of SDPE in the majority of eyes and improved or stabilized VA in nearly on half of eyes. In most cases, signs of neovascularization were present. After the SDPE regression, the chorioretinal atrophy prevented the better functional results. TTT is not economically expensive and widens treatment possibilities in exsudative form of ARMD including SDPE.

[Transpupillary thermotherapy in age-related macular degeneration. Preliminary results]

OBJECTIVE

To evaluate anatomical and functional results of transpupillary thermotherapy (TTT) in age-related macular degeneration (ARMD) with a chorioid neovascular membrane (CNVM).

MATERIAL AND METHODS

TTT was performed by means of a diode laser (Iris Medical Oculight Six) in 38 eyes of 35 patients aged 46-93 years, mean 70.6 years. Ocult CNVM was treated in 34 eyes, classical CNVM in 4 eyes. In TTT we applied 1 to 5 points (on average 1.9 spot) and used a laser beam with a diameter of 0.5-3 mm (mean width 1.61 mm). In 10 eyes with occult CNVM (29%) TTT was repeated after 1-6 months. The patients were followed up after TTT for 6-18 months on average for 9.5 months.

RESULTS

The final visual acuity (VA) improved after TTT in two eyes (5.3%), remained unchanged in 22 eyes (57.9%) and deteriorated in 14 eyes (36.8%). The mean VA after TTT declined from 0.23 to 0.17. Biomicroscopic manifestations of exudation disappeared or receded in 29 eyes with occult CNVM (85.3%) and in 3 eyes with classical CNVM (75%). Fluoroangiographic examination revealed a reduced or absent extravasation of the dye in 24 eyes with occult CNVM (70.5%) and in 3 eyes with classical CNVM (75%). Optic coherent tomography confirmed regression of exudative changes and the development of a chorioretinal scar in 23 eyes with occult CNVM (67.6%) and 3 eyes with classical CNVM (75%).

CONCLUSION

TTT is a new potential therapy of ACMD with CNVM. It is indicated in particular in occult CNVM. It can be however used also in classical CNVM. TTT is not economically pretentious and can be used also in other than large clinical departments. It is important to test the possibilities and limitations of TTT on a large number of patients and assess its position among other therapeutic procedures.

[Tears of the retinal pigment epithelium] ]

The authors describe spontaneous tears of the retinal pigmented epithelium in three eyes of two patients with age-related macular degeneration. In all instances the development of the tear was associated with an occult choroidal neovascular membrane detected by fluoroangiography. The authors describe typical clinical features and contemporary views regarding the pathogenesis of the tear.

[The idiopathic uveal effusion syndrome]

The authors describe two cases of idiopathic uveal effusion syndrome, in one instance affecting consecutively both eyes, in the second patient the finding is unilateral so far. In the female patient with the bilateral finding reattachment of the retina and improvement of the visual acuity developed only after surgery (sclerotomy). The second patient, where the disease was detected only accidentally, is so far only under observation. The authors discuss the causes of this rare disease, the variability of clinical symptoms, diagnostic and therapeutic possibilities.

[Diffuse retinal pigmented epitheliopathy--a variant of central serous chorioretinopathy of the aged]

The authors describe a group of eight patients (four women and four men) with diffuse retinal pigmented epiteliopathy (four times unilateral and four times bilateral) confirmed by fluoroangiography, in one instance with bullous elevation of the retina. The mean age of the patients was 57.3 years, the investigation period was 4 to 23 years, with a mean of 8.6 years. After laser coagulation which was implemented in four patients vision improved in one instance, in the remaining patients vision was stabilized. In the patient with the bullous elevation of the retina vision improved after spontaneous flattening of the ablation. The authors discuss the pathogenesis and clinical features typical for diffuse retinal pigmented epitheliopathy.

[Retinal cavernous hemangioma associated with intracerebral cavernous hemangioma in a 33-year follow-up study]

Cavernous hemangioma of the retina is congenital, mostly unilateral lesion, with autosomal dominant transmission. Usually can be easily recognized by its characteristic appearance of cluster of dark-red saccular aneurysms, partly covered by a fine glial membrane. It may be associated with similar lesions of the skin, brain and other organs. A 23-year-old patient with cavernous hemangioma of the retina, who preventively underwent argon laser therapy has been followed up in our department. During the observation no symptomatic ocular hemorrhage occurred. We presuppose that a preventive laser treatment forestalled a possible retinal and vitreous bleeding. However, in a long-term follow up we have detected slowly growing number of retinal hemangiomas. Patient's life is hardly damaged by complications of cavernous hemangioma of the brain. Because of autosomal dominant transmission all family members, with and without fundus findings, should undergo computed tomography or magnetic resonance imagining of the brain to preclude intracranial vascular anomaly.

[Evaluation of the success of cataract surgery from the viewpoint of the patient]

The relationship between visual acuity assessed by the ophthalmologist and functional visual disorders evaluated by the patient himself by means of special tests is an important indicator of successful cataract operations. At present for this purpose four tests are used: VF 14, CSS, evaluation of problems of vision, evaluation of satisfaction with vision. The use of the above tests under local conditions was tested in a small group of 60 patients, 43 (72%) being women. One third of the patients had cataracts of both eyes operated. 20% of the patients suffered from the dry from of age related macular degeneration of the fundus before operation. These patients suffered after surgery from poorer near vision and a poorer resulting corrected far vision. The results of the trial provided evidence that the patients are indicated for surgery of the second eye when vision is better and the subjective complaints are smaller, in order to restore rapidly binocular vision. This corresponds with higher values of the VF index after surgery of both eyes. In patients with age related macular degeneration there is a markedly reduced value of the VF index after surgery, while the CSS before surgery is the same as in patients with a normal finding. This test cannot be used for accurate evaluation of the part played by age related macular degeneration and cataract in the deterioration of visual functions.

[Chronic conjunctival inflammation in clinical ambulatory practice]

The authors present an account on a group of 50 patients with chronic conjunctivitis. The necessity of interdisciplinary collaboration is emphasized. The results of laboratory and other auxiliary examinations should be compared with the clinical picture of the disease.

[Keratomycoses]

Mycotic inflammations of the anterior segment of the eye are relatively rare in our geographical zone. The clinical picture, isolation of the pathogenic organism and possible treatment are discussed with reference to three patients with keratomycosis treated at the First Ophthalmological Clinic of the First Medical Faculty, Charles University Prague. Microscopic examination of the affected tissue revealed Fusarium 1x and Candida alb. also on cultivation. Natamycin 5.0% suspension cured Fusarium keratitis and improved the symptoms of Candida infection. In two patients perforating keratoplasty was necessary in one instance because of imminent perforation of a posterior mycotic corneal abscess and in the second patient because of subsequent bacterial reinfection.

[Treatment of herpes simplex keratouveitis with systemic and local administration of acyclovir]

Sixteen patients with relapsing or chronic HSV keratouveitis were treated during a new attack by acyclovir 15 mg/kg/day by the i.v. route for 5 days with local combination of acyclovir 3% ung. and steroids. In all 16 patients improvement of signs of keratouveitis occurred on the fourth day of therapy, in 10 patients with improvement of visual acuity. In 5 patients perforating keratoplasty was performed on account of turbidity of the cornea. The authors observed four relapses of the disease in the course of 12 months after termination of treatment.

[Cataract surgery in patients with endogenous uveitis]

The authors present an account of surgery of complicated cataract in 20 patients with anterior and intermediate uveitis. During a one-year follow-up period they evaluate the difference of postoperative development and visual acuity in extracapsular extraction without or with implantation of an intraocular lens. In 10 patients (5x m. Fuchs, 3x anterior uveitis, 2x intermediate uveitis) they performed only ECCE. In 10 patients with the same diagnosis an intraocular lens was implemented. The authors did not find marked differences between the ECCE operation and ECCE operation with an intraocular lens in patients with uveitis. The visual acuity improved in all 20 patients, a marked inflammatory reaction in the anterior chamber was observed in both groups only during the first days after surgery. The two groups did not differ markedly as regards late complications. From the investigation ensues that implantation of an intraocular lens is well tolerated in patients with anterior and intermediate uveitis assuming a minimum 12-week remission of the disease.

[Anterior ischemic optic neuropathy and increased intraocular pressure]

PURPOSE

To find out the occurrence of an increased intraocular pressure (IOP) in the anterior ischemic optic neuropathy (AION).

METHODS

We studied 17 patients (10 men, 7 women, mean age 62.8 years) with AION. We measured the IOP at the beginning of observation and during the systemic corticosteroid therapy.

RESULTS

We found an increased IOP in 4 patients (23.5%).

CONCLUSIONS

The occurrence of an increased IOP in AION patients is higher than in a normal population. The increased IOP seems to be one of possible risk factors in the pathogenesis of AION.

[The CO2 laser in ophthalmology. II. Use of the CO2 laser in facial skin disorders]

The authors present an account on results of CO2 laser therapy in facial skin and conjunctival affections during the period between 1990 and 1993. In the evaluated group, comprising 60 patients with an observation period of 18 months, this method was used 82 times, incl. four where it was used repeatedly. In the technique of the procedure simple vaporization markedly predominates over combined operations or laser incisions (continual regime). The defect after vaporization heals by tissue which has the same colour as surrounding skin, in a very small minority with slight local depigmentation without a tendency of major scarring and with a satisfactory cosmetic effect. The authors discuss indications of CO2 lasers in ophthalmology. The method is recommended in strictly defined affections of the skin and conjunctivae.

[The CO2 laser in ophthalmology. I. Physical and biological properties and indications for the 20-C CO2 laser made by Pfizer Laser Systems]

The authors describe physical and biological properties of a CO2 laser operating in the infrared area (wave length 10,600 m). The authors discuss the use of this laser in ophthalmology and draw attention to its advantages as well as shortcomings. They describe the apparatus 20-C of Pfizer Laser Systems, incl. safety measures required for operation of the CO2 laser.

[Initial experience with therapy of endogenous uveitis with Consupren--the Czech cyclosporin A]

The authors treated as part of a controlled trial, five patients with Consupren, Galen a Co, i.e. the Czech preparation of cyclosporin A. All patients suffered from endogenous uveitis which was refractory to treatment with a combination of prednisone and cyclophosphamide or prednisone and azathioprin. Mitigation of the disease was achieved already during the first three weeks of treatment. In two patients during treatment a slight relapse of the inflammation was observed. As to side effects of this treatment, the authors observed only once readily controllable hypertension and a rise of some indicators of liver metabolism which returned to normal already during treatment. Side-effect in conjunction with renal affection were not observed in any of the patients. Based on these preliminary results the authors assume that Consupren is in the given indication, and when the described pattern of administration is used, effective and justifies the authors to continue with their investigation.

[Clinico-histopathologic correlations in cytomegalovirus retinitis in the acquired immunodeficiency syndrome]

The authors describe histological changes of the retina and chorioid in cytomegalovirus retinitis in a patient with manifest AIDS who died after a severe opportunic infection. Consistent with data in the literature, they describe in addition to necrotic changes also inflammatory manifestations in the retina and chorioid and the presence of intranuclear inclusions typical for CMV infection.

[Implantation of anterior chamber lenses]

From January 1989 till July 1993 85 anterior chamber lenses were implanted at the 1st Department of the 1st Medical School of the Charles University in Prague. In 30 cases the anterior chamber lenses were implanted primarily and in 55 cases as a secondary procedure. In all cases flexible lens of Kelman type was used. The incidence of postoperative complications was almost the same as was described in literature. The complications were less frequent after secondary implantations. After more extent loss of vitreous during extracapsular cataract extraction it is recommended to delay the implantation of anterior chamber lens at least after half a year. Final visual acuity 6/6-6/12 was achieved in 70% primary and in 85.5% secondary implantations.

[Endogenous uveitis]

In a brief historical review of views on inflammatory affections of the uveal tissue the authors focused attention also on distinguished personalities in Czech ophthalmology who worked at the Czech Ophthalmological Clinic and participated in the development of uveology. Based on their own observations, they give an account on of their experience with the diagnosis of endogenous uveitis. Consistent with the world literature, they were able to reveal in a group of 174 patients with endogenous uveitis that the condition was associated with a systemic disease in 30%, in 9% they found an infectious aetiology and the remaining 61% were described as idiopathic endogenous uveitis. From the group of idiopathic uveitis they separated clinical entities diagnosed in 29%.

[Diabetic maculopathy]

After review of literature about diagnosis and treatment of diabetic macular edema own results with mean observation time of 5 months are presented. After photocoagulation the visual acuity improved in eyes with focal maculopathy in 28.9%, stabilized in 62.2% and in 8.9% it was worse. In eyes with diffuse maculopathy improvement was observed in 29.6%, stabilisation only in 37%, deterioration in 33.3%. In ischemic maculopathy the visual acuity improved in 23%, stabilised in 76.9% and in none case deterioration was stated. We plan to reevaluate our results during longer observation time.

[Personal experience with immunosuppressive therapy of endogenous uveitis]

The authors investigated 43 patients with the original diagnosis of endogenous idiopathic uveitis for a period of one year. Comprehensive ophthalmological, immunological and rheumatological examination revealed that in all investigated cases either systemic disease was involved or diseases associated with impaired immunity or endogenous idiopathic uveitis. The patients were treated by immunosuppressive therapy either by Prednisone alone or by a combination of Prednisone and Cyclophosphamide. In all instances remission was achieved, contrary to previous therapy employed in these patients. In the majority of patients/21 of 23 and 12 of 18 resp./remission persisted for at least one year. The authors discuss indications and pitfalls of immunosuppressive therapy based on recommendations found in the literature.

[Charlin's syndrome--nasociliary nerve neuralgia]

The history, etiopathogenetical factors, clinical symptomatology, differential diagnosis and therapy of neuralgia nervi nasociliaris--Charlin's syndrome are described. The authors give an account of an 18-years-old male patient.

[The individual A constant in the SRK II formula]

The authors investigated the postoperative dioptric deviation from the calculated optic power of emetropic intraocular lenses by means of the formula SRK II without and with use of the individual regression constant A. Within the range of +/- 1.5 D the deviation varied for both methods in 87.7% of operated eyes; between -1.0 and +1.0 D the percentage of dioptric deviations without personalization was 66.2 and with the use of the individual constant A it was 73.8.

[Calculations for intraocular lenses]

The authors deal with the postoperative dioptric deviation from the calculated optic potency of the emetropic intraocular lens, using formulae SRK II, SRK/T and Holladay's formula. Within the range +/- 1.5 D the deviation varied in 84% of the operated eyes where the intraocular lens was assessed according to formula SRK II; in 76% when formula SRK/T was used and in 74% when Holladay's formula was used. The authors give also an account of possible sources of errors during measurement, calculation and evaluation of results.

[Evaluation of the long-term therapeutic effect of bacterial vaccines administered 1960-1968 to patients with recurrent anterior uveitis]

The authors evaluate after an interval of many years the effectiveness of treatment of relapsing anterior uveitis by streptococcal vaccines administered in the sixties by L. Klenka, I. Hána, M. Koleckárová. The evaluation is based on a survey conducted by means of questionnaires. After 21 years 91% of the respondents do not report relapses. The authors discuss possible reasons why this desensitization treatment is successful.

[Cryotherapy of neovascular glaucoma in diabetics]

The authors give an account of the long-term results of cryotherapy of neovascular glaucoma in 15 eyes of 12 patients with proliferative diabetic retinopathy. The operation was repeated in three instances (20%). Cyclocryothermy was used nine times, cyclocryothermy with retinal transconjunctival cryocoagulation also nine times. Within five days after operation the intraocular pressure was compensated in all patients. Within six months after cryotherapy the intraocular pressure rose above 21 Torr (2.799 kPa) in three eyes. After repeated cryosurgery the intraocular pressure in these eyes was normal. In the remaining 12 eyes at the end of the observation period--average 14.7 months--the intraocular pressure was within the range of 4.8-20.6 Torr (0.639-2.746 kPa). The pain in the eye receded in 100% of the patients. After operation eventually in all patients rubeosis receded. Deterioration of eyesight after the operation is ascribed to the duration of the high intraocular pressure and gradual progression of the proliferative diabetic retinopathy.