AUGENHEILKUNDE 213/1999ISSUE 1

Abstracts:


S. 01-08 (Art. 366)

Risk factors for trabeculectomy failure
Tobias LF Koller, Jörg Stürmer, Balder Gloor

Background Trabeculectomy is today the filtering procedure of choice, because complications are rare and success-rates high. A modification of our technique (fornix-based conjunctival flap closed by a running suture) introduced 3 years ago, has lead us to this retrospective assessment of complications and success-rates. Some of the risk factors for failure are known, others however remain obscure. This retrospective series was also used to further identify some of these risk factors for trabeculectomy failure.

Patients and Methods All 388 trabeculectomies performed between January 1992 and June 1994 at our hospital were included in the study. Important pre- and postoperative data were retrospectively assessed from patients case notes, with a special interest in the course of post-operative intra-ocular pressure (IOP). Two major groups were differentiated: Those with open-angle glaucoma (OAG) (i.e. primary open-angle glaucoma (POAG), pseudoexfoliation glaucoma (PEX) and pigment dispersion syndrome(PDS)), and other various glaucoma diagnoses. Risk factors were assessed using Cox-proportional hazard model adopting three different criteria for success.

Results The best success-rate after 12 months of follow-up had patients with narrow angle glaucoma (93.1%)(at least those suitable for filtering surgery), followed by patients with POAG (92.8%), 2° open-angle glaucoma (81.8%), aphakic (75%), juvenile (70.6%) and PDS (52.9%). Pseudophakia and development of an encapsulated bleb (Tenon' cyst) were identified as significant (p < 0.05) risk factors for failure. In addition, YAG-Laser Iridotomy in OAG-group and Aphakia in the group of various glaucoma diagnoses were identified as risk factors for successful post-operative IOP control.

Conclusions Filtering surgery (trabeculectomy) is a potent method to reduce IOP. Pseudophakia and an encapsulated bleb are the main risk factors for surgical failure. Because of amazingly high success-rates we tend to perform filtering surgery today earlier than ten years ago, especially as previous long-term topical antiglaucoma treatment may reduce filtering surgery success.

Key words glaucoma - trabeculectomy - encapsulated bleb - glaucoma diagnoses - topical antiglaucoma treatment - Argon-Laser trabeculoplasty - pseudophakia-aphakia - cyclocryocoagulation

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S. 09-14 (Art. 371)

Long-term results of conjunctiva-limbus autografts in patients with pterygia
Petra Pulte, Arnd Heiligenhaus, Jörg Koch, Klaus-Peter Steuhl, Theo Waubke

Background Conjunctiva-limbus autografting is known as a safe surgical technique for the removal of pterygia, with a low rate of recurrence. However, the long-term effect of this surgical maneuver is not clear. This study now investigates the long-term efficacy of conjunctiva-limbus autografts to prevent pterygium recurrence.

Methods Conjunctiva-limbus transplants for primary (n=62) or recurrent (n=8) pterygia were reevaluated 11 to 83 months after surgery (mean: 44.97 months). Slit-lamp appearance and photomicrographs were studied with respect to the configuration of the transplant and the recurrence of the fibrovascular tissue typical of pterygia.

Results Corneal pterygium recurrence has been observed in 2 cases. Fibrovascular tissue was found at the peripheral transplant-margin in 15 cases, and transplant compression towards the limbal margins were detected in further 7 patients. These conjunctival changes have not been observed during the first postoperative months.

Conclusions Conjunctiva-limbus autografts in pterygia have excellent efficacy against recurrence within the first few years. The transplant compression and fibrovascular changes within the peripheral conjunctiva seen in this study suggest that recurrencies might, however, develop on the long-term.

Key words pterygium - conjunctiva - cornea - conjunctival autograft

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S. 15-22 (Art. 368)

Botulinum toxin A-induced protective ptosis in indolent corneal ulcers or erosions
Gabriele-Charlotte Gusek-Schneider, Frank Erbguth

Background Botulinumtoxin A has been introduced as a local injection therapy of different conditions with focal muscular hypercontractions. In the ophthalmologic field the toxin has proven its efficacy in the therapy of blepharospasm and hemifacial spasm. There are only few reports on the use of a botulinum toxin A to induce a protective ptosis in patients with persistent corneal ulcers.

Patients and methods 21 patients who failed to respond to conservative therapy of corneal erosions or ulcers of different origin received a botulinum toxin A injection into the levator palpebrae superioris muscle.

Results The ptosis began after a mean of 1.5 days (1-3 days) and was complete after a mean of 5.1 days (3-12 days) after injection. Complete recovery of the levator function could be observed after a mean of 12.4 weeks (4-24 weeks). In 13 patients (61,8%) the botulinum toxin A induced protective ptosis lead to a complete healing of indolent ulcers or erosions, in 4 patients (19%) an additional tarsorrhaphy was necessary. In 3 patients no healing could be observed during follow up, in one patient (with neuroparalytic ulcer) the injection was given prophylactically. The period of healing on average was 3,8 weeks. There was no relationship between the healing rate and the duration of the corneal disease prior to the botulinum toxin injection. The mean healing rate of younger patients was higher (75%) than that of older patients (53.8%) and higher in erosions (70%) than in ulcers (30%). No side effects were observed besides in one patient the undesirable duration of the ptosis of a half year.

Conclusion The induction of a protective ptosis with botulinum toxin A injection is an efficacious treatment alternative in persistent corneal erosions and ulcers before performing a tarsorrhaphy. This method is preferrable especially in patients with lagophthalmos due to facial nerve paresis with potential recovery.

Key words botulinum toxin A- corneal ulcers- corneal disease- protective ptosis

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S. 23-31 (Art. 355)

Characteristics of RPE-Autofluorescence in Different Lesions of the Late Age-related Macular Degeneration
Georg Spital, Martin Radermacher, Christian Müller, Gabriele Brumm, Albrecht Lommatzsch, Daniel Pauleikhoff

Background Lipofuscin is the main fluorophore of the human fundus. Because lipofuscin is the result of the accumulation of metabolic debris in pigmentepithelial cells (RPE), the autofluorescence can be interpreted as a clinical sign for the metabolic activity of the RPE. In order to get informations of RPE-function in different types of late AMD, the autofluorescence patterns in patients with late AMD were analyzed.

Material and method A prospective examination of the fundus-autofluorescence of 64 eyes of 52 patients with different types of late AMD was performed using a confocal scanning-laser-opthalmopscope. The autofluorescence images were categorized in respect to the type of late AMD according to the opthalmoscopic and fluoresceine-angiographic findings.

Results Reduced autofluorescence was found in the centre of occult (78.6%) and classic (100%) choroidal neovascularisations (NV) as well as in the occult NV of RPE detachments. A loss of autofluorescence was related to the RPE free area of RPE-tears (100%) and to RPE-atrophy (88.9%) with sometimes increased autofluorescence at the rim. Increased autofluorescence could be seen at the surface of RPE-detachments (71.4%), in the area of the shrink age of RPE in RPE-tears (100%) as well as at RPE-proliferations in small occult NV (100%). Disciforme scars showed variable patterns of autofluorescence.

Conclusion The autofluorescence of the RPE can be analyzed clinically with the described method. Different patterns of autofluorescence could be revealed in different types of late AMD. Increased autofluorescence was found in lesions with proliferative or phagocytotic metabolic activity of the RPE like RPE-detachments, shrinked RPE in RPE-tears or occult NV with RPE-proliferations. The reduced autofluorescence in occult or classical choroidal NV can be interpreted as a sign of decompensation of the RPE and was also seen in areas with RPE-loss.

Key words Age-related macular degeneration - Autofluorescence - Lipofuscin - retinal pigment epithelium

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S. 32-37 (Art. 359)

Dynamics of the changes of lipofuscin distribution in the retinal pigment epithelium in age-related macular degeneration
Andrea von Rückmann, Karl-Georg Schmidt, Fredrick W Fitzke, Alan C Bird, Karl Wilhelm Jacobi

Background It is thought that lipofuscin plays a central role in the pathogenesis of age-related macular degeneration (AMD). The lack of histopathological material has been a severe limitation in our knowledge on lipofuscin in this disease. A new technique has been developed that allows in vivo imaging of fundus autofluorescence derived from lipofuscin in the retinal pigment epithelium (RPE) using a confocal Laser Scanning Ophthalmoscope (LSO). We studied the dynamics of lipofuscin accumulation and degradation in patients with AMD.

Materials and Methods Serial examinations of the spatial distribution of fundus autofluorescence were performed in 148 eyes of 74 patients with AMD using a LSO over a period of 1-3.5 years.

Results Fundus autofluorescence changed over time in almost all eyes studied. Areas of increased autofluorescence occurred progressively during follow up in eyes with drusen and hyperpigmentation. The size of pathologic autofluorescence increased over time in almost all eyes with geographic atrophy, subretinal neovascularisations and disciform scars. Irregular autofluorescence was seen over most subretinal neovascularisations. Autofluorescence intensity decreased in old subretinal neovascularisations and disciform scars over time.

Conclusions Changes of the distribution of autofluorescence occur in eyes with AMD over time. Fundus autofluorescence imaging allows in vivo analysis of the dynamics of accumulation and degradation of lipofuscin in the RPE in eyes with AMD and documentation of metabolic activity of the RPE.

Key words lipofuscin - laser scanning ophthalmoscope - age related macular degeneration - autofluorescence

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S. 38-44 (Art. 373)

Keratocytes density in the in vivo cornea. Automatic quantification with a modified confocal microscope MICROPHTHAL
Joachim Stave, Christine Slowik, Susanne Somodi, Christian Hahnel, Gerald Grümmer, Rudolf Guthoff

Background The MICROPHTHAL is a confocal slit light scanning microscope for a non-invasive in-vivo examination of corneal structures of human eyes. With this instrument even thin layers of corneal tissue can be imaged in good quality. Otherwise, blurring of single frames and deviations from the z-axis in video-sequences caused by high speed movements of the eye would normally prevent a measurement the density of keratocytes in the cornea.The goal of the investigation was optical pachymetry, the automatical measurement of the keratocytes density and a 3D-dimensional reconstruction of the central cornea in-vivo under constant imaging conditions.

Materials and Methods We developed a low-vacuum suction cup system for stabilizing the eye in front of the microscope objective during the z-scan through the cornea. A stepmotor shifting system for the objective locates inside the suction cup with a central hole was installed underneath themicroscope. Control of this system via computer facilitated shifting the focal plane along the z-axis. The layer images were recorded using a S-VHS-tape and saved on the PC. The digital analysis was performed using a special software to automatically and off-line evaluate the density of keratocytes in combination with the 3D-reconstruction. The software also corrected the background illumination and small axial jitter. After this procedure the keratocytes density and the 3D-reconstruction in 70 images of the z-scan were calculated. We examined 47 corneas of 25 healthy probands. The range of age was 25-56 years. Independent control evaluation of the video sequences were taken manually on an INDIGO HIGH IMPACT workstation.

Results By assign all keratocytes to the corneal measurement volume we found a averaged density of 15 730 cells/mm3 in the central cornea. The averaged thicknes of the cornea was 0.556 mm. The control valuation of identical video-sequences on the workstation accomplished the same result of 16 000 keratocytes/mm3, also similar the result of the automatically measurement with the modified software.

Conclusions This modification of the microscope is a promising in-vivo tool for optical pachymetry and quantitative examination of corneal microstructures. The stabilization effect of the low-vacuum suction cup system in the front of the microscope for computer-controlled valuation of the density profile of keratocytes and the 3D-reconstruction of a central corneal volume element has produced encouraging results. Characterization of pathophysiological changes in the distribution of keratocytes after excimer laser ablation for phototherapeutic or photorefractive keratectomy, for example, can be estimated without pain for the patients.

Key words confocal scanning microcopy - eye movement - suction stabilization - density of keratocytes - 3D-reconstruction

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S. 45-47 (Art. 364)

The Holzwig Irisretractor and its use in cases of narrow pupils
Detlef H Holzwig

Background The objective was to develop an easy to handle tool for temporary implantation to dilate narrow pupils.

Material and Methods High molecular PMMA was used to lathe cut a v-shaped device with sides of 6.9 mm length, 0.8 mm height and 0.4 mm width which opens 7.0 mm. Positioning holes of 0.5 mm diameter are located in the caudal ends of the sides. The HIR was used during cataract extraction in 24 patients with mydriatic-resistent pupils,amblyopia or distinctive macula degeneration.

Results In all 26 cases cataract extraction was made easier due to physiologically dilated pupils. The risk of an intraoperative miosis was effevtively eliminated. In two cases removal was difficult as the lower tunnel lip interfered with the removal of the HIR.

Conclusion In comparsion with the commercially available devices, the HIR is the simplest, safest and most physiologic alternative.

Key words irisretractor - miosis - pupildilatator - pupil expander - cataractoperation

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S. 48-50 (Art. 343)

Topical application of Metronidazole gel as an effective alternative treatment for chronic Demodex blepharitis - a case report
Anna K Junk, Andreas Lukacs, Anselm Kampik

Background Blepharoconjunctivitis is the commonest manifestation of ocular rosacea. Cilia epilation proves Demodex folliculorum, considered an etiologic factor in rosacea. Complications and differential diagnosis include dry eyes, seborrheic, bacterial and allergic blepharoconjunctivitis. Treatment involves lid scrubs and mercury ointment, its duration is limited to 6 weeks under frequent control due to corneal toxicity of mercury.

History and signs 30-year-old female with complaint of red, irritated eyes for 21 years, resistant to antibiotics and antiallergics. General medical history unremarkable, mercury allergy. Acuity: R/L 20/20. Biomicroscopy: red, thickened eyelid margins, crusty debris on rarefied, partially broken lashes, conjunctival telangiectasia, low tear meniscus, furth-er ophthalmologic examination unremarkable. Diagnosis: chronic Demodex blepharoconjunctivitis.

Therapy and outcome Conventional treatment was contraindicated due to mercury allergy. Alternative oral minocycline 100 mg daily brought no subjective nor objective relief. Combination of lid scrubs and 2% Metronidazole gel relieved symptoms and halved number of mites after 1 month, lashes grew again after 2 months. Treatment was discontinued after 6 months as Demodex folliculorum proof remained negative. No relapse occurred during 1 year.

Conclusions Topical Metronidazole 2% proved to be an effective treatment of chronic Demodex blepharoconjunctivitis in our case and thus may offer a new and save alternative to existing therapies. Neither ocular nor systemic side effects occurred. Controversial theories on the aetiology of blepharitis are discussed.

Key words rosacea - Demodex - chronic - blepharitis - blepharoconjunctivitis - Metronidazole

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S. 51-54 (Art. 375)

Choroidal infiltration in myelodysplastic syndrome
Faramarz Madjlessi, Katharina Dann, Christoph Althaus, Rainer Sundmacher, Guido Meckenstock

Background Myelodysplastic syndrome is a clonal disease of the hematopoetic system characterized by insufficiency of affected bone marrow cell lines. After long-term course of myelodysplastic syndrome an acceleration towards acute myeloic leukemia is a frequent finding. Involvement of the eye is a well known phenomenon in acute leukemia or in blast crisis with chronic leukemias. Eye involvement in myelodysplastic syndrome showing its transition into acute myeloic leukemia however has been published in only few cases.

Case report We present a 70-year-old male patient suffering from myelodysplastic syndrome, complaining of an acute visual decrease to 0.05 in the left eye. Clinical findings, ultrasound and fluoresceine angiography were in accordance with choroidal infiltration. From the hematologic findings, the myelodysplastic syndrome had been in partial remission after chemotherapy without any sign of relapse or exacerbation. Only because of the ophthalmologic diagnosis, bone marrow aspiration was performed and revealed progression of myelodysplastic syndrome to acute myeloic leukemia. Prompt administration of chemotherapy and external radiation of the posterior pol of the eye led to complete resolution of the fundus lesion within 10 days and visual acuity recovered to 0.8.

Conclusion To the best of our knowledge this is the first patient with a choroidal infiltration as the initial sign of progression of myelodysplastic syndrome to acute myeloic leukemia. Realizing this possibility helps for an early diagnosis and rapid therapy which is so crucial in prolonging life.

Key words Choroidal infiltration - Myelodysplastic syndrome - diagnosis - therapy

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S. 55-59 (Art. 354)

Prevention of amblyopia in children with sudden-onset eyelid closure - A new method of keeping the visual axis open by insertion of a scleral immersion shell
Joachim Esser

Background Complete eyelid closure by capillary eyelid hemangioma or ptosis in the first months of life is an indication for acute measures to prevent amblyopia. Since it is sometimes not possible to hold up the affected upper eyelids with adhesive tape (mechanical obstacle, danger of skin maceration in involvement of the forehead) or not sufficently (intense divergence), an alternative method will be presented for emergency treatment of blockade of the optical axis.

Methods The eyelids are kept open mechanically with a cylindrical tube of perspex (scleral immersion shell), which is normally used for echography of the anterior segment and for biometry (immersion technique). After surface anesthesia, it can be readily inserted. Its area of contact to the sclera has the form of a scleral shell. A drop of lubricant is applied into the tube at intervals of about five minutes.

Patients and Results In a six-week-old girl with complete eyelid closure owing to a facial hemangioma, adequate eyelid opening could only be achieved by insertion of the scleral immersion shell. In an eleven-months-old boy with complete ptosis and divergence as well as vertical deviation, the optical axis could only be kept open by insertion of the scleral immersion shell and by simultaneous displacement to the temporal side (adhesive tape). The uncomplicated performance for up to two hours daily was initially carried out in the hospital and later by the parents, and could be terminated after five and three and a half weeks, respectively, thanks to improvement due to therapy or spontaneous improvement.

Conclusions Mechanical eyelid opening by insertion of a scleral immersion shell serves to bridge over the time interval to the onset of spontaneous improvement or the success of a causal therapy. The advantages consist in the good handling, also for parents, the low danger of injury and the ubiquitous and rapid availibility (basic equipment of an ophthalmological ultrasonography unit).

Key words Deprivation amblyopia - capillary eyelid hemangioma - ptosis - prevention of amblyopia - emergency case - scleral immersion shell

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S. 60-62 (Art. 267)

Ophthalmomyiasis externa caused by oestrus ovis in Franconia
Michael JM Groh, Anselm Jünemann, Rudolf Zilch

Background Ophthalmological diseases caused by parasites are a very rare entity in middle europe. Ophthalmomyiasis caused by parasites living in our country are only reported as case history in literature.

Patient We report on a 28-year old patient, seen in our department in august 1997 suffering from ophthalmomyiasis externa.

Case history The male patient was riding on a motorbike when a fly gets into his right eye. 12 hours later he had a feeling of pain in the eye. When having a closer look to his right eye, he found some fly larva (2.0!0.8 mm) in the conjunctival sack. The patient could extract the fly larva from the conjunctival sack by himself. On examination at our department we found a unspecific irritation of the conjunctiva. The fly larva was identified as larva of oestrus ovis ("Schafsbremse").

Conclusion Although ophthalmomyiasis is a very rare entity in middle europe single appearance is possible even in our country. No specific therapy was necessary in this case.

Key words ophthalmomyiasis externa - unspecific conjunctivitis - fly larva - oestrus ovis

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S. 63-64 (Art. 377)

Latanoprost induced macular edema
Alexander Reis, Christoph Althaus, Rainer Sundmacher

Background Latanoprost represents a new therapeutic option in the treatment of chronic open angle glaucoma. It has only recently been reported for the first time that latanoprost caused cystoid macular edema in pseudophakic patients.

Case report A 60-year-old pseudophakic patient who suffered from a 10-year history of glaucoma, revealed a cystoid macular edema on fluorescence angiography after 10 days of treatment with latanoprost. One week after cessation of latanoprost therapy the cystoid edema in fluorescence angiography had resolved and the vision improved from 0.4 to 0.8.

Conclusions With respect to this severe complication, latanoprost should be used with great care and in clear indications, particularly in patients with risk of blood-aqueous leakage e.g. pseudophakic patients.

Key words Glaucoma - medical therapy - side effects

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