AUGENHEILKUNDE 212/1998 – ISSUE 2

Abstracts:

S. 067-073 (Art. 266)

Visual field, its historical development
Jörg Draeger, Corinna Hendriock

Even in greeque medicine the visual field has been described and recognized. Besides the visual acuity, references are given on early observations of the visual field and its defects. Ptolemaeus (87-165 n. Chr.) first mentioned a method to test the visual field and also gave some physical definitions. Further developments are described in detail.
From this oldest method it was a long way to develop techniques for measurement and quantification which could be used in clinical practice. There was an amazing high number of different inventions and parallel developments of methods testing the visual field in the last century.

Key words perimetry - medical history

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S. 074-079 (Art. 264)

Can the extent of glaucoma damage be quantified using the difference of peripapillary height measurement values between upper and lower retinal halves?
Stefan Serguhn, Eugen Gramer

Background Peripapillary height measurements are possible using 2 different reference planes of the Heidelberg-Retina-Tomograph. It is not tested yet, whether the extent of glaucoma damage should be better quantfied using reference plane 1 or 2.

Patients and Methods In 32 eyes of 32 glaucoma patients with a defined up-down asymmetry of visual field loss is tested I.) if there is a significant correlation between peripapillary height and visual field loss comparing reference plane 1 and 2. II.) if there is a conformable up-down asymmetry of the peripapillary height using a new "retinal-asymmetry-difference" (RAD). III.) if conformity between peripapillary height and visual field loss depends on the distance from the disc margin.

Results I.) For an advanced visual field loss there was a significant correlation between visual field loss and peripapillary height using reference plane 1. II.) In eyes with a big up-down asymmetry of visual field loss there was a bigger conformity between the up-down asymmetry of visual field loss and the up-down asymetry of the peripapillary height (11 of 12 eyes), as for a small up-down asymmetry (12 of 20 eyes). III.) Conformity decreases with the distance from the disc margin.

Conclusions Peripapillary height should be examined using measurement circles near the disc margin. Because of its independence on the age and on different reference planes additional calculation of an up-down "retinal-asymmetry-difference" (RAD) seems to be useful. Using this up-down "retinal-asymmetry-difference" (RAD) a big up-down asymmetry of visual field loss, equivalent to an advanced glaucomatous disease, is quantified with high sensitivity.

Key words glaucoma - height of the retina - laser-scanning-tomography - Heidelberg-Retina-Tomograph (HRT) - glaucoma hemifield test

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S. 080-083 (Art. 259)

Aqueous flare and albuminuria in type-I diabetics
Marcus Blum, Ulrich Alfons Müller, Antje Höche, Wilgard Hunger-Dathe, Günter Stein, Jürgen Strobel

Background Chronic hyperglycaemia causes microangiopathy with manifestations in different organ systems. The purpose of this study was to investigate whether anterior chamber protein concentrations and albuminuria in patients with diabetes mellitus type 1 have any correlation.

Patients and methods 23 patients with type 1 diabetes were examined in both eyes by the use of the laser flare-cell meter (LFCM). After clinical exclusion of urinary tract infection urin-samples were taken on the examination-day. Patients were divided into two groups: group 1 consisted of 13 patients with albuminuria (8´ microalbuminuria, 5´ macroalbuminuria), group 2 comprised 10 controlls with normal urine albumin concentrations.

Results Both groups were identical according to age and gender. The flare values in the group with albuminuria were significantly elevated (10.7±7.1 counts/msec) in comparison to those of the control group (3.7±1.9 counts/msec) (p=0.042). The duration of the diabetes was as well significantly different in both groups (7.9±6.9 yrs. vs. 23.9±13.4 yrs.) (p=0.02). A correlation was found between albuminuria and flare values (r=0.67; p=0.003).

Conclusions Our results demonstrate a correlation between protein concentration in aqueous and albuminuria. In future flare measurements could possibly offer a non-invasive diagnosis of diabetic nephropathy.

Key words Diabetes mellitus - laser flare-cell photometer - albuminuria - blood-aqueous barrier - blood-retinal barrier

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S. 084-087 (Art. 241)

Toxoplasma retinochoroiditis, a comparison of treatment between spiramycin and pyrimethamine/sulfadiazine
Markus Hacker, Roland Richter, Hermann Gümbel, Traute Richter, Christian Ohrloff

Background The treatment of toxoplasma retinochoroiditis with spiramycin is an alternative to sulfadiazine and pyrimethamine. The treatment with sulfadiazine is associated with multiple side effects. Sulfadiazine is contraindicated during pregnancy and breastfeeding period. Spiramycin has less side effects and is recommended during pregnancy and breastfeeding period. The efficacy of spiramycin in treatment of toxoplasma retinochoroiditis is still a matter of controversy.

Patients and methods In a retrospective study, side effects and outcome of therapy in 44 patients with toxoplasma retinochoroiditis treated with sulfadiazine and pyrimethamine (n=30) or spiramycin (n=14) were compared. We assessed duration of therapy and healing, ophthalmoscopic findings and observed side effects.

Results The mean healing time in the group of spiramycin was 63,83 days in comparison to 88 days for the group of patients treated with sulfdiazine/pyrimethamine. The frequency of side effects was lower in the group treated with spiramycin.

Conclusion In comparison to a combined application of sulfadiazine and pyrimethamine the treatment with spiramycin alone requires a shorter duration of therapy and healing period. Additionally, side effects and contraindications appear to be less frequent. In view of these findings, spiramycin therapy must be considered as a promising approach in the treatment of toxoplasma retinochoroiditis.

Key words spiramycin - Toxoplasma retinochoroiditis

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S. 088-092 (Art. 254)

The multiple flash ERG in cone dystrophies and cone-rod dystrophies
Peter Walter, Randolf A. Widder, Richard Brunner

Background Scotopic electroretinograms elicited with a multiple flash procedure were reported to be helpful in diagnosis of macular diseases. To evaluate the contribution of rods and cones to the recovery of light responses as recorded with this technique we performed a triple flash ERG procedure in patients with cone dystrophies and cone-rod dystrophies.

Materials and methods In 8 patients with cone dystrophy and 8 patients with cone-rod dystrophy and also in 18 healthy controls we recorded a standard ERG and the scotopic triple flash ERG with intensities between 0.01 and 0.2 cds/m2. Interflash intervals were adjusted at 140, 280, and 560 ms. Responses of the standard ERG were analysed as well as b-wave amplitudes at the short dark interval (140 ms) and the longer dark interval (280 ms). These responses were compared to responses after a long interflash interval (560 ms). Using a theoretical model parameters of b-wave recovery were determined and compared between the groups.

Results In cone dystrophies responses of the scotopic triple flash ERG and the b-wave recovery parameters were normal whereas in combined dystrophies the triple flash responses were abnormal and the recovery data were pathologic.

Conclusions Cones did neither contribute to responses obtained with the multiple flash technique nor did they affect b-wave recovery as tested with this technique. Pathologic responses as described earlier with this technique in macular diseaes could only be attributed to pathomechanisms globally affecting the rod system, e.g. dysfunction of retinal energy metabolism.

Key words adaptation - b-wave suppression - cone dystrophy - cone-rod dystrophy - electroretinogram - multiple flash stimulation - recovery

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S. 093-100 (Art. 256)

Multifocal electroretinography in macular diseases
Ulf Kretschmann, Torsten Schlote, Nicole Stübiger, Krisna Gendo, Eleonora Hipp, Eberhart Zrenner

Background Multifocal electroretinography allows physiological mapping of the central retina. The purpose of this study was to describe the spatial distribution of ERG-activity in patients with impairment of macular function which usually do not exhibit a pathologic Ganzfeld-ERG.

Subjects and methods 6 patients with macular lesions due to uveitis (4), retinitis centralis serosa (1), and contusio bulbi (1) were examined using the multifocal ERG technique.

Results In normal volunteers the response density of the multifocal ERG decreased with eccentricity according to cone density distribution. In eyes with impaired central vision the foveal and macular responses were markedly diminished while surrounding signals were of normal or moderately decreased amplitudes.

Conclusions With the multifocal ERG disturbances of macular function due to oedema and secondary structural changes were detected in the presented cases and the extension of the central lesions was estimated.

Key words contusio bulbi - maculopathy - multifocal ERG - retinitis centralis serosa - uveitis - cone function

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S. 101-105 (Art. 265)

Ultrasound biomicroscopic evaluation of filtering blebs
Teresio Avitabile, Maurizio G Uva, Vincenzo Russo, Johannes P Ott, Britta Paulick, Alfredo Reibaldi

Background Sometimes in glaucomatous patients treated with trabeculectomy there is not a correlation between bleb shape and intraocular pressure. So we studied the functional anatomy of the filtering bleb by a ultrasound biomicroscope, using high frequency (50 Mhz) probe, which provides high resolution images of filtering blebs.

Materials and methods A total of 46 filtering blebs of 46 patients after trabeculectomy were analyzed by ultrasound biomicroscopy (50 Mhz). Dimensions, shapes and structure of blebs were evaluated in 2 groups of patients.

Results It was possible to obtain longitudinal or transverse images of filtering blebs, to measure the height, to evaluate the reflectivity inside and to follow the route under the scleral flap. Blebs with lower reflectivity and a visible route under the scleral flap had a lower intraocular pressure while the height was not important for a good intraocular pressure.

Conclusions So ultrasound biomicroscopy can be a useful method to study filtering blebs and also to explain the mechanisms of filtering structures in patients who underwent trabeculectomy.

Keywords Ultrasound biomicroscope - glaucoma - filtering bleb - trabeculectomy

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S. 106-110 (Art. 260)

The driving habits of patients admitted to a county eye department for cataract surgery - is an unlimited driving licence still acceptable? Results of an analysis of 1124 patients
Josef Ruckhofer, Günther Grabner

Background The aim of the study was to evaluate the driving habits and patterns of those patients, who underwent cataract-surgery during a one year period at the Landesaugenklinik Salzburg and to compare the preoperative visual acuity with the legal requirements in effect in Austria.

Materials and Methods The best-corrected visual acuity prior to surgery and the individual driving customs were noted on a detailed questionaire.

Results A minimum of 5.6% of the overall number of patients with cataract (not taking visual field defects into account) were driving a motor vehicle with a visual acuity not sufficient to meet current legal requirements. Considering only those drivers licence holders that admitted to still driving a motor vehicle it can be concluded that 26% have a legally unsatisfactory visual acuity. As between 28.000 and 31.000 cataract-operations are performed yearly in Austria, this study seems to clearly indicate that at least 1.600 of these persons - regardless of an additional visual field defect - are illegally driving a motor vehicle. It can be additionally concluded that the number of undetected cases is significantly higher.

Conclusions It therefore seems appropriate to call for a mandatory eye exam by a qualified ophthalmologist of all persons holding a driving licence, possibly beginning at the age of 60. The license issued therafter should be valied for an age-related period of time only.

Key words Driving licence - driving habits - cataract - visual acuity - legal requirements

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S. 111-115 (Art. 263)

Teleconsultation network for ophthalmology - experiences and results
Gudrun Zahlmann, Hans-Dietrich Walther, Bernd Liesenfeld, Hansgeorg Kaatz, Stefan Kluthe, Eberhard Fabian, Dieter Klaas, Klaus-Dieter Schnarr, Lorenz Neubauer, Marko Obermaier, Aharon Wegner, Manfred Mertz, Gerd Mann

Motivation Telemedical services for ophthalmology are developed within the OPHTEL project, which has been funded by the European Union and by the Bavarian government in the Bavaria-online initiative.

Methods Seven private ophthalmologists, one university eye clinic, one clinical Diabetes center and an informatics research institute are connected within a teleconsultation network. Asynchronous (based on Internet E-Mail) and synchronous (based on ISDN-mediated videoconferencing tools) types of teleconsultations are realized.

Results 86 teleconsultations (62 asynchronous, 23 synchronous) took place within the first 10 months. Complex and rare eye diseases as well as interdisciplinary questions (ophthalmology - diabetology) are the main area of medical communication interest. Legal and security problems are discussed.

Conclusions Telemedical services must be understood as a complete process of medical care on the basis of modern communication technologies, which influences also the management of this process.

Key words teleconsultation - ophthalmology - telemedicine

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S. 116-119 (Art. 262)

Widespread idiopathic telangiectasia with conjunctival involvement
Beate Swensson, Ole Swensson, Georg Häring

Background Widespread idiopathic telangiectasia (generalized essential telangiectasia) is a rare skin disorder characterized by the development and gradual spreading of telangiectases. The condition tends to affect women in their midthirties. For no apparent reason telangiectases start to appear on the lower extremities and progress steadily to involve the skin of the trunk, the arms, and the face. General health is not affected by the condition and standard laboratory tests consistently yield normal results.

Case report In February 1997 a 78-year-old lady was admitted for treatment of cataracta corticonuclearis of her left eye. Complete ophthalmological and dermatological examinations were performed. She presented marked conjunctival telangiectases of both eyes and widespread cutaneous telangiectases involving her face, trunk, arms, and legs. Complete blanching of lesional skin was observed on diascopy. The Rumpel-Leede-test was normal. Cutaneous and conjunctival changes appeared not to be associated with internal disease or bleeding abnormalities.

Discussion The patient presented here shows widespread idiopathic telangiectasia with marked conjunctival involvement. Ocular changes rarely have been reported in patients with generalized essential telangiectasia to date. Concomittant conjunctival and cutaneous telangiectases may be seen in other conditions such as hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease) and ataxia telangiectasia (Louis-Bar syndrome). The former shows an associated bleeding abnormality and is transmitted autosomal dominantly. The latter presents associated neurological signs such as cerebellar ataxia, strabism, nystagmus, apraxia, and mental retardation.

Key words Telangiectasia - conjunctiva - skin

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S. 120-122 (Art. 244)

Bilateral endogenous endophthalmitis
Regine Augsten, Ekkehart Königsdörffer, Albrecht Oehme, Jürgen Strobel

Background The endogenous endophthalmitis is a septic-metastatic late complication of a generalized bacterial or fungal infection or an asymptomatic fungaemia. Aspergillus organisms are a rare cause of endophthalmitis. Aspergillus ocular manifestations have been mostly reported in connection with immunosuppression, severe diseases or drug abuse.

Patient and methods A 51-year-old man underwent a kidney transplantation, an immunosuppressive therapy, and, in addition, treatments for some other generalized diseases. Endogenous endophthalmitis was diagnosed in both eyes at an interval of about eight weeks. The treatment included pars-plana-vitrectomy on both eyes.

Results At first, an endogenous endophthalmitis was found in the right eye which was assumed to be induced by bacteria. About eight weeks later, however, an endogenous endophthalmitis was diagnosed in the left eye , also, which was caused by Aspergillus. The patient received an intensive medical care including operative, antiacterial and antimycotic treatments. The bacterial endophthalmitis in the right eye was healed, and the state of the left eye was found to be postoperatively stabilized. Unfortunately, the patient died of a septic shock in systemic Aspergillus infection.

Conclusion Endogenous endophthalmitis has a very poor prognosis. To our knowledge, the described medical history seems to be the first reported case of an endophthalmitis on both sides, apparently caused by bacteria in one eye and by fungi in the other one.

Key words endogenous endophthalmitis - Aspergillus - pars-plana-vitrectomy - vitreous puncture

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S. 123-124 (Art. 225 DF)

Molluscum contagiosum bei Immunsuppression mit Methotrexat
Claus Cursiefen, Leonard M Holbach

Background Poxvirus induced molluscum contagiosum is known to occur in children, elderly people and in patients with the acquired immune deficiency syndrome AIDS.

Patient and methods We report on a 49-year-old patient who presented with a three-month history of multiple skin-coloured prominent warts on his right upper and lower eyelid. On examination, the warts showed a central cavity and measured 2-6 mm in diameter. For his "mixed connective tissue disease" (MCTD) the patient took methotrexate in a weekly dosage of 7.5 mg since 3 years. Diagnosis of MCTD was made 7 years before. The warts were excised and studied histopathologically. One year postoperatively, there was no recurrence of the lesions.

Conclusion Drug induced immunosuppression as with methotrexate may be associated with multiple periocular lesions due to molluscum contagiosum.

Key words Molluscum contagiosum - immunosuppression - eyelid tumors - mixed connective tissue disease - methotrexate - sharp syndrome - acquired immune deficiency syndrome

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S. 125-126 (Art. 268 DF)

Untypisches Non-Hodgkin-Lymphom der Bindehaut als Zufallsbefund bei Unterlidentropium
Karina DB Küper, Jens Martin Rohrbach

Purpose We want to demonstrate an unusual conjunctival Non-Hodgkin-Lymphoma with bleedings.

Patient A 77-year-old female patient presented with an entropion of the left lower eye-lid. Bilaterally reddish, soft tumors showed in the lower fornices with circumscript bleedings. On account of an absolute arrhythmia of the heart the patient has been on a medication of cumarine-derivates since 9 years. Histologically we found underneath the epithelium densely packed lymphocytic cells with small uniform nuclei intermingled with many erythrocytes. The immunohistological investigations revealed a Non-Hodgkin-Lymphoma of B-cell origin.

Conclusions Bleedings in a conjunctival Non-Hodgkin-Lymphoma can alter the clinical aspect of the tumor. It is necessary to inspect each entropion thoroughly in order to rule out any other pathological lesions.

Key words Non-Hodgkin-lymphoma - conjunctiva - entropion - histology

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S. 127-128 (Art. 246 DF)

Epitheliale Riesenimplantationszyste 50 Jahre nach Enukleation ohne Orbitaimplantat
Anselm Jünemann, Leonard M Holbach

Text nur in Englisch verfügbar:

Background Conjunctival cyst formation following enucleation may occur in 3% to 7% of patients receiving orbital implants, especially secondary implants. We present a patient with a giant epithelial inclusion cyst of the anophthalmic orbit 50 years after enucleation without orbital implant.

Patient A 54-year-old male presented with increasing proptosis of the ocular prosthesis, shallowing of the inferior fornix, a palpable orbital mass, and difficulty in retaining the ocular prosthesis. At the age of 1 year enucleation of the right eye without orbital implant was performed following perforating ocular trauma. Results of examination of the other eye were unremarkable. Transillumination of the orbital mass was possible. The clinical diagnosis of an epithelial inclusion cyst was confirmed using ultrasonography and CT scan. An incision of conjunctiva and cyst wall and subsequent marsupialization were performed. Nine months postoperatively there was no evidence of recurrence of the cyst. The ocular prosthesis was well in place.

Conclusion Conjunctival cyst formation following enucleation may rarely ocur in patients receiving orbital implants, especially secondary implants. The presentation of a conjunctival cyst formation following enucleation without obital implant 50 years after surgery is noteworthy in comparison to implantation cysts which are known to occur more commonly within the first two years following secondary orbital implants.

Key words Conjunctival cyst - epithelial implantation cyst - enucleation - anophthalmic socket - orbital implant

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