AUGENHEILKUNDE 212/1998 – ISSUE 3

Abstracts:

S. 129-140 (Art. 277)

"Vertical tilt" after penetrating keratoplasty - Comparison between nonmechanical trephination with the excimer laser and motor trephination
Achim Langenbucher, Berthold Seitz, Murat M Kus, Gottfried OH Naumann

Background Besides decentration of the graft/host trephination and "horizontal torsion" "vertical tilt" is an important factor for reduced visual outcome after penetrating keratoplasty (PK). The purpose of this study was to evaluate the time course of vertical tilt in absolute value and direction and to correlate it with functional results after PK.

Patients and methods Fifty patients each (20 primary dystrophies, 30 keratoconus) underwent nonmechanical trephination (NMT) (excimer laser MEL60, Aesculap-Meditec, Heroldsberg, Germany) or mechanical motor trephination (MT) (Geuder, Heidelberg, Germany) in penetrating keratoplasty. All procedures (7.5 mm in dystrophies, 8.0 mm in keratoconus, 8 orientation teeth in NMT, double-running 10-0 nylon suture) were performed by one surgeon (GOHN). At a postoperative gate of 6 weeks, 6 months, before partial suture removal and after complete suture removal, corneal topography analysis (TMS1, Tomey, Tennenlohe, Germany) was performed. After a Gram-Schmidt-orthogonalization corneal topography height data of 25 noncentric rings in 256 hemimeridians were decomposed into Zernike components of radial order n=16 in the sense of minimizing the root mean square error. The tilt of the surface relative to the videokeratoscope axis was calculated from the Zernike components Z11 and Z1-1. The meridional power at the cardinal meridians was derived from all parabolic Zernike terms. Tilt and the difference between both meridians of the Zernike representation (ZA) were correlated with the results of Zeiss keratometry (KA), Simulated Keratometry (SimK) of the TMS-1, subjective refraction (RZ) and best-corrected visual acuity.

Results After NMT, vertical tilt of the graft was 3° without significant change over time. Following MT, an equivalent time course could be observed before partial suture removal. However, after complete suture removal, a significant increase of the tilt was measured to 5° (p=0,02). No significant difference could be detected comparing keratoconus and Fuchs' dystrophy both in NMT and MT. The direction of the vertical tilt component piled up to the hemimeridian defined by the knot of the first running suture. At all postoperative follow-up examinations, the ZA of the Zernike decomposition showed a good correlation to the RZ, whereas the KA and the SimK did not. At the end of the follow-up, best-corrected visual acuity after NMT was 2 decimal lines better than after MT.

Conclusions The Zernike decomposition of topographic height data is a suitable tool for extraction and quantifying vertical tilt of the graft following penetrating keratoplasty. In contrast to conventional keratometry with its 4-point measurement, a decomposition of topographic height data into orthogonal polynomials enables a detection of both cardinal meridians even in corneas with a high degree of local irregularities.

Key words vertical tilt - corneal topography - Zernike decomposition - penetrating keratoplasty - excimer laser - nonmechanical trephination - motor trephination

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S. 141-148 (Art. 280)

Optical coherence tomography of age-related macular degeneration. Correlation of diagnostic techniques of fluorescence angiography and OCT
Christoph W. Spraul, Gabriele E. Lang, Gerhard K. Lang

Background Age-related macular degeneration (AMD) is the leading cause of blindness in industrialized countries. In this study, we used optical coherence tomography for evaluation of patients with AMD.

Methods Optical coherence tomography imaging is analogous to ultrasound, except that reflected light instead of sound is used. The analysis of the reflected light is processed with the technique of low-coherence interferometry. In this study, 33 patients with different stages of AMD were examined with optical coherence tomography. The classification of AMD was according to the guidelines as proposed by the "International ARM Epidemiological Study group".

Results With this method we were able to identify drusen, alteration of the retinal pigment epithelium, and secondary retinal changes. Other structures such as basal laminar (linear) deposits could not be identified with this method. Choroidal neovascularization was evident in the tomogram. Classic choroidal neovascular membranes presented with well-defined boundaries on optical coherence tomography and occult choroidal neovascular membranes had a less delineable structure with optical coherence tomography.

Conclusion Optical coherence tomography cannot replace conventional diagnostic techniques. This method provides no additional information in patients with non-exsudative AMD. In patients with choroidal neovascular membranes secondary to AMD optical coherence tomography may be able to characterize the relation of the membrane to the retinal pigment epithelium and imaging may be possible through hemorrhage. The interpretation of the optical coherence tomogram needs further studies including clinico-pathologic correlation.

Key words Age-related macular degeneration - choroidal neovascular membranes - drusen - optical coherence tomography - retinal pigment epithelium

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S. 149-153 (Art. 279)

Early posterior capsular fibrosis after combined cataract and vitreoretinal surgery with air/SF6-gas tamponade
Kerstin Scharwey, Sima Pavlovic, Karl Wilhelm Jacobi

Background The surgical approach in treating coexisting vitreoretinal disease and cataract is controversial. We report on patients who developed early posterior capsular fibrosis after combined cataract and vitreoretinal surgery with air/SF6-gas tamponade.

Patients and methods The medical records of 15 consecutive eyes (13 patients) who underwent combined phacoemulsification with intraocular lens implantation and vitreoretinal surgery with intraocular air/SF6-gas tamponade were retrospectively analyzed. The indications for vitreous surgery included: subfoveal neovascular membrane in age-related macular degeneration (5 eyes), macular hole (4 eyes), macular pucker (2 eyes), rhegmatogenous retinal detachement (2 eyes), persistent vitreous haemorrhage after branch retinal vein occlusion (1 eye), persistent vitreous haemorrhage and/or tractional retinal detachement in proliferative diabetic retinopathy (1 eye). The mean follow-up period was 7 months (1-13 months). A control group consisted of 15 eyes (15 patients) who underwent the equal combined operation without intraocular tamponade. The indications for vitreous surgery were persistent vitreous haemorrhage in proliferative diabetic retinopathy (5 eyes), persistent vitreous haemorrhage after branch retinal vein occlusion (5 eyes), asteroid hyalosis (2 eyes), macular pucker (1 eye), posttraumatic vitreous haemorrhage (1 eye), acute retinal necrosis (1 eye). The mean follow-up was 8 months (2-13 months). The posterior capsule was examined at the slit lamp microscopy with maximal dilated pupils. We defined posterior capsular opacification (PCO) as severe if posterior capsule was fibrotic, diffusely thickened and opaque. Modest PCO was characterized by focal fibrotic opacifications at otherwise clear posterior capsule.

Results Severe posterior capsular fibrosis developed in 9 eyes (60%) after 2-14 weeks postoperatively (mean 8 weeks) including 3 of 6 eyes with air tamponade (50%) and 6 of 9 eyes with 20% SF6-gas tamponade (66.7%). In 6 eyes (40%) Nd:YAG-laser capsulotomy was performed 4-14 weeks postoperatively (mean 8.5 weeks). In the control group modest PCO developed in 8 eyes (53.3%) 1-13 months postoperatively (mean 6.5 months) none requiring Nd:YAG-laser capsulotomy during follow-up period.

Conclusions Combined cataract and vitreoretinal surgery with intraocular air/SF6-gas tamponade induces severe posterior capsular fibrosis in the early postoperative period. The capsular fibrosis is presumably caused by accumulation of fibrin and proliferation stimulating factors in the narrow space between intraocular lens and air/SF6-gas bubble.

Key words cataract - vitreoretinal surgery - posterior capsular fibrosis - intraocular tamponade - SF6

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S. 154-158 (Art. 281)

Lattice corneal dystrophy type I. Clinical and molecular genetic analysis in a large family
Moritz Meins, Markus Kohlhaas, Gisbert Richard, Andreas Gal

Background Lattice corneal dystrophy type I is one of the frequent forms of stromal dystrophies following autosomal dominant inheritance. The b-IG-h3 gene encoding keratoepithelin on the long arm of chromosome 5 has recently been described as disease gene for lattice corneal dystrophy type I as well as for three other corneal dystrophies with autosomal dominant pattern of inheritance.

Patients and methods Ten family members in three generations of a large family with autosomal dominant lattice corneal dystrophy were analyzed clinically by slit-lamp biomicroscopy. Mutation analysis in the b-IG-h3 gene was carried out at the mRNA level by RT-PCR and cDNA sequencing.

Results A heterozygous single-base substitution (417C®T) in exon 4 of the b-IG-h3 gene was detected predicting the replacement of arginine-124 by cysteine. Analysis of 10 family members showed perfect cosegregation of the mutation and lattice corneal dystrophy type I. The investigation excluded this mutation in one family member previously classified as potentially affected.

Conclusions The investigation confirmed autosomal dominant inheritance with complete penetrance in the family described. The mutation 417C®T has already been found earlier in another family of different geographic origin. These results suggest a mutation hot spot at position 417. In addition, no evidence of genetic heterogeneity of lattice corneal dystrophy type I was detected. Molecular genetic analysis (in conjunction with genetic counselling) therefore may be useful in routine diagnostics as the confirmation of the diagnosis by histological examination is possible only after keratoplasty. The common pathomechanism in lattice corneal dystrophy type I may facilitate development of new therapeutic concepts; the easy accessibility of the target organ may provide new possibilities e.g. for gene therapy.

Key words lattice corneal dystrophy - histology - human genetics - b-IG-h3 gene - mutation

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S. 159-162 (Art. 278)

Intracanalicular trabeculostomy - A new approach in glaucoma surgery
Juergen Kampmeier, Karl Stock, Raimund Hibst, Gabriele E. Lang, Rudolf Steiner, Gerhard K. Lang

Background A new "ab externo" technique for glaucoma trabecular surgery creating multiple perforations of the trabeculum to improve outflow facility was tested.

Material and Method In order to perform a draining canal to the anterior chamber, a quartz fiber (Æ: 300 µm) with a side-firing tip, coupled to an Er:YAG laser, was inserted into Schlemm's canal of an enucleated human eye.

Results Eight pulses of 8 mJ each were sufficient to perforate the trabecular meshwork. Histologic analysis showed a rippled canal with 50 µm average diameter and a surrounding necrosis zone of 15-35 µm.

Conclusions The Er:YAG laser trabeculostomy, in conjunction with special fibers, shows promise as a new "ab externo" technique for minimally invasive therapy of open angle glaucoma.

Key words Er:YAG-laser - glaucoma - trabeculum - Schlemm-canal

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S. 163-165 (Art. 261)

Eye injury during a laser show
Helmut G Sachs, N Baumgathuber, Chris P Lohmann

Background Laser injuries are usually described in case reports concerning military persoal or scientists who had an accidential exposition to a laser. Today laser injuries to uninvolved persons become more frequent. The potential danger for eye injuries was discussed by Birngruber and Gabel (2) in 1984.

Patient A patient presented 4 days after the accident with a monocular decline in vision and a scotoma after being hit by a ray of a discotheque laser. At the time of the accident the patient was standing on the dance floor watching a laser show. From that moment he reported a scotoma on the affected eye. The examination of the patient by an ophthalmologist 3 days later revealed a monocular decline in vision to 0.3 and a scotoma. Reading problems were reported. The fluorescence angiography confirmed the biomicroscopical barely visible line shaped defect next to the foveola which was according to our clinical experiance caused by the ray of a laser. The vision defect and the scotoma remained stable during the follow up period.

Conclusions Before the first use of a show-laser unit it gets approved. Every change of the unit or the change of its position requires a new technical check by authorised institutions. At present many show lasers in use are not met with this requirement. Manipulations to the lasers are easy to perform and improve the intended show effect. The missing contol practice provokes eye threatening situations for an enormous number of persons who are not aware of the danger.

Key words eye injury - closed globe injury - laser - laser show

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S. 166-169 (Art. 269)

Consequent use of Aachen's therapeutic concept after severe chemical burn of both eyes
Thomas Herboth, Gerd Geerling, Gernot Duncker, Gerd-Otto Bastian, Theodor Seiler

Background Severe chemical burn and its complications still are a serious threat to the afflicted eye, particularly in case of insufficient treatment. Rehabilitation of visual acuity can be achieved only in the minority of cases.

Patient We present a 49-year-old female patient, who suffered a severe chemical burn in both eyes by alcaline detergent. Visual acuity was OD 20/50, OS light perception. After directly started acute treatment as well as peritomy, peridectomy, tenon plasty and application of a PMMA contact lens a stabilization was achieved. Complete rehabilitation of visual acuity was gained by EDTA abrasion, excimer treatment, penetrating keratoplasty and cataract surgery. Last examination showed a visual acuity of 25/20 in both eyes.

Conclusions Even in severe chemical burn an optimal result can be achieved by using an adequate treatment conception. Immediate beginning of therapy is important as well as persistent and persevering application of the treatment. Repeated, if necessary daily, excisions of necrotic tissue associated with tenon plasty and application of a PMMA contact lens have special importance.

Key words chemical burn - tenon plasty - PMMA contact lens - excimer - keratoplasty - visual acuity

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S. 170-174 (Art. 282)

Indocyanine green angiography in acute posterior multifocal placoid pigment epitheliopathy
Tanja Bohlender, Josef Weindler, Alena Ratzkova, Klaus-Wilhelm Ruprecht

Background Acute posterior multifocal placoid pigment epitheliopathy (APMPPE) is an idiopathic posterior segment inflammatory disorder of young adults. The pathogenesis remains unsettled. The placoid lesions and characteristic findings on fluorescein angiography have been interpreted as representing a primary pigment epithelial disorder or a choroidal vascular disease.

Patient Using Fluorescein and Indocyanine green angiography we examined one patient with APMPPE.

Results In the acute phase, the fluorescein angiogramm showed early hypofluorescence of the ophthalmoscopically visible lesions followed by late hyperfluorescence with centripetal staining of fluorescein at the level of the pigment epithelium. Indocyanine green angiograms showed in the acute stage of this disease areas of hypofluorescence in both the early and late pictures that nearly correlated with the placoid lesions. Three weeks later we saw apart from involution of the initial lesions, new angiographic hypofluorescent lesions at the posterior pole of the left eye, which were ophthalmoscopically not visible. During the next four weeks the older and newer lesions went smaller and left scars. Also the choroidal blood flow was restored partially.

Conclusion Indocyanine green choroidal videoangiography has shown hypofluoresscence of the placoid lesions. This may be explained by choroidal hypoperfusion as the pathogenesis of acute posterior multifocal placoid pigment epitheliopathy.

Key words Acute posterior multifocal placoid pigment epitheliopathy - indocyanine green angiography - fluorescein angiography

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S. 175-177 (Art. 274)

Alagille syndrome (arteriohepatic dysplasia): follow up of 23 years of stable ocular findings
Michael JM Groh, Hartmut Wenkel, Ursula M Mayer

Background Alagille syndrome is a arteriohepatic dysplasia which is in most cases correlated with ocular disorders. The most common ocular defect is a posterior embryontoxon.

Patient We report on a 27-year-old patient suffering from Alagille syndrome, seen in our department for 23 years. Within these 23 years the ophthalmological status concerning visual acuity and intraocular pressure of the patients was stable. Iris-stroma-atrophy showed a small increase on both eyes.

Conclusion In comparision to patients with Axenfeld anomaly a development of glaucoma is not observed in these patients. Maybe the anomalies of the anterior chamber angle are less severe or different from those in Axenfeld anomaly. The disease is also correlated with hepato- or/and splenomegalie by biliary hypoplasia, cardiac disorders etc. Cooperation of paediatricians, internal specialists and ophthalmologists are necessary for the treatment of these patients.

Key words Alagille syndrome - posterior embryontoxon - arteriohepatic dysplasia - case history

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S. 178-180 (Art. 250 DF)

Subepidermal calcified nodule (calculus) of the eyelid
Jens Martin Rohrbach, Harald Preßler, Bernhard Kreutzer

A 9-year-old boy presented with a painless hard tumor in the right lower lid. It had grown slowly since 12 months. Three months before presentation cryotherapy was administered by a dermatologist because of a presumed wart. Both eyes were normal. Clinical differential diagnosis included a keratoakanthoma and a wart. Excisional biopsy was performed. Histology revealed granular deposits which stained positive with hematoxylin-eosin and von Kossa stain. Though a secondary (dystrophic) calcinosis of the lid following cryotherapy could not be ruled out a diagnosis of an idiopathic subepidermal calcified nodule (calculus) of the lid was established.

Key words subepidermal calcified nodule - calculus - calcinosis cutis - wart - eyelid

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S. 181-183 (Art. 252 DF)

Orbital sarcoidosis - a case with an unusual course
Claudia Auw-Hädrich, Jürgen Gerling, Heinrich Witschel

Background Most cases of orbital sarcoidosis are associated with a systemic sarcoidosis.

Patients and methods A 67-year-old woman suffered from an orbital mass on the right side, which led to disturbance of the ocular motility. Slight improvement was achieved by the administration of systemic steroids

Results Histologically a chronic granulomatous inflammation was revealed in the biopsy of the orbital mass. The suspected diagnosis was sarcoidosis, but three conventional chest X-rays within 10 months and the serum angiotensin-converting-enzyme were normal. Suprisingly a computertomography of the chest showed mediastinal lymphomas.

Conclusion Granulomatous orbital inflammation without any local cause or other systemic granulomatous disease strongly suggests a systemic sarcoidosis. In case of missing lymph node enlargement in conventional chest X-ray computertomography should be performed.

Key words Orbital granulomatous inflammation - sarcoidosis - computertomography

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S. 184-185 (Art. 230 DF)

Ocular Chalcosis
Wido M. Budde, Anselm Jünemann

Text nur in Englisch verfübar:

Purpose To report on a patient including measurements of retinal changes in ocular chalcosis.

Patient and Methods After having suffered an open-globe injury presumably due to a small foreign body after a grenade explosion, a 30-year-old man presented six years later with ocular chalcosis including sunflower cataract, a multitude of tiny brownish particles in the anterior vitreous, a fibrillar degeneration of the posterior vitreous and brilliant patches overriding the foveal region. The patches were measured by confocal scanning laser tomography (HRT) and optical coherence tomography (OCT).

Results Besides an acquired cyandyschromatopsia, psychophysical and electrophysiologic tests were unremarkable. Vision was 20/20. The central patches measured 200 to 700 mm in diameter (HRT) and 150 to 200 mm in height above the inner retinal surface (HRT and OCT).

Discussion With exception of a Kayser-Fleischer ring of the cornea the patient presents all morphologic signs of ocular chalcosis. Although the observed patches on the central retina in ocular chalcosis are described in the literature, their nature is not known.

Key words Chalcosis - sunflower cataract - maculopathy - intraocular foreign body complication - laser scanning tomography - optical coherence tomography

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