AUGENHEILKUNDE 213/1999 – ISSUE 6

Abstracts:

S. 315-319 (Art. 436)

Prognosis of keratoplasty in keratitis phlyctenulosa peracta
Carsten Meyer, Hans-Jürgen Meyer

Background In spite of clear transplants the results of keratoplasty are often disappointing. We looked for possible reasons for these failures.

Patients and methods We analyzed in 204 eyes of 115 patients the factors influencing the prognosis. Our results are based on medical records and on demanded reports of the treating ophthalmologists. Patients were divided after different aspects (method of operation, beginning of the disease, operation of the first or second eye).

Results A frequently associated cataract and the method of surgery (aphakia, one- or two-step, triple procedure) has no influence on the prognosis. However, age of onset and density of corneal scars are crucial. This is especially evident in eyes first operated on. In case of early onset (before the age of five) visual acuity only reached 0.21 average postoperatively, whereas patients with late onset gained visual acuity of 0.59. The fellow eye (np89) had postoperative visual acuity of 0.48. In patients with poor postoperative visual improvement (^ two lines) high myopia was apparent in 50%.

Conclusion For estimating the prognosis besides early childhood amblyopia we must take into account high myopia induced by formdeprivation (FDM). Exact evaluation of patients' history and preoperative ultrasound biometry are recommended.

Key words Keratitis phlyctenulosa peracta - keratoplasty - age of onset - formdeprivation myopia - preoperative biometry

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S. 320-325 (Art. 435)

External trabecular excision (ETE) - as an alternative to filtering procedures in patients with primary open angle glaucoma
Jörg Schmidt, Peter Kroll, Gabriele Beate Kuba

Background Postoperative complications concerning glaucoma filtering surgery (trabeculectomy, goniotrepanation) often include hypotonia that may lead to athalamia or choroidal detachment, which are difficult to handle. Cystic non filtering blebs are due to postinflammatory reactions, and may limit the success of filtering surgery. Aim of the study was to compare the success and the complications of a new operating technique, which will be described, with those of usual glaucoma filtering surgery.

Patients and methods In 24 open angle glaucoma patients with mean intraocular pressure of 28.12 mm Hg (±8.6) we performed external trabecular exzision in 25 eyes since june 1997. Preoperative visual acuity and peak intraocular presure were compared retrospectively in all eyes with the values of the first postoperative day, in 22 eyes after one month and in 17 eyes after 3 months.

Results Intraocular pressure measured between 0 mm Hg and 16 mm Hg on the first postoperative day (7.64 mm Hg ±4.3), after one month between 10 mm Hg and 30 mm Hg (17.81 mm Hg±5.5) and after 3 months between 9 mm Hg and 26 mm Hg (15.29 mm Hg±4.2). After 1 month 10 of 22 (45%) and after 3 months 7 of 17eyes (42%) required antiglaucomatous drugs; 3 eyes needed gonitrepanation (2 weeks, 1 month, 3 months after ETE). Concerning postoperative complications, we observed 6 choroidal detachments, once erythrocoytes in the anterior chamber, twice hyphemata, twice inflammatory reaction in the anterior chamber, two flat anterior chambers and twice a positive seidel test.

Conclusion Complications after ETE are similar to those after filtering surgery. Postoperative intraocular pressure dip after ETE in most eyes was not as pronounced as after goniotrepanation or trabeculectomy, and postoperative complications were all reversible. 45% of the eyes again needed antiglaucomatous drugs after one month and 42% after 3 months. A prospective long-term study has to verify the success respectively the complications of ETE.

Key words External trabecular exzision - glaucoma filtering surgery - primary open angle glaucoma

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S. 326-330 (Art. 430)

Behaviour of intraocular eyepressure after Nd:YAG-laser-capsulotomy - a critical judgment by prophylactic application of a topical carbonic anhydrase-II-inhibitior dorzolamide hydrochloride (Trusopt®)
Claudius Lachmann, Klaus-Michael Jörg, Reinhard Trinkmann

Background The aim of the present study was to examine the influence of the topical carbonic anhydrase-II-inhibitor dorzolamide hydrochloride (Trusopt®) in regarding to behaviour of intraocular eyepressure after Nd:YAG-laser-capsulotomy.

Patients and methods The study was carried out as a double-blind-test. In a period of nine months, 120 patients underwent Nd:YAG-laser-capsulotomy. One group was given dorzolamide hydrochloride (Trusopt®), the other group (placebo) remained without medication. The intraocular pressure was measured bevor capsulotomy and four hours post-op. For statistical evaluation the t-test of not-associated spot-checks was performed.

Results The prophylactic use of the topical carbonic anhydrase-II-inhibitor dorzolamide hydrochloride (Trusopt®) after nd:YAG-laser-capsulotomy shows a highly significant lowering of intraocular pressure, i.e. 1.09 mm Hg in the average.

Conclusions It was demonstrated that a single dose of dorzolamide hydrochloride (Trusopt®) after Nd:YAG-laser-capsulotomy could lower intraocular pressure significantly. Prophylactical usage of dorzolamide hydrochloride (Trusopt®) is a useful method to prevent the increase of intraocular pressure and thus to protect the eye against harzadous damage.

Key words glaucoma - intraocular pressure - Nd:YAG-laser-capsulotomy - dorzolamide

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S. 331-340 (Art. 444)

Diffuse malignant melanomas of the uvea
A clinico-pathologic study of 39 patients
Ulrike C Braun, Volker C Rummelt, Gottfried OH Naumann

Background Focal malignant melanomas involving only the iris have a very good prognosis. Involvement of the iris and /or diffuse growth makes the prognosis worse. The prognostic parameters of diffusely growing malignant anterior uveal melanomas are analysed.

Patients and methods From 1981-1995 serial sections of 39 eyes, 23 women and 16 men, of diffusely growing malignant anterior uveal melanomas were histologically examined. Patients were between 9 and 80 years old (median 56 years). Follow-up was between 2 months and 15 years. At the end of the study, 13 patients had died from metastasis, all showed involvement beyond the iris. Four patients died from other causes.

Results The 39 diffuse malignant melanomas were categorized into 10 affecting only the iris, 18 iris and ciliary body and 11 involving iris, ciliary body and choroid. 14 spindle- cell, 23 mixed-cell and 2 epitheliod- cell tumors were identified. We observed between 0 and 4 mitoses in 40 high-power fields. Only 4 melanomas showed more than 100 tumor-infiltrating lymphocytes in 20 high-power fields. Nine tumors showed extra-scleral spread, nine displayed vascular networks. Univariate Kaplan-Meier survival curves showed as significant prognostic factors: localisation in the iris only (pp0.0008), spindle cell type (pp0.0002) and absence of vascular networks (pp0.01). This was confirmed by multivariate Cox analysis.

Conclusion Patients with diffuse malignant melanoma confined to the iris alone have a good prognosis for survival. Diffuse tumor cell spread can be diagnosed at the slitlamp with high magnification. Conservative follow-up is acceptable, as long as ciliary body involvement is ruled out. Eye with medically uncontrollable secondary glaucoma should be enucleated. Anti-glaucoma filtering procedures are contraindicated because of the danger of extraocular spreading malignant cells.

Key words malignant melanoma - anterior uvea - diffusely growing malignant uveal melanomas - vessel parameter - vascular network - iris melanoma - iris- and ciliary body melanoma - iris- ciliary body- choroidal melanoma - extrascleral spread - malignant melanocyte

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S. 341-346 (Art. 432)

Peak pulse blood volume and topical antiglaucomatous drugs in a cynomolgus monkey high tension glaucoma model
Karl-Georg Schmidt, Andrea v. Rückmann, Dieter Eisenmann, Daniel Y Stegman, Thomas W Mittag

Background The present study was designed to investigate the effect of topical antiglaucoma drugs on Peak Pulse Blood Volume (PPBV; German abreviation: PGBV) in cynomolgus monkey eyes without (CMNG; German abreviation: RA-KTL) and with lasersurgically induced glaucoma (CMG; German abreviation: RA-LHDG).

Methods CMG unilaterally received 2-3 laser treatments so as to develop the lasered-eye glaucoma model. Intraocular pressure (IOP; German abreviation: IOD) and Ocular Pulse Amplitude were measured and PPBV was determined until the glaucoma model had stabilized. Consecutively topical antiglaucoma drugs (epinephrine, paraaminoclonidine, pilocarpine, timolol) were investigated in 4-8 animals in CMNG and CMG eyes.

Results IOP and PPBV were not significantly altered in CMNG. In the CMG eyes epinephrine and paraaminoclonidine did not significantly alter IOP or PPBV, whereas pilocarpine and timolol sig. (p < 0.01) reduced IOP and significantly (p < 0.05) increased PPBV. Conclusion With respect to improved PPBV in the CMG eye the rank order of drug effectiveness is timolol > pilocarpine > paraaminoclonidine > epinephrine.

Key words Experimental primary open angle glaucomas - intraocular vascular system - ocular pulse amplitude - peak pulse blood volume - topical glaucoma drugs

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S. 347-350 (Art. 390)

Peak pulse blood volume during manipulation of local perfusion parameters
Karl-Georg Schmidt, Andrea v. Rückmann, Volker Klingmüller, Lutz E Pillunat, Thomas W Mittag

Background Choroidal autoregulation is discussed controversially. The present study was designed to investigate for the effect of standardized manipulation of local perfusion parameters on choroidal hemodynamics in cynomolgus monkey eyes with lasersurgically induced glaucoma (CMG; German abreviation: RA-LHDG).

Methods CMG unilaterally received 2-3 laser treatments so as to develop the lasered-eye glaucoma model. Intraocular pressure (IOP; German abreviation: IOD) and Ocular Pulse Amplitude (OPA) were measured and Peak Pulse Blood Volume (PPBV; German abreviation: PGBV) was determined.

Results In CMG PPBV was not significantly (sig., p > 0.05) altered in laser-treated eyes - despite a sig. (p < 0.05) increase in IOP. Untreated contralateral control eyes of monkeys with an IOP-increase > 5 mm Hg in laser-treated eyes showed a sig. (p < 0.05) increase in PPBV.

Conclusion Unchanged PPBV in laser-treated eyes of CMG and an increase in PPBV in control eyes point at a bilateral autoregulatory compensatory mechanism, which is more manifest in eyes with IOPs in the normal range.

Key words Experimental open angle glaucomas - choroid - ocular pulse amplitude - peak pulse blood volume - autoregulation

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S. 351-354 (Art. 425)

Pars plana vitrectomy for Borrelia burgdorferi endophthalmitis
Petra Meier, Rosemarie Blatz, Martina Gau, F.-Bernhard Spencker, Peter Wiedemann

Background Ocular manifestations of Lyme borreliose present with unusual forms of conjunctivitis, keratitis, optic nerve disease, uveitis, vitritis and rarely endophthalmitis.

Case report A 57-year-old man working as logger in Saxony-Anhalt suffering from an endophthalmitis on his left eye was referred to us. The vision of his left eye was intact light perception and hand motions. The slit-lamp examination revealed severe inflammation of the anterior chamber with hypopyon, posterior synechiae, and opacity of the posterior lens capsule. Funduscopy showed no red reflex, no retinal details. In the local hospital serum analysis was performed and showed in Western-Blot IgM- and IgG-antibodies against Borrelia burgdorferi. Despite of intravenous application of ceftriaxon for 14 days panuveitis persisted, and endophthalmitis developed when antibiotic therapy was finished.

Results During pars plana vitrectomy a sharply delineated cystic lesion containing yellowish fluid was revealed, and cremy yellow fluid was aspirated. Microscopically in hematoxylineosin stained slides of the aspirate structures consistent with Borrelia burgdorferi were found. Postoperatively vision increased to 1/15. Despite of a second intravenous ceftriaxon treatment for 14 days we observed a retinal vasculitis in the follow up of 6 months.

Conclusions Despite intravenous ceftriaxon-therapy borrelia burgdorferi must have survived in the vitreous body. Further investigations are required with respect to the use of other antibiotics or immunsuppressives.

Key words Borrelia burgdorferi - endophthalmitis - pars plana vitrectomy - retinal vasculitis

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S. 355-357 (Art. 434)

Optic neuropathy following erythema infectiosum
Helmut Wilhelm, Christiane Hartmann, Vera Boesche-Abele

Background Optic neuropathies can not always easily be classified as neuritis or ischemic disease.

Case report A 39 year old woman suffered from unilateral optic neuropathy 9 days after the acute onset of a general disease with erythema and joint swellings. The optic disc swelling and visual fields resembled an anterior ischemic optic neuropathy, however, a marked improvement was achieved by steroid treatment. The general disease proved to be erythema infectiosum.

Conclusions Erythema infectiosum as a frequent children's disease causes very rarely central nervous involvement, optic neuropathy has not been reported yet. In cases of atypical optic neuropathies search for an underlying systemic disease is of value.

Key words Optic neuropathy - steroid treatment - erythema infectiosum

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S. 358-361 (Art. 437)

Uveitis-masquerade syndrome of M.Gaucher
Causal treatment with alglucerase-substitution-therapy
Katharina Dann, Christoph Althaus, Andreas Kersten, Stephan vom Dahl, Rainer Sundmacher

Background Gaucher's disease, a sphingolipidose transmitted by autosomal-recessive inheritance, is caused by a deficiency of the lysosomal enzyme b-glucocerebrosidase which is responsible for hydrolysation of glucocerebroside to ceramid and glucose. Thus glucocerebroside is accumulated in the reticuloendothelial cells of spleen, liver and bone marrow and pathognomonic Gaucher's cells are formed.

Case report In May 1997 a 42-year-old female patient presented with left-sided intermediate uveitis of unknown origin and decreasing visual acuity to perception of hand movements and intact projection of light since September 1996. To exclude a systemic disease a thorough medical examination - showing hepatoslpenomegaly, anemia, thrombocytopenia and bone lesions - was iniciated and revealed advanced M. Gaucher (Type I) by bone marrow punction. Intravenous therapy with alglucerase was administered promptly. After five months of treatment vitreous opacities resolved almost completely and visual acuity increased to 0,7.

Conclusions The dramatic improvement occurred under treatment with alglucerase after no response to steroid treatment. Thus intermediate uveitis with severe vitritis can be interpreted as uveitis masquerade syndrome with M. Gaucher. To the best of our knowledge, this is the first case of M. Gaucher presenting initially as intermediate uveitis and showing successful clinical improvement during administration of alglucerase.

Key words Intermediate uveitis - M. Gaucher - alglucerase treatment

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S. 362-366 (Art. 433)

Juvenile neuronal ceroid-lipofuscinosis (Batten's disease)
Birte Neppert, Bianka Kemper

Background The neuronal ceroid-lipofuscinosis (NCL) belongs to progressive neurodegenerative disorders of childhood with both ophthalmologic and neurologic symptoms. In the most common type in Germany, the juvenile type, the ophthalmological examination is essential for an early diagnosis.

Patient A 5-year-old boy had exhibited a loss of visual acuity, visual field and colour perception in his pre-school age. His clinical features and electrophysiologic data are presented. The final diagnostic clues were drawn from the neuropediatric and cytologic examinations.

Results This patient shows the typical clinical feature of the juvenile NCL with a relatively rapid visual loss with bull's eye maculopathy in the pre-school- to early school age. His electroretinogram was abolished, and his EEG showed pathologic results. The diagnosis could be established by electron microscopy of his lymphocytes. Epilepsy and intellectual defects are expected to set in only few years later.

Conclusions Although there is no therapy, the ophthalmologist should be aware of this rare entity because prognostic counselling, social help and perhaps genetic counselling could be offered to the families. In many cases, a prenatal diagnosis is possible.

Key words bull's eye maculopathy - ceroid-lipofuscinosis - electroretinogram - visual evoked potentials - electron microscopy of lymphocytes - storage disease - gene defect - genetic counselling

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S. 367-369 (Art. 421 DF)

The removal of a Loa Loa worm in a Westafrican tourist
Helmut G Sachs, Markus Heep, Veit-Peter Gabel

Background Loa Loa is a chronic parasitemic disease which is endemic in the tropical rain forests of western africa. Vector of this disease is a mancrove fly with the name Chrysops. Besides the eye worm and skin affections a systemic infection with microfilariae is common.

Patient A Westafrican tourist from Bangibe showed up at the university eye clinic. His complaints were a red eye and a mobile subconjunctival tumor (Fig. 1) that showed vermiform movements. The worm was transparent and 4-5 cm in length. After topical anaesthesia and the attempt to paralyse the worm (1) with Pilocarpine 2% it vanished. Two days later the patient showed up in the morning for the planned blood test. No worm was visible at that time but at noontime the blood test was carried out and at that time the worm was visible in the nasal conjunctiva. This time the worm was removed without delay under topical anaesthesia. The worm was fixed with a forceps through the conjunctiva which was opened for 0.5 cm. The worm was grasped with a second forceps and drawn out under massive vermiform movement. Systemic therapy was recommended with Hetrazan (Diethylcarbamazine) using Corticosteroides and Antihistamine to minimize allergic side effects by the therapy due to the systemic microfilariae blood load. Eosinophilia was 8%.

Conclusions A subconjuctival Loa Loa worm can be removed under topical anaesthesia by fixing it with a forceps through the conjunctiva and opening it and grasping the worm with a second forceps. According to our experience the paralysation with Pilocarpine cannot be realized. Careful systemic therapy avoiding reported allergic side effects with Hetrazan which is not available in Germany is necessary.

Key words Loa loa - Filariasis - Eye-Diseases-parasitology - Loiasis

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