[Acanthamoeba endophthalmitis-a case report]. / Akanthamöbenendophthalmitis ­ Ein Fallbericht.

Diagnosis of acanthamoeba keratitis is often a clinical challenge. In most cases it is primarily confused with herpes keratitis. A coinfection with bacteria or fungi can also lead to a delayed diagnosis and initiation of treatment. A few cases reported the detection of acanthamoeba in the anterior chamber. In the case of endophthalmitis without the detection of bacteria or fungi acanthamoeba should therefore always be considered as a potential differential diagnosis. The local and systemic administration of voriconazole can be successfully used to treat acanthamoeba endophthalmitis.

[Astigmatism]. / Astigmatismus.

Astigmatism is the most frequent refractive error worldwide followed by hyperopia and myopia. Internal astigmatism has to be differentiated from external astigmatism. Furthermore, external astigmatism can be divided into "with the rule", "against the rule" and "oblique". The summation of internal and external astigmatism results in the refractive cylinder. Astigmatism has for a long time been regarded as a two-dimensional phenomenon; however, only a three-dimensional consideration expanded the view on existing analytical methods (topography and tomography). Alpins' vector analysis is a commonly used method for treatment planning. Multiple options exist for treatment of astigmatism with conservative approaches, such as eyeglasses or toric contact lenses as well as various surgical procedures, such as photorefractive keratectomy, femtosecond laser-assisted keratotomy, laser in-situ keratomileusis, small incision lenticule extraction and toric intraocular lens implantation.

[Corneal refractive surgery despite systemic diseases?] / Refraktive Hornhautchirurgie trotz systemischer Erkrankungen?

According to the literature there are a large number of potential systemic contraindications for corneal refractive surgery. In cases with relative contraindications, surgery should be performed only after weighing up the individual risks and under controlled disease conditions; however, the "evidence" for many of these contraindications is based only on case reports or series, expert opinions or known complications in non-laser-assisted eye surgery. Randomized clinical trials are therefore required.

[Prevalence and age-related changes of corneal astigmatism in patients before cataract surgery]. / Prävalenz und Altersabhängigkeit von kornealem Astigmatismus bei Patienten vor Kataraktchirurgie.

BACKGROUND: The aim of this study was to determine the extent and the distribution of corneal astigmatism in patients awaiting cataract surgery in a mid-European tertiary clinic centre and hence to establish the demand for methods reducing corneal astigmatism. PATIENTS AND METHODS: Keratometry measurements of cataract surgery candidates assigned to a university clinic between January 2013 and October 2014 were recorded and analysed retrospectively. RESULTS: A total of 6900 eyes of 3450 patients with a mean age of 72.5 ± 12.2 were analyzed. The corneal astigmatism was more than 0.5 dioptres (D) in 5193 eyes (75.3 %), >1.0 D in 2641 eyes (38.3 %), >1.5 D in 1304 eyes (18.9 %), >2.0 D in 644 eyes (9.3 %), >2.5 D in 363 eyes (5.3 %), >3.0 D in 236 eyes (3.4 %) and >3.5 D in 149 eyes (2.2 %). With increasing age a shift from with-the-rule astigmatism towards against-the-rule astigmatism was observed. CONCLUSION: Of the patients admitted for routine cataract surgery at our clinic, 2641 eyes (38.3 %) had an astigmatism greater than 1.0 D. Our data could be helpful in establishing a protocol for using toric intraocular lenses and to determine the costs.

Laser-assisted subepithelial keratomileusis with mitomycin C for myopic astigmatism ≥2.00 diopters using a Zeiss MEL 80 Excimer.

To examine the refractive and visual outcome of laser-assisted subepithelial keratomileusis (LASEK) with mitomycin C(MMC) in eyes with myopic astigmatism ≥2.00 diopters (D). This study comprised 82 eyes of 82 consecutive patients (37 male, 45 female; mean age at surgery 34.7 ± 9.0 years) with preoperative topographic astigmatism ≥2.00 D and mean preoperative spherical equivalent (SE) -4.50 ± 1.13 D. To assess whether the refractive results differed with the amount of corrected sphere, the data were separated by preoperative SE thereby defining two groups with SE < -5.00 D (-2.00 to -4.75 D) and ≥-5.00 D (-5.00 to -7.75 D). Mean manifest refraction spherical equivalent (MRSE) of -0.39 ± 0.52 D was obtained at the 6-months (5.4 ± 1.6 months) follow-up. The results were within ±1.00 D of the attempted correction in 89 % of patients. The mean postoperative corrected distant visual acuity was -0.02 ± 0.065 logMAR (range -0.10 to 0.15 logMAR). Sixty-seven (81.7 %) of all eyes did not change lines in safety. There was no statistically significant difference (P = 0.262) in safety between the SE groups. Mean efficacy was 0.89 ± 0.27. There was a statistically significant difference in efficacy (P = 0.024) between the preoperative SE groups. Larger ablation zones were associated with better visual outcome, confirmed by safety, efficacy and predictability. The data reported here demonstrated that LASEK using a Zeiss MEL 80 excimer laser with an additional application of MMC is a safe and efficient technique with predictable results for the correction of eyes with myopic astigmatism ≥2.00 D.

[Refractive predictability and stability of three-piece versus single-piece intraocular lenses in patients with high axial myopia]. / Refraktive Vorhersagbarkeit und Stabilität von 3-teiligen vs. 1-teiligen Intraokularlinsen bei hoher Achsenmyopie.

BACKGROUND: Based on previous data on single-piece and three-piece intraocular lenses (IOLs) there is no evidence for significant differences in decentration, tilt and refractive shift. The purpose of the current study was to compare single-piece and three-piece IOLs in patients with high axial myopia. MATERIAL AND METHODS: A total of 68 eyes of 50 patients with high axial myopia (axis length ≥ 28.00 mm) with and without cataract who underwent complication-free phacoemulsification and IOL implantation were retrospectively examined. To compare single-piece and three-piece IOLs, the patients were retrospectively grouped depending on IOL type: group 1 acrylic single-piece IOL (n = 37; ACR6D SE, Corneal, France) and group 2 acrylic three-piece IOL with fixed haptic frame (n = 31; AF-1 UY, Hoya, Japan). Patient files were analyzed regarding best spectacle-corrected visual acuity (BSCVA), refractive predictability and stability. RESULTS: In this study the mean BSCVA was determined as 0.22 ± 0.12 logMAR and 0.13 ± 0.11 logMAR 6 months postoperatively for the ACR6D SE group and the AF-1 UV group, respectively (p = 0.09). Refractive predictability was less accurate in the ACR6D SE (+ 1.75 ± 2.2 dpt) compared to the AF-1 UV (- 0.37 ± 1.1) treated eyes (p = 0.001). Refractive stability, defined as the difference in diopters between the first week and the sixth month after surgery, resulted in + 0.40 ± 1.7 dpt and -0.16 ± 1.2 dpt for the ACR6D SE and the AF-1 UV, respectively (p = 0.022). CONCLUSIONS: The three-piece AF-1 UV showed satisfactory refractive predictability and stability in patients with high axial myopia. The ACR6D SE has a high refractive unpredictability and should not be used in eyes with high axial myopia.

Intravitreal VEGF levels in uveitis patients and treatment of uveitic macular oedema with intravitreal bevacizumab.

PURPOSE: Clinical data suggest a role for VEGF in uveitic cystoid macular oedema (CME), even though the data on intravitreal VEGF levels in these eyes is still inconclusive. We determined intravitreal VEGF levels and treated uveitis patients with intravitreal bevacizumab. METHODS: Intravitreal VEGF levels were measured in eight uveitis patients and 10 controls using cytometric bead array technology. In 11 eyes of a second group of uveitis patients, CME was treated using 1.25 mg bevacizumab intravitreally. Re-injections of bevacizumab were given in patients showing a transient positive effect, defined as an increase of the best-corrected vision of at least two lines on a snellen chart. Alternatively, triamcinolone was given in patients, not responding to bevacizumab. RESULTS: Mean intravitreal VEGF concentration was 82.75+/-171.71 pg/ml (+/-SD) (range, 0.0-502.1 pg/ml), and below the detection levels in controls. A significant reduction of retinal thickness was seen at weeks 2 (P=0.001) and 4 (P=0.007). A significant improvement in VA was seen at week 2 (P=0.02). Patients presenting with a CME in baseline fluorescein-angiogram responded well towards bevacizumab treatment, unless an extensive leakage from the choroid or a leakage of the optic disk was detectable. In these patients, only intravitreally administered triamcinolone led to a reduction of the CME. CONCLUSIONS: Our data suggest that patients presenting with a diffuse leakage from the choroid in the fluorescein angiogram or an extensive leakage of the optic disk should be treated with intravitreal triamcinolone, whereas in patients presenting only a cystoid macular oedema bevacizumab treatment seems like a good choice.

[Visual function with blue light filter IOLs]. / Visuelle Funktion mit Blaulichtfilter-IOL.

BACKGROUND: Recently, intraocular lenses (IOLs) with a blue light filter have been introduced to protect the retina from age-related macular degeneration (AMD) after cataract extraction. A reduction of longitudinal chromatic aberration by filtering blue light may enhance patient's visual function. In this study we compared subjective and objective parameters of visual function following implantation of blue light filter (yellow) IOLs and IOLs of the same design without filter. PATIENTS AND METHODS: 21 patients (21 eyes) underwent implantation of an IOL with a blue light filter (AF-1 UY, Hoya, Japan), 22 patients (22 eyes) received an IOL without blue light filter (AF-1 UV, Hoya, Japan). Patients were examined three months postoperatively for uncorrected and best corrected spectacle visual acuity, mesopic and photopic contrast sensitivity, colour vision and subjective quality of vision by a standard questionnaire. RESULTS: Eyes with blue light filter IOLs did not show any significant difference in any parameter analysed when compared to eyes without the blue light filter IOL. Subjective quality of vision was considered to be high by all patients and no significant difference was observed between the two IOL groups. CONCLUSION: The visual function of patients with blue filter IOLs is not significantly different to those without blue light filter IOLs. Since blue light filter IOLs did not show any functional disadvantage, but potentially protect the macula from AMD, blue light filter IOLs may be considered as a reasonable alternative to traditional IOLs, especially in eyes with a high risk for the development of macular degeneration.

Lamellar corneal dissection for visualization of the anterior chamber before triple procedure.

PURPOSE: Open-sky cataract extraction during triple procedure can be associated with higher risk of complications owing to the missing counterbalance by the cornea. Herein, we present a fast and easy technique for visualization of the anterior chamber and the lens in eyes with opaque corneas planed for triple procedure. MATERIALS AND METHODS: Four patients with corneal oedema due to Fuchs' endothelial dystrophy and cataract underwent triple procedure. As the anterior chamber view was limited, the central 7.0 mm of the cornea was marked. Then, 60-80% of the corneal thickness was removed by lamellar dissection and filled with hydroxypropylmethylcellulose. Continuous curvilinear capsulorhexis (CCC) and phacoemulsification with intraocular lens implantation through a corneoscleral tunnel were then performed and at the end the remaining corneal tissue was excised and the donor tissue fixed with a single running continuous suture. RESULTS: Lamellar corneal dissection enhances the anterior chamber view and CCC can be performed under stable anterior chamber condition. Phacoemulsification via sclerocorneal tunnel could be easily performed under good anterior chamber view in all cases. The operation time was 60-75 min in all cases. CONCLUSION: Lamellar corneal dissection in opaque corneas before cataract extraction is a useful technique for enhancing anterior chamber view in cases of triple procedure.

Adverse skin reactions to infliximab in the treatment of intraocular inflammation.

TNFalpha inhibitors are more widely used in the treatment of intraocular inflammation, thus ophthalmologists should become aware of possible adverse events, associated with this form of treatment. Herein we report two cases of cutaneous adverse events in uveitis patients treated with infliximab. In one patient, the primary outbreak of pustular psoriasis was observed after her third infusion. A second patient developed impetigo contagiosa induced by Staphylococcus aureus. Thus patients undergoing treatment with infliximab should be monitored carefully since dermal infections and pustular psoriasis, which may be triggered by streptococcal infection, may occur under this regime.

[ABO blood group expression in corneal allograft failures]. / ABO-Blutgruppenexpression in Hornhäuten mit Transplantatversagen.

BACKGROUND: ABO blood group antigens are only expressed by the epithelial cells of normal human corneas. Since AB0 blood group antigens are also known to be expressed on stromal and endothelial cells of inflamed corneas, this study aimed to investigate the extend of ABO blood group antigen expression in corneal allograft failures. MATERIAL AND METHODS: Twenty-two failed corneal allografts of 22 patients were examined. In 12 cases the patients had clinically proven corneal allograft rejection. In 10 cases there was no evident history of allograft rejection and the diagnosis graft failure due to chronic endothelial cell loss was made. Immunohistochemical staining of paraffin embedded sections was performed with monoclonal mouse antibodies to human blood group antigen A or B using the streptavidin-biotin-peroxidase complex technique. RESULTS: Blood group antigens A or B were expressed by stromal keratocytes in 5 out of 12 and by endothelial cells in 7 out of 12 corneas with clinically proven immunologic graft rejection. Corneal transplants with chronic endothelial cell loss expressed blood group antigens A and/or B on the endothelial cells in three out of ten cases. CONCLUSION: The results of this study show that ABO blood group antigens can be up-regulated in cases of corneal allograft failure, especially in cases of immune mediated graft rejection. This phenomenon might play a role in corneal allograft rejection.

Antibody targeted gene transfer to endothelium.

BACKGROUND: One of the drawbacks of the currently available vectors for gene therapy is the lack of selectivity in gene delivery. We have therefore investigated a strategy to generate immunoliposomes to target non-viral vectors to cell surface receptors on endothelium. MATERIALS AND METHODS: We have developed a novel method of coupling antibodies (Abs) to liposomes complexed to DNA, using mild heat treatment to aggregate the immunoglobulin G (IgG). The interaction of plasmid DNA, liposomes and Abs was measured using a gel retardation assay and a resonant mirror biosensor. The size of the transfection complex was determined by light scattering, and the binding and internalization of the complex to cells was followed using flow cytometry. The transfection ability was tested on cell lines and primary cells in vitro and human corneal or vascular tissues ex vivo. RESULTS: The interaction of antibodies with liposomes is relatively stable (t(1/2) congruent with 45 min). The size of the liposome, Ab and DNA complex was found to be around 500 nm in 4% BSA. The addition of anti-transferrin receptor Abs increased the internalization of the liposome-DNA complex into cells. Abs against both transferrin receptor and E-selectin were shown to augment transfection efficiency of liposomes to cell expressing the appropriate antigens. They are also shown to be efficient in mediating gene delivery to corneal and vascular tissues ex vivo. CONCLUSIONS: We have shown that our novel vector is capable of in vitro and ex vivo gene delivery to cells and human tissues including cornea, artery and vein. In particular, an Ab against E-selectin was effective at selectively delivering genes to activated endothelial cells expressing the adhesion molecule. Such a strategy will have applications for targeting these tissues prior to transplantation or autologous grafting, and, in the longer term, may allow in vivo targeting of gene therapy to inflammatory sites.

[Octreotide scintigraphy for the diagnosis of active Graves' ophthalmopathy]. / Oktreotidszintigraphie zur Diagnose der aktiven endokrinen Orbitopathie.

PURPOSE: In this study the diagnostic accuracy of orbital octreotide uptake in patients with presumed active Grave's ophthalmopathy (GO) was evaluated. PATIENTS AND METHODS: A prospective study of 23 patients suffering from GO was carried out. Single photon emission computed tomography (SPECT) images were obtained 4 h after iv injection of 3 mCi 111 indium octreotide. The results were correlated with the patients clinical state during a follow-up of 17.5+/-6 months. RESULTS: Octreotide scintigraphy was positive in 15 and negative in 8 cases, 12 patients with positive octreotide scintigraphy underwent immunosuppressive treatment and showed a clinically positive response with regression of symptoms. In three cases the patients refused immunosuppressive treatment. Patients with negative pathologic orbital octreotide uptake did not undergo any treatment. CONCLUSION: Octreotide scintigraphy is a useful tool to determine the activity state of Graves' ophthalmopathy. Since Graves' ophthalmopathy must be treated in the active phase, octreotide scintigraphy should be performed in subacute cases to facilitate the indications for immunosuppressive treatment.

[A clinico-pathological case report of necrotizing ulcerating keratopathy due to topical anaesthetic abuse]. / Nekrotisierende ulzerierende Keratopathie nach Lokalanästhetikamissbrauch Ein klinisch-pathologischer Fallbericht.

BACKGROUND: Topical anesthetic abuse is rare, but difficult to diagnose since most patients deny its use and the clinical changes are very similar to other corneal diseases. CASE REPORT: A 45-year-old medical doctor with a 30-year history of soft contact lens wear and recurrent corneal erosion was admitted to our clinic with a ring-shaped keratitis and intense ocular pain. A corneal smear was negative for bacterial infections and acanthamoeba but the contact lens box contained a few dead acanthamoeba and many cocci. Due to the clinical findings and the acanthamoeba found in the contact lens box acanthamoeba keratitis was diagnosed and treatment with gentamycin, pentamidine isethionat (Brolene((R))) and hexamidine (Desomedine((R))) was started. The clinical appearance did not change for 6 weeks after onset of treatment and a perforating corneal transplantation was performed for pain relief and visual rehabilitation. An iris ectropion lacking iris motility and dense cataract developed within 5 weeks and the patient admitted on direct questioning to having taken topical anesthetic (oxybuprocain) by self-medication. The histological investigation revealed few inflammatory cells. The epithelium was largely missing and few vital cells could be found in the stroma and the endothelial cell layer. Acanthamoeba could not be detected in the tissue. CONCLUSION: Topical anesthetic abuse can mimic different corneal diseases and be difficult to diagnose if the patient denies its use. In cases of keratitis with no response to treatment and strong ocular pain, topical anesthetic abuse should be considered.

[Intracorneal silicone oil deposits]. / Intrakorneale Silikonölablagerung.

BACKGROUND: A patient with intraocular silicone oildeposits underwent paracentral corneal incision but the corneal sutures were never removed and 7 years later a perforating corneal transplantation was performed due to corneal opacification. METHODS: The corneal button was fixed in 10% buffered paraformaldehyde, embedded in celloidin and sections 200 microns thick were cut and stained with van Gieson. Some of these sections were embedded in paraffin and 5 microns thick sections were cut. RESULTS: Celloidin sections showed intrastromal silicone oil droplets located adjacent to defects in Descemets' membrane and corneal sutures but the endothelial cells contained no silicone oil droplets. CONCLUSION: Silicone oil can penetrate the corneal stroma in cases of defects in Descemets' membrane.

[Therapy of neurotrophic keratopathy in trigeminal schwannoma with radiosurgery]. / Therapie einer neurotrophen Keratopathie bei Trigeminusschwannom mittels Radiochirurgie.

BACKGROUND: We present a patient with neurotrophic keratopathy due to a trigeminal nerve neurinoma, who was successfully treated by radiosurgery. PATIENT: A patient was referred to us with recurrent corneal erosions of unknown origin in his left eye. In addition, he suffered from mild hypoesthesia in the distribution of the first branch of the trigeminal nerve. He was started on topical lubricants (hyaluronic acid 0.5%) and antibiotic ointments (gentamycin), but since no corneal healing occurred, a soft contact lens was applied. The patient developed severe corneal neovascularization within four weeks and the contact lens had to be removed. Three months later an MRI scan was performed, which showed an intracranial tumor originating from the first branch of the trigeminal nerve. Neurinoma of the trigeminal nerve was suspected, and this presumed diagnosis was confirmed by fine needle biopsy. The patient underwent radiosurgery seven weeks later. The epithelium closed, the cornea recovered and stayed stable until the last examination 18 months after radiosurgery. CONCLUSION: Radiosurgery is a promising alternative to conventional microsurgery in cases of neurinomas of the trigeminal nerve including neurotrophic keratopathy, to keep or restore vision.

MMP-9 is predominantly expressed in epithelioid and not spindle cell uveal melanoma.

Extracellular matrix-degrading enzymes are crucial for cancer metastases. One group of enzymes that has been increasingly implicated in the breakdown of the extracellular matrix, and hence the intravasation and dissemination of tumour cells, is the family of metalloproteinases. In the recent past, increasing efforts have led to the development of more or less specific matrix metalloproteinase (MMP) inhibitors. Data concerning the molecular nature and timing of the contribution of MMPs to tumour spread is of paramount importance in clarifying which MMP is an appropriate target for more selective MMP inhibition in future tumour therapy. This study immunohistochemically characterized the expression pattern of MMP-2, -3, and -9 in 26 uveal melanomas. Forty-six per cent of the uveal melanomas expressed MMP-2 and/or MMP-9. MMP-3 expression was seen in 17 out of 26 uveal melanomas. MMP-9, previously shown to play an important part in tumour dissemination, was predominantly present in epithelioid melanomas (71.4%) or the epithelioid portion of mixed cell uveal melanomas (67%), whereas only one out of ten spindle cell melanomas showed MMP-9 expression (10%). MMP-2 and MMP-9 expression was associated with a significantly higher incidence of metastatic disease. The survival rate of patients with MMP-2-positive melanomas was 31% vs. 85% for patients with MMP-2-negative (p<0.05); for MMP-9-positive uveal melanomas the survival rate was 27% vs. 85% with MMP-9-negative uveal melanomas (p<0.04). The fact that patients suffering from TIMP-1- as well as TIMP-2-positive uveal melanomas tended to show a better survival rate (72% vs. 45% for TIMP-1; 88% vs. 37% for TIMP-2) supports the view that proteolytic enzymes are of importance in tumour spread.