[Vitreoretinal surgery in Oman]. / Chirurgische Behandlung vitreoretinaler Erkrankungen in Oman.

PURPOSE: Vitreoretinal diseases in Middle Eastern countries currently rank in importance behind cataract, trachoma and glaucoma. This study reports on the most frequent causes of vitreoretinal diseases and the results of vitreoretinal surgery in Oman in order to gain insights into requirements in training and equipment. METHODS: Demographic data and biomicroscopic examinations were performed over a 5-year period. Pars plana vitrectomies were carried out with the Accurus 800CS (Alcon) and EyeLite® 532 nm Laser (Alcon), endotamponade with silicone oil 5600 cs (adatomed) or C3F8 Ispan (Alcon), oval silicone sponge scleral buckles 5.5 x 7.5 mm type 507 (Geuder®) in adults and oval silicone sponge scleral buckles 3.0 × 5.0 mm type 506 (Geuder®) in children (up to 12 years) were sutured with Mersilene parallel to the limbus. Patients were followed after 4 weeks and 1 year. Evaluation of data was done by descriptive statistics (Fisher exact and χ²-tests). RESULTS: From 2002 to 2006, 2,910 vitreoretinal surgeries were performed on 784 adult and 101 pediatric eyes. Main indications were proliferative diabetic vitreoretinopathy (PDVR) (229/784 eyes=29%), followed by trauma (166/784=21%), and PVR retinal detachment (112/784=14.3%) in adults and in children the main indication was trauma (73/101 eyes=73%). The postoperative vision in adults with trauma, PVR retinal detachment, epiretinal gliosis and IOL extraction was significantly different and better (p=0.003, p=0.044, p=0.029, p=0.001, respectively) and the postoperative vision in PDVR with uncontrolled diabetes mellitus II significantly different and worse (p=0.001). Of the eyes with PDVR in uncontrolled diabetes mellitus 165 out of 229 (72%) lost distance vision (p=0.00014). All patients with serious macular edema and an HbA(1c) of ≥9.5% lost 5 m distance in vision. The mean HbA(1c) in all patients who experienced postoperative blindness was 13.5%. Postoperative vision was significantly better in children operated for trauma complications (p=0.046) whereby patients with contusion of the globe had a significantly better final result (p=0.0302) than patients with penetrating injuries. Revision surgery was indicated most frequently after surgery for proliferative vitreoretinopathy due to prior retinal detachment surgery. CONCLUSIONS: The most frequent causes of preventable retinal blindness in Oman are pediatric trauma and advanced diabetic vitreoretinopathy. Eyes operated for trauma had a better outcome than PDVR in patients with uncontrolled diabetes mellitus. The large number of eyes with PDVR in the final stages and sequelae of trauma legitimates preventive medical measures and an expansion of vitreoretinal services with supportive external training of specialists and allied health professions.

[Ipsilateral autorotational keratoplasty and cataract extraction in patients with trachoma and trauma in Oman. Report on visual rehabilitation]. / Ipsilaterale Autorotationskeratoplastik und Kataraktextraktion bei Patienten mit vernarbendem Trachom in Oman. Ein Erfahrungsbericht zur optischen Rehabilitation.

AIM: To report on the results of visual rehabilitation by ipsilateral rotational keratoplasty (IRK) and cataract extraction in 17 patients with trachoma and with trachoma and trauma in Oman over 3 years. PATIENTS: Of 25 patients operated from 2001-2004 with IRK, extracapsular cataract extraction, and intraocular lens implantation, 17 eyes of 17 patients with cicatricial trachoma (WHO stage CO) could be followed up after 1 year. Group 1 comprised 11 eyes with ciatricial trachoma. In group 2, six eyes had additional traumatic corneal scars. METHODS: Surgery was performed using a motor trephine Keratron (Geuder), the Accurus 800 (Alcon) phacovitrectomy machine, and calculation for intraocular lens implantation (IOL: MZ60BD, Alcon) with a topography (Atlas, Humphrey Zeiss)-supported SRK II formula (OcuScanRxP, Alcon). RESULTS: Although only four of 17 patients had preoperative visual acuity (VA) at 5 m and one of 17 had VA at 1 m, postoperatively seven of 17 patients gained VA at 5 m and six of 17 at 1 m. Ambulatory vision was regained in 13 of 17 (78%) patients. Patients with trachoma and trauma benefited more from the surgery [vision increase in trachoma: eight of 11 eyes (73%); trachoma and trauma: five of five eyes (100%)]. Postoperative spherical refraction was -12.0D to +4.0D (median:+4.0D), and astigmatism ranged from 10D to 0.3D (median 5.35D). One eye was lost because of uncontrolled keratitis. CONCLUSIONS: IRK with cataract extraction may provide ambulatory vision in patients with cicatricial trachoma and secondary dry eye syndrome living in developing countries where donor grafts are difficult to obtain and where postoperative follow-up of high-risk keratoplasty is impaired.

Mathematical modelling of epidemics under specific regard of adenoviral keratoconjunctivitis.

At first ADV is presented as a typical pandemic. The contagiosity of adenovirus is high because of the viability of the virus on inorganic surfaces in medical offices up to 35 days. Outbreaks and epidemics occur 3-30 days after infection, which is mainly contracted from medical facilities. EKC is considered a notifiable condition in most countries, and outbreaks, suspects and infections must be reported. Symptoms like "pink eye", foreign body sensations, photophobia, pain, signs such as follicles, hemorrhages and corneal infiltrates, and vision decrease associated with malaise are frequently observed first in one eye, later involving the fellow eye. Unilateral disease has a high rate of misdiagnosis. Currently no vaccine or virustatic is available, which is effective, cost-efficient and tolerable. Treatment is symptomatic and antiinflammatory. Late scarring may be amenable to phototherapeutic keratectomy. Infection control measures focus on the disinfection of equipment and hands of staff, the handling of infected patients with gloves, spatial separation of infected individuals resp. cohorting of infected patients, use of unit-dose eye solutions, and the chlorination of pools by approved and registered disinfectants and germicides. In connection with this it is shown how to handle the dynamics of infections by mathematical models like cellular automation, systems of differential equations and to visualize periodic effects by Fourier Analysis and to calculate costs by mathematical programming. Using mathematical analysis the percentage of a population needing vaccination to prevent spreading of pandemic can be calculated. It is shown here that especially the method of cellular automation is a simple way to simulate complex epidemiological situations without completely knowing the mathematical details.

[Post-traumatic inflammation with an intraocular foreign body]. / Posttraumatische "Endophthalmitis" mit intraokularem Fremdkörper.

BACKGROUND: To report on the diagnosis and management of a"firecracker" injury presenting with a post-traumatic intraocular inflammation. CASE REPORT: A 10-year-old boy sustained a penetrating 16-mm cornea-sclera blast injury to his left eye with uveal prolapse and hemophthalmus and doubtful light perception. The cranial computed tomography revealed a metallic intraocular foreign body (IOFB), retinal detachment, and subretinal and subchoroidal hemorrhage. After primary wound closure and antibiotic treatment for 1 week, increasing cell infiltration and amaurosis developed, and a lensectomy, pars plana vitrectomy, and extraction of the 17x7x7-mm encapsulated IOFB via a scleral tunnel was indicated. RESULTS: A vitreous specimen did not reveal microbial growth; however, plenty of polymorphonuclear cells, macrophages, and lymphocytes were observed. Spectroscopy of the IOFB showed copper, zinc, silicon, lead, and other metals. A diagnosis of noninfectious inflammation due to heavy metals, primarily copper (=chalcosis), was made. The postoperative course was unremarkable, the intraocular lens in place, fundus CDR 0.2, retina and macula attached, intraocular pressure 9 mmHg. Three weeks after surgery, the flash VEP showed absent potentials. CONCLUSIONS: Large projectiles or parts should be removed from the eye immediately in order to prevent complications from toxic metallosis and early fibrotic reactions.

[Microbial keratitis: a 4 year study of risk factors and traditional/complementary medicine in Oman]. / Mikrobielle Keratitis: Vierjahresstudie zu Risikofaktoren und traditioneller/komplementärer Medizin in Oman.

PURPOSE: To determine the risk factors and the influence of complementary/alternative medicines (CAM) for infectious keratitis in a monsoon-free region of the Sultanate of Oman. STUDY DESIGN: Retrospective single center cohort study. OUTCOME MEASURES: Demographic data, risk factors, and pathogens. METHODS: Patients with purulent stromal keratitis admitted from 2001-2004 were evaluated for clinical and microbiological data, CAM use, duration of hospitalization, and outcome of treatment. STATISTICS: chi(2)-test, Z-test. RESULTS: A total of 320 patients (326 eyes) out of 7,524 admissions had severe infectious stromal keratitis requiring inpatient treatment. The average age was 35.1+/-2.5 years (range 1.5-63 years), the male:female ratio was 2:3 in the age group >or=13 years and 2:1 in the age group

[Diseases of the adnexa in the tropics: amnion membrane transplantation for noninfectious trachoma-associated corneal ulcers]. / Erkrankungen der Adnexe in den Tropen: Amniontransplantation bei nichtinfektiösen Trachom-assoziierten Hornhautulzera.

BACKGROUND: Corneal ulcers with fornix shortening associated with late stages of cicatrizing trachoma contribute significantly to blindness in many developing countries. We report on the outcome of ocular surface and fornix reconstruction using amnion membrane transplantation. PATIENTS AND METHODS: From 2001 to 2005, cryopreserved human amnion membrane without mitomycin C was grafted to 25 eyes of 17 patients with trophic corneal ulcers and symblepharon (cicatrizing trachoma: 19 eyes of 14 patients, Stevens-Johnson syndrome: 4 eyes of 2 patients, alkali burns: 2 eyes of 1 patient) in a controlled case series. Follow-up was done up to 6 months. STATISTICS: Fischer's exact probability test. RESULTS: Of 25 eyes, 9 of 19 eyes with trachoma, 3 of 4 eyes with Stevens-Johnson syndrome, and 2 of 2 eyes with chemical burns showed complete reepithelialization and stromal recovery after 28-35 days (mean: 31+/-2.3 days). The primary success rate of trachoma eyes was not significantly different from the other indications (p=0.256). At 6 months post-op, 15 of 19 trachoma eyes (79%) compared to 2 of 6 non-trachoma eyes (33.3%) had developed a recurrence of symblephara (p=0.0592), and 13 of 15 eyes (86.6%) with a cicatricial trachoma compared to 1 of 6 with non-trachoma diagnosis experienced a recurrence of corneal vascularization (difference nonsignificant: p=0.1752). Persistent long-term reepithelialization was observed only in 1 of 19 trachoma eyes (5.3%) versus 4 of 6 non-trachoma eyes (66.7%, p=0.005); 3 of 19 trachoma eyes with a recurrence of ulcers had perforated after 6 months. CONCLUSIONS: Human amnion membrane without mitomycin C can be used for ocular surface reconstruction in selected patients with cicatrizing trachoma. Its efficacy in the long-term rehabilitation of cicatrizing trachoma seems to be limited due to the progressive scarring.

[Conceiving and implementing an ISO 9001:2000 quality management system: quality improvement and efficiency increase over 3 years at the Dept. of Ophthalmology, Sultan Qaboos University in Oman]. / Konzeption und Implementierung eines Qualitätsmanagementsystems nach ISO 9001:2000: Qualitäts- und Effizienzsteigerung über 3 Jahre an der Augenklinik der Sultan Qabbos Universität in Oman.

BACKGROUND: Oman is a developing country of the Middle East with a University Hospital in a national health system. Problems related to documentation, structure, and procedure prevailing in a multicultural environment result in a lack of productivity. The aim of this study was to test the feasibility of introducing a quality management system according to ISO 9001:2000 into a university department of ophthalmology with special reference to quality and efficiency data over 3 years. MATERIALS AND METHODS: Standardized types of documentation (35 documents, 183 forms and formats, and 453 registers) under a formal roof (booklets for work instructions, quality management, procedures) were conceived in 2001 and implemented, and were evaluated by descriptive statistics over the years 2002-2005 with respect to quality and efficiency. In 2005, the departmental QMS was merged into the QMS of the whole hospital. RESULTS: Establishment of "responsibility clusters" with structured surveillance tasks, procedural improvements, and continuous audits resulted in a significant quality improvement already during the implementation until ISO 9001:2000 certification in 2002, and over the following 3 years. The data were assessed by non-conformities documented monthly (total inpatients: -50%, outpatients: -20%, operating theater: -100%, teaching: -10%; p <0.05) and increased efficiency assessed by the most important performance indicators (before QMS vs a median of 3 years with QMS): major surgery: +459%, inpatient stay: -49.7%, occupancy rate: +63.9%, technical diagnostics: +292.9%, postgraduate teaching total: +740%, research output total: +330% (p <0.05). CONCLUSIONS: It is feasible to introduce the quality management system according to ISO 9001:2000 into a developing country in the Middle East. It has an immediate effect on the increase of efficiency (measured by performance indicators) and quality in all systems providing the possibility for regional benchmarking.

[Cataract patients with pseudoexfoliation (PEX) syndrome among a population with high prevalence of PEX. Clinical findings and morphological and surgical characteristics]. / Kataraktpatienten mit Pseudoexfoliations- (PEX-)Syndrom in einer Bevölkerung mit hoher PEX-Prävalenz. Klinische Befunde, morphologische und operative Besonderheiten.

BACKGROUND: Cataracts are the most frequent treatable cause of noninfectious blindness in Oman. Therefore, in 2002 a study was performed at our department of ophthalmology to evaluate cataract patients for pseudoexfoliation. METHODS: In a prospective comparative cohort study, 370 age-related cataract eyes out of an evaluable population of 498 cataracts were evaluated by biomicroscopy, confocal corneal analysis, and electron microscopy and followed up after 6 months. RESULTS: Of 370 age-related cataracts without glaucomas 171 had PEX. Preoperative manifestations were 89 subluxations, 15 vitreous prolapses, 6 ciliolenticular blocks, and 7 intravitreal dislocations. In 40 Omani cataract eyes without PEX the endothelial cell count was normal compared to the age-matched US norm and corneal thickness was less than Caucasians, but more than Afro-Americans. CONCLUSIONS: This study reports on a high incidence and frequent preoperative complications (68%) of the surgical cataract cases in an Arabic population. The development of serious complications and blindness is related to the duration of the disease and the lack of timely surgery.

[Patients with secondary open-angle glaucoma in pseudoexfoliation (PEX) syndrome among a population with high prevalence of PEX. Clinical findings and morphological and surgical characteristics]. / Patienten mit sekundärem Offenwinkelglaukom bei Pseudoexfoliations- (PEX-)Syndrom in einer Bevölkerung mit hoher PEX-Prävalenz. Klinische Befunde, morphologische und operative Besonderheiten.

BACKGROUND: The second most frequent treatable cause of noninfectious blindness in Oman is high-pressure glaucoma. Therefore, in 2002 a study was performed at our department of ophthalmology to evaluate pseudoexfoliation (PEX) in glaucoma patients. METHODS: In a prospective comparative cohort study, of 204 glaucoma eyes, 135 open-angle glaucomas were evaluated by biomicroscopy, papillometry, and electron microscopy and followed up after 6 months. RESULTS: The incidence of PEX glaucomas relative to all glaucomas was 50.9% and to open-angle glaucomas 77%. The IOP level in PEX was higher than in POAG; the CDR, neuroretinal rim zone, and the visual field loss were not significantly different. In 38 of 104 operated PEX glaucoma eyes, the postoperative visual acuity deteriorated although the IOP was controlled. CONCLUSIONS: PEX high-pressure glaucomas account for half of all glaucomas in the eastern region of the Arabian peninsula. Surgical outcomes feature a high percentage of postoperative reduction of vision in the late PEX stage.

En bloc excision of intraocular epithelial cystic downgrowth using syngeneic auricular cartilage.

AIM: To describe the surgical management of epithelial cystic downgrowth by en bloc excision and use of syngeneic auricular cartilage in two children. STUDY DESIGN: Retrospective interventional case series. METHOD: The charts of two patients treated for epithelial cystic downgrowth with en bloc excision and auricular cartilage transplant were reviewed. Details of ocular history, preoperative and postoperative visual acuity, intraocular pressure, ocular examination findings, surgical procedure and subsequent management were noted. RESULTS: Two children aged 4 and 6 years, with epithelial cysts who underwent en bloc excision were identified. The cysts had developed following penetrating eye injury. Surgery involved en bloc resection of the cyst and associated tissue, and replacement of the excised corneoscleral tissue with syngeneic auricular cartilage. One patient additionally required synechiolysis, discission of a secondary cataract and anterior vitrectomy. In both cases, the epithelial tissue was successfully removed and the auricular cartilage transplant was well-apposed. Visual acuity remained at the preoperative level in the first patient due to amblyopia; in the second patient visual acuity improved to 6/7.5 with mild astigmatic correction. CONCLUSION: En bloc excision provides the most definitive surgical treatment of cystic epithelial downgrowth. Auricular cartilage may be used for sclerokeratoplasty when donor cornea or sclera is unavailable.

[Intraocular epithelial downgrowth - report on 14 cases from 1986 to 2000]. / Intraokulare Epithelimplantation - Bericht über 14 Patienten 1986 - 2000.

BACKGROUND: Diffuse and cystic epithelial downgrowth occur rarely, but they represent a mostly preventable potential cause of blindness as sequels to trauma and surgery. The aim of this study is to report on the etiology and course of disease in patients with histologically verified epithelial downgrowth. PATIENTS AND METHODS: From 1986 until 2000 the ophthalmopathological laboratory of the University Eye Hospital Hamburg-Eppendorf received 13 (4 external) referrals. Ten patients with cystic of diffuse intraocular epithelial downgrowth were treated and 9 eyes were operated on in the Hospital. RESULTS: At presentation 4/10 patients had a visual acuity of < or = 0.1, and 2/10 had no light perception. A cystic epithelial downgrowth was verified histologically in 9/13, and a diffuse form in 4/13 patients. Mucin production was proven histochemically in 1/9 intraocular epithelial downgrowth sections. In one case a spontaneous iris cyst was detected by the immunohistological examinations. Trauma (10/14) and surgery (3/14) were the most frequent causes and were symptomatic on average 17 years after the primary event. A curative surgery was done in 13/14 patients (5 x en bloc excision, 2 x penetrating keratoplasty, 1 x iridectomy, 2 x enucleations, 3 x external) resulting in no recurrences during the follow-up of 4(1/2) years (1 - 12 years). The postoperative visual acuity was ameliorated in 5/9, worsened in 2 patients, and 2 were enucleated. CONCLUSIONS: Epithelial downgrowth is a rare but preventable cause of blindness. The most important prophylaxis is meticulous primary surgery including a sufficient wound closure. The visual outcome depends on the preoperative conditions.

[Final clinical indications and etiology in 1,023 enucleations. Descriptive databank evaluation with SPSS software in variable response mode with dummy variables]. / Letzter klinischer Anlass und Atiologie bei 1023 Enukleationen. Deskriptive Datenbankauswertung mittels SPSS-Software im Antwortvariablenmodus mit Platzhaltervariablen.

BACKGROUND: A new data bank developed for ophthalmopathology using a computer-generated, multidigital data code is expected to be able to accomplish complex clinicopathologic correlations of diagnoses and signs, as provided by (multiple) clinical events and histopathologically proven etiologies, and to facilitate the documentation of new data. PATIENTS AND METHODS: In the ophthalmopathology laboratory 2890 eyes were examined between January 20, 1975 and December 12, 1996. The main diagnoses and patient data from this 22-year period were recorded. To facilitate the presentation of data, a 10-year period with eyes of 976 patients enucleated from December, 1986 to December, 1996 was chosen. Principal and secondary diagnoses served for establishing the data bank. The frequencies of successive histologic and clinical diagnoses were evaluated by a descriptive computing program using an SPSS-multi-response mode with dummy variables and a categorical variable listing of the software (SPSS version 10.0) classified as (a) non-filtered random, (b) filtered by multiple etiologies, and (c) filtered by multiple events. RESULTS: The principal groups (e.g., histologic diagnoses concerning etiology) and subgroups (e.g., trauma, neoplasia, surgery, systemic diseases, and inflammations) were defined and correlated with 798 separate diagnoses. From 11 diagnoses/events ascribed to the clinical cases, 11,198 namings resulted. CONCLUSIONS: Thus, a comparative study of complex etiologies and events leading to enucleation in different hospitals of a specific area may be performed using this electronic ophthalmopathologic data bank system. The complexity of rare disease and integration into a superimposed structure can be managed with this custom-made data bank. A chronologically and demographically oriented consideration of reasons for enucleation is thus feasible.

[Subretinal granuloma, retinal vasculitis and keratouveitis with secondary open-angle glaucoma in schistosomiasis]. / Subretinales Granulom, retinale Vaskulitis und Keratouveitis mit sekundärem Offenwinkelglaukom bei Schistosomiasis.

BACKGROUND: More than 250 million people in Africa and Asia currently suffer from schistosomiasis, however, ocular manifestations of this disease are rare in Germany. PATIENT AND FOLLOW-UP: We present the case of a 32-year-old patient from Gambia who had been resident in Germany for 3 years and suffered from a painful persistent diarrhoea, fever and a reduction of visual acuity (R > L). On admission, the patient reported a schistosomiasis in 1994, which was diagnosed by a skin test and was not adequately treated because of the side-effects of praziquantel. Vision was OD-0.75 sph 0.8, OS sc 1.0, IOD OD 31, OS 18 mmHg. Biomicroscopy: R > L fatty retrocorneal precipitates, especially in the lower circumference (ARLT), large inflammatory cells and Tyndall ++, vitreous with large inflammatory cells, Fundus: OD at 11 o'clock large subretinal granuloma in the periphery. Serum lysozyme was elevated (22.2 mg/l, normal range 10-17 mg/l), a syphilis stage II-III (TPHA 1:5000, VDRL neg.) and an IgG-antibody titre for Schistosoma mansoni of > 30 micrograms/ml was detected by enzyme immunoassay. In the faeces and urine no schistosoma eggs were found. Before the specific treatment for schistosomiasis could be initiated, the patient left the hospital because of reduced ocular pain due to the corticosteroids and fear of the side-effects of the treatment. DISCUSSION: In patients who present a subretinal granuloma and report a painful persistent diarrhoea, schistosomiasis, which is one of the most frequent tropical diseases should be considered, even if they have been living in central Europe for several years. Although the disease cannot become established due to the lack of specific hosts in this area, a curative treatment should be enforced in order to prevent late manifestations of chronic inflammatory organ manifestations.

[Correlation of 55 samples of contact lens fluid and direct swabbings of the eye surface of symptomatic wearers of contact lenses]. / Korrelation von 55 Kontaktlinsenflüssigkeiten mit Direktabstrichen von der Augenoberfläche bei symptomatischen Kontaktlinsenträgern.

BACKGROUND: The microbiological examination of contact lens storage solutions may reveal the etiological organisms responsible for keratitis and additionally harbour environmental contaminants. PATIENTS AND METHODS: From 1995 to 1998, conjunctival and corneal smears and scrapes, as well as the storage solutions of 55 soft contact lens wearers were examined microbiologically in a prospective non-randomised cohort study involving 53x unilateral and 2x bilateral cases of keraitis. RESULTS: In 42 of the in-use contact lens storage solutions, the following organisms were found: 8x Bacillus sp., 7x P. aeruginosa and 8x other pseudomonads, 6x Alcaligenes xylosans, 4x Serratia liquefaciens, 4x Enterobacter sp., 4x coagulase negative staphylococci, 3x Serratia marcescens, 3x S. aureus, 2x Streptococcus faecalis, 1x Klebsiella oxytoca and 5x Acanthameba. A significant correlation of ocular cultures was found for Pseudomonas, Enterobacter, Serratia, S. aureus, S. faecalis and Acanthameba, but not for Bacillus, Alcaligenes, and coagulase negative staphylococci. Fungi were not found. The more pronounced the clinical picture, the more Gram-negative bacteria were isolated. CONCLUSIONS: The microbiological examination of soft contact lens storage solutions of 55 keratitis patients confirmed that the microbes responsible were to be found in the fluid, in addition to environmental contaminants.

[Immunosuppressive therapy with mycophenolate mofetil (CellCept) in treatment of uveitis]. / Immunsuppressive Therapie mit Mycophenolat Mofetil (CellCept) in der Behandlung der Uveitis.

BACKGROUND: Severe forms of uveitis can often only be managed sufficiently with systemic immunosuppression. All available drugs are known for their relative high rate of side-effects. Mycophenolate mofetil (MMF), an immunosuppressant successfully used in management after organ transplantation and many autoimmune diseases, has shown remarkably less side-effects when used for various forms of uveitis in monotherapy or in combination with corticosteroids. The aim of this multicenter-study was to investigate if monotherapy with MMF is effective in various forms of uveitis. METHOD AND PATIENTS: Ten patients with anterior uveitis (n = 3), intermediate uveitis (n = 2), panuveitis (n = 4) and retinal vasculitis (n = 1) were treated in a prospective study with 2 x 1 g MMF daily. Previous immunosuppression had been discontinued because of side-effects or ineffectivity in all patients. In these patients MMF was given in addition to the other immunosuppressant at the beginning of treatment. RESULTS: The follow-up time ranged from 1 to 12 months (mean 4.5 months). Under therapy with MMF (monotherapy in 4 patients, additional prednisolone in 5 patients and additional metotrexate in 1 patient) 8 patients remained free of recurrences. In one female patient depression of inflammation activity was only achieved after cessation of therapy with Cyclosporin A in combination with MMF and a switch to methotrexate. Another patient with a bilateral uveitis was free of recurrences in only one eye, the second eye did not develop recurrence due to the additional corticosteroid treatment. Side-effects were diarrhoea in one patient and probably gastrointestinal problems in another (leading to cessation of therapy in both patients) and in another case nausea, vomitus and alopecia 10 months after beginning therapy. CONCLUSIONS: MMF as a new immunosuppressant stopped inflammation or drastically reduced the rate of recurrences in 8 out of 10 patients with uveitis which was previously not brought under control by other immunosuppressants. The side-effects were tolerable in comparison with other immunosuppressive agents. More patients, longer follow-up times and a comparative study with Cyclosporin A are required to assess the long-term therapeutical success.

[Early clinical results with mycophenolate mofetil in immunosuppressive therapy of ocular pemphigoid]. / Erste klinische Erfahrungen mit Mycophenolatmofetil bei der immunsuppressiven Therapie des okulären Pemphigoids.

BACKGROUND: Ocular cicatrical pemphigoid can lead to severe structural damage or loss of vision at worst. Longterm therapy with dapsone or systemic immunosuppressive therapy, e.g. with cyclophosphamide is often inevitable. Immunosuppression may cause severe side effects in some patients. PATIENTS AND METHODS: Data are presented on 5 patients with ocular cicatrical pemphigoid who were treated with mycophenolate mofetil 2 g daily. Criterion of effectiveness was the clinical course of the condition defined as nonprogression of the morphologic alterations. Patients were initially examined and interviewed routinely every four weeks for the first four months, then every eight weeks. Patients were asked about side effects and underwent monthly blood checks. RESULTS: All patients were followed for at least 12 months. Mycophenolate mofetil proved to be effective with respect to the clinical course in 9 out of 10 eyes. All patients showed regression of inflammatory conjunctival alteration and improvement of their complaints. In one eye the inflammatory process restarted after surgery due to excessive symblephara had been performed. Gastrointestinal side effects were reported in the initial phase, e.g. lack of appetite, nausea and mild diarrhoea. CONCLUSIONS: Mycophenolate mofetil proved to be an effective immunosuppressant for the treatment of ocular cicatrical pemphigoid. Namely side effects were less severe and frequent compared to those known from other currently administered immunosuppressants. Longterm results and larger case numbers are needed to sustain these early results.

[Combined pars-plana-vitrectomy and tectonic keratoplasty; indications for and results from 15 patients]. / Kombinierte Pars-plana-Vitrektomie und tektonische perforierende Keratoplastik--Indikationen und Ergebnisse bei 15 Patienten.

BACKGROUND: Acute endophthalmitis requires a vitrectomy. Vitrectomy and autokeratoplasty has been reported, if the infection originates from a stromal keratitis in an aphakic eye. This retrospective non-randomized cohort study points out the requirements, indications and results of combined keratoplasty and vitrectomy in keratitis and endophthalmitis compared with noninfectious corneal and vitreoretinal problems. PATIENTS AND SURGERY: In 1995-1999, a vitrectomy and keratoplasty was performed on 15 patients (16 eyes), 10 of these with an endophthalmitis (median 71 years) and a follow-up of 2-60 months (median 19.3 months). 14 of 15 patients had had multiple prior surgery. Stromal keratitis as a sequela of keratoplasty was seen in 5 eyes (3x ruptured suture), 5x diffuse infiltration in compromised corneas (1x with a perforation, 2x with Fuchs' corneal dystrophy, 3x postoperative). In the patients without endophthalmitis 6 eyes were aphakic with corneal scars and no fundus visualization. Five eyes had a retinal detachment, one had an intraocular foreign body. An allogeneic keratoplasty was done in 14, and an allogeneic sclerokeratoplasty and an autologous sclerokeratoplasty in one eye each. RESULTS: Keratoplasty without keratoprosthesis allowed for fundus visualization, and a pars plana vitrectomy was done with a wide angle contact lens, 8x with C2F6-, 1x with silicone oil 5000 cs instillation, and gentamicin and 15 micrograms r-tPA added. In 5 vitrectomy specimens (50%) pathogenic bacteria were found. No recurrences of infection were seen. Conservation of the eyes and postoperative fundus visualization was possible in each case. The postoperative increase in visual acuity of 0.1 or better was significant in both patient groups. 2 eyes remained at preoperative levels, 14 ameliorated by > 1 lines. Complications were 1x directly postoperative graft decompensation, 1x rejection after 40 months, 6x persisting secondary glaucomas, 2x hypotony syndromes, 1x with phthisis and enucleation, 1x epiretinal gliosis. CONCLUSIONS: Curative surgery of acute keratitis and endophthalmitis by vitrectomy and keratoplasty may result in similarly successful outcomes as in noninfectious corneal scars and vitreoretinal pathology, if some requirements (e.g. adequate antibiotic treatment, graft material, skilled anterior and posterior segment surgeon) are fulfilled.