The significance of intraoperative measurements in acquired ptosis surgery.

During a series of 101 levator procedures to correct acquired ptosis we measured the motility of the aponeurosis, the necessary advancement of the aponeurosis to adjust the eyelid height and the motility of Whitnall's ligament. We compared these intraoperative data with the data of the preoperative examination and did not find any correlation. The necessary amount of advancement of the aponeurosis to adjust the height of the eyelid was not related to the motility of the aponeurosis, the levator function or the amount of ptosis. However, we did find that the motility of Whitnall's ligament is closely related to the motility of the aponeurosis. Therefore connecting both structures is useful in ptosis adjustment without risking limited eyelid motility.

[Adjustment of eyelid level in levator surgery for ptosis. Surgical aspects]. / Justierung der Lidhöhe in der Levatorchirurgie bei Ptosis. Operationstechnische Aspekte.

The main aim in ptosis surgery is to achieve a sufficient and symmetric adjustment of the lids. Successful adjustment is possible when consideration is given to preoperative factors and intraoperative findings. Any necessary postoperative readjustment using adjustable sutures or revision surgery in the 1st week can optimize results in some cases. This article reviews the relevant surgical aspects of adjustment. We made a comparative analysis of diagnostic and surgical factors that influence the adjustment of the lid level.

[Functional results after surgical extraction or photocoagulation of choroid neovascularization (CNV) in age-related macular degeneration]. / Funktionelle Ergebnisse nach CNV-Extraktion oder Photokoagulation bei alterskorrelierter Makuladegeneration.

BACKGROUND: SLO microperimetric examination after the extraction of choroidal neovascular membranes (CNV) in age-related macular degeneration (AMD) shows absolute scotoma in the area of pigment epithelial loss. Laser treatment also causes complete functional loss. The functional results of these two methods should be compared before the surgical procedure is expanded. METHODS AND PATIENTS: Five eyes of five patients with large subfoveal well-defined CNV were treated by photocoagulation following the MPS criteria. Functional results were compared with similar phenotypes from a group of 78 patients operated upon. Before and after the treatment visual acuity was tested following the ETDRS criteria. The need for magnification for reading was tested using the ZEISS charts. Fundus-controlled microperimetry was performed using the scanning laser ophthalmoscope (Rodenstock) to detect deep and relative scotomata. RESULTS: The recurrence rate (OP 2/5; ALK 1/5) was normal regarding the small number of patients. Visual results are slightly better in patients operated on (mean: pre 0.08; 6 weeks 0.09; 3 month 0.13; last 0.13) than in laser-treated patients (mean: pre 0.06; 6 weeks 0.07; 3 months 0.08; last 0.12). Deep scotoma can be reduced with surgical extraction of the CNV (mean factor: 6 weeks 0.6; last control 0.8) while laser treatment of the margins enlarges the scotoma (mean factor: 6 weeks 2.3; last control 2.2). CONCLUSIONS: Because of the minimal functional advantages of the surgical procedure we do not think it is the method of first choice. For both methods the treatment of well-defined CNV increases the possibility of low-vision rehabilitation.

[Surgical removal of subfoveal choroid neovascularization in senile macular degeneration]. / Chirurgische Entfernung subfovealer chorioidaler Neovaskularisationen bei AMD. Prä- und postoperative fundusperimetrische Befunde mit dem SLO.

UNLABELLED: The follow-up of central scotomas and fixation--next to visual acuity--are important parameters for the evaluation of new therapies in AMD. PATIENTS AND METHODS: Twenty-three patients (age 67 to 91 years) with subfoveal CNV had SLO fundus-controlled perimetry before and 6-8 weeks after surgical removal of the CNV. The size and location of deep (0 dB) and relative (12 dB) scotomas were measured. Stability and location of fixation were analyzed. RESULTS: Fifty-six percent of patients gained (10% lost) more than 2 lines of VA; 52% of deep scotomas decreased in size (26% increased). No relative scotoma increased, but 63% decreased, some remarkably. Most scotomas had steeper borders postoperatively. Five of 7 patients were able to fixate again. Fixation moved slightly more peripheral in 4 patients and was otherwise unchanged. None of 7 patients whose fixation was close to their fovea preoperatively lost that fixation. CONCLUSION: Subfoveal surgery may stabilize the course of subfoveal CNV in AMD at 6 weeks follow-up. In some patients the major benefit can be a reduction of relative scotoma due to reattachment of the retina. As the location of fixation changes little with surgery and is typically located within the area of relative scotoma, visual function can improve.

Surgical extraction of subfoveal choroidal new vessels and submacular haemorrhage in age-related macular degeneration: results of a prospective study.

BACKGROUND: The surgical extraction of subfoveal choroidal new vessels (CNV) is one of several possibilities to treat subfoveal CNV or haemorrhages in age-related macular degeneration (ARMD). METHODS: Prospective study, follow-up 3-6 months. Clinical and angiographic differentiation of three subgroups: (1) subfoveal well-defined CNV (24 eyes); (2) subfoveal ill-defined CNV with or without well-defined components (10 eyes); (3) submacular haemorrhages (20 eyes). RESULTS: The mean and median visual acuity and the proportion of eyes with > or = 20/200 vision increased slightly in group 1 and decreased slightly in group 2; the differences were not significant. Group 3 demonstrated mean improvement but was heterogeneous, depending on the site and type of underlying CNV. The proportion of eyes with 3 or more lines of improvement after 3 months was 35.3% (7/17), 10% (1/10) and 38.9% (7/18) respectively. The proportion of eyes with a loss of 3 or more lines after 3 months was 5.9% (1/17), 20% (2/10) and 5.6% (1/18) respectively. The recurrence rate was 29.2% (7/24), 8.3% (1/11) and 25% (5/20). Intraoperative complications were iatrogenic central tears in 7.3% (4/55), peripheral tears in 14.5% (8/55) and peripheral retinal detachment in 3.6% (2/55). A postoperative retinal detachment was observed in 2 of 55 eyes (3.6%). All these complications could be managed without ill effect. CONCLUSION: Subfoveal surgery might preserve remaining retinal function in eyes with well-defined CNV. However, subgroups of the MPS subfoveal laser trials with comparable initial visual acuity demonstrated postoperative functional stabilisation and similar recurrence rates in well-defined CNV. Though selected cases of submacular haemorrhage did profit from surgery, TPA-assisted gas injection will probably be a better alternative. Unfortunately, surgery for ill-defined CNV, found in the vast majority of eyes with exudative ARMD, seems to worsen the natural course. Surgery has to be combined with restoration of Bruch's membrane before it can become a possible therapeutic option in ARMD.

[Recurrent choroid neovascularization in age-related macular degeneration. Fluorescein angiographic morphology after surgical membranectomy]. / Rezidivierende choroidale Neovaskularisationen bei altersbezogener Makuladegeneration. Fluoreszenzangiographische Morphologie nach chirurgischer Membranektomie.

UNLABELLED: The surgical removal of choroidal neovascularization (CNV) in age-related macular degeneration (AMD) causes a retinal pigment epithelial defect (RPED) corresponding to the area of diffuse RPE damage. We describe angiographic features of recurrent CNV in AMD after surgical membranectomy in order to elucidate the nature of persistence and recurrence. METHODS: After digitalization of the pre- and postoperative fluorescein angiographic images of eight patients with recurrent CNV in AMD we determined the morphology (well or ill-defined) and the area of the CNV and of the subretinal hemorrhage preoperatively and of the recurrent CNV and of the RPE defect postoperatively. RESULTS: The nature of recurrences showed differences between preoperatively well- and ill-defined CNV. Four preoperatively well-defined CNV with surrounding subretinal hemorrhage showed recurrences in the entire area of the preoperative CNV excluding the retinotomy 8-9 weeks postoperatively. Four preoperatively ill-defined CNV with subretinal hemorrhage developed marginal recurrences at the rim of the RPED. There was no background fluorescence in the area of the RPED. CONCLUSION: The nature of recurrences extending over the entire area of the preoperatively well-defined CNV without loss of background fluorescence only a few weeks after surgical removal of well-defined CNV suggests partial persistence. The removal of the subretinal well-defined CNV could leave sub-RPE parts in locations that preoperatively cannot be visualized angiographically. The marginal recurrence of preoperatively ill-defined CNV weeks to months postoperatively shows angiographic similarities to recurrent CNV after laser coagulation.

[Choroid neovascularization in age-related macular degeneration. Correlation of histological and fluorescence angiography findings]. / Chorioidale Neovaskularisationen bei AMD. Korrelation histologischer und fluoreszenzangiographischer Befunde.

BACKGROUND: Recent studies have raised confusion about the fluorescein angiographical and histopathological correlation of CNV. MATERIAL AND METHODS: The preoperative fluorescein angiograms of four patients with subfoveal CNV due to ARMD extracted by pars plana vitrectomy were classified as wellor ill-defined CNV and were correlated to the histopathologically (in serial sections) verrified CNV-location (subneuroretinal (= type II according to Gass) versus sub-RPE (type I according to Gass)). RESULTS: The locations of all four CNV could be classified by histopathological landmarks as there were RPE, BLD/drusen, and inner Bruchs membrane. Angiographically welldefined membranes were type II membranes according to Gass, whereas the ill-defined membrane represented type I. The CNV with well- and ill-defined borders consisted of type II and type I parts according to Gass. CONCLUSION: We find subneuroretinal locations of the well-defined CNV examined (type II membranes according to Gass). Correspondingly, ill-defined CNV or ill-defined parts of a CNV seem to be beneath the RPE (type I). The correlation of fluorescein angiography and histopathology should be studied in greater numbers of well- and ill-defined CNV.

Accuracy of stereotactic brain tumor biopsy: comparison of the histologic findings in biopsy cylinders and resected tumor tissue.

Appropriate treatment for intracranial mass lesions depends upon accurate morphological diagnosis. In 47 of 360 patients the findings in stereotactically obtained tissue cylinders were compared with tumor resection (n = 38) or autopsy (n = 9) tissue material to define the accuracy of our stereotactic biopsy method. These biopsies were performed using the LEKSELL CT stereotactic frame and a spiral needle which procured about 10-mm-long tissue cylinders. Usually, three to four successive biopsy specimens were taken along the target trajectory placed through the whole lesion and its margins according to the CT imagings. Final morphological diagnosis was exclusively based on the histological findings of permanent paraffin sections. In 42 cases (89%), the histological results in biopsy and resection/autopsy tissue were identical, including mainly cases of low and high grade gliomas as well as some brain lymphomas, metastases, and cases of inflammatory brain lesions (aspergillosis, toxoplasmosis). In 3 patients with a diagnosis of brain lymphoma and low grade glioma on the basis of the surgical specimens, stereotactic biopsy revealed only unspecific reactive tissue changes. In two cases of the early part of the study, sampling errors occurred. This study provides evidence for the high diagnostic accuracy of the established stereotactic biopsy method which is characterized by representative tissue sampling and histological processing of the specimens.