[Tonometry and pachymetry to evaluate fluctuations of intraocular pressure in the context of SCUBA diving]. / Tonometrie und Pachymetrie zur Erfassung der Augeninnendruckschwankungen beim Scuba-Tauchen.

BACKGROUND: It is currently still not clarified whether diving using a self-contained breathing apparatus (SCUBA) is associated with intraocular pressure (IOP) fluctuations of clinical relevance and whether intensive diving could exacerbate the damage in glaucoma patients. OBJECTIVE: This study aimed to evaluate the effect of SCUBA diving on IOP in healthy volunteers without prior eye injuries or surgery. HYPOTHESIS: recreational diving does not lead to significant increases or fluctuations of the IOP. MATERIAL AND METHODS: The study included 16 divers (5 female) who performed a total of 96 dives with air or nitrox32 to a depth of 20-30 m for an average of 50 min. The central cornea thickness was measured using ultrasonic pachymetry Pocket IITM (Quantel Medical Pocket II™, Quantel Medical, Clermont-Ferrand, France), and the IOP was measured using an Icare® PRO (Icare® PRO, Icare Finland Oy, Espoo, Finland) directly before the dive and 10 min after surfacing. RESULTS: All data refer to the right eye. Average IOP values ranged from 15.6 to 19.2 mm Hg pre-dive and 16.8 to 18.2 mm Hg post-dive. The range of IOP values was 2.2-11.5 mm Hg pre-dive (∆ = 9.3 mm Hg) and 2.7-14.8 mm Hg post-dive (∆ = 12.1 mm Hg). Of the divers 11.5% vs. 18.8% had increased IOP values > 21 mm Hg (pre-dive vs. post-dive). CONCLUSION: This study found no significant differences in IOP values between pre-dive and post-dive measurements in healthy SCUBA divers. Therefore, recreational SCUBA diving is unlikely to affect the IOP in healthy individuals.

Exact matching of trabectome-mediated ab interno trabeculectomy to conventional trabeculectomy with mitomycin C followed for 2 years.

PURPOSE: We used exact matching for a highly balanced comparison of ab interno trabeculectomy (AIT) with the trabectome to trabeculectomy with mitomycin C (TRAB). METHODS: A total of 5485 patients who underwent AIT were exact-matched to 196 TRAB patients by baseline intraocular pressure (IOP), number of glaucoma medications, and glaucoma type. Nearest-neighbor-matching was applied to age. Success was defined as a final IOP of less than 21 mmHg, IOP reduction of at least 20% reduction from baseline, and no secondary surgical interventions. Outcomes were measured at 1, 3, 6, 12, 18, and 24 months. RESULTS: A total of 165 AIT could be matched to 165 TRAB. The mean baseline IOP was 22.3 ± 5.6 mmHg, and the baseline number of glaucoma medications was 2.7 ± 1.1 in both groups. At 24 months, IOP was reduced to 15.8 ± 5.2 mmHg in AIT and 12.4 ± 4.7 mmHg in TRAB. IOP was lower than baseline at all visits (p < 0.01) and lower in TRAB than AIT (p < 0.01). Glaucoma medications were reduced to 2.1 ± 1.3 in AIT and 0.2 ± 0.8 in TRAB. Compared to baseline, patients used fewer drops postoperatively (p < 0.01) and more infrequently in TRAB than in AIT (p > 0.01). Secondary surgical interventions had the highest impact on success and became necessary in 15 AIT and 59 TRAB patients. Thirty-two challenging events occurred in TRAB and none in AIT. CONCLUSION: Both AIT and TRAB reduced IOP and medications. This reduction was more significant in TRAB but at the expense of four times as many secondary interventions.

[Combined XEN and Baerveldt implant-principles and management of complications]. / Kombiniertes XEN-Baerveldt-Implantat ­ Prinzip und Management von Komplikationen.

The treatment of congenital glaucoma requires special expertise and often novel surgical approaches. The combined use of a XEN and a Baerveldt implant is an alternative to conventional tube implants and may be less harmful for long-term corneal endothelial damage. If this technique does not provide sufficient long-term control of intraorbital pressure (IOP), a direct implantation of the Baerveldt tube can be easily performed in a second intervention.

[Comparison of canaloplasty with trabeculectomy]. / Kanaloplastik und Trabekulektomie im Vergleich.

BACKGROUND: Trabeculectomy (TET) is still the gold standard in incisional glaucoma surgery. It achieves an efficient intraocular pressure (IOP) reduction. Unfortunately postsurgical complications of the procedure are frequent. Canaloplasty is a non-penetrating procedure, which aims at restoration of the natural aqueous outflow pathways, without subconjunctival drainage. AIM: This study has compared both surgical procedures concerning IOP, defined success criteria, postoperative medication, visual acuity and postoperative complications/interventions. PATIENTS AND METHODS: In a retrospective study 22 eyes after trabeculectomy and 22 eyes after canaloplasty were included. IOP, complete and qualified success, postoperative medication, visual acuity and complications/interventions were recorded at 6 month, 12 month and at last follow-up postoperatively. RESULTS: The mean IOP in the trabeculectomy and canaloplasty groups decreased from 23.91 ± 10.68 mmHg to 10.82 ± 3.67 mmHg and from 23.68 ± 7.57 mmHg to 14.50 ± 3.80 mmHg, respectively. The postoperative complications and interventions between the two groups did not reveal a statistically significant difference. Complete success (IOP < 21 mmHg and 20 % IOP reduction from baseline without medication) was achieved in 18 eyes (81.8 %) after trabeculectomy and in 11 eyes (50.0 %) after canaloplasty (p = 0.026). CONCLUSION: Canaloplasty and trabeculectomy are safe and effective procedures in the treatment of open-angle glaucoma. Both surgical methods reduce the IOP and the postoperative medication to a statistically significant extent. Trabeculectomy attains higher long-term complete success rates accompanied by slightly increased early postoperative complication rates (n. s.), compared to canaloplasty.

[Modern filtration surgery. An update]. / Moderne Filtrationschirurgie. Ein Update.

Preoperative treatment with steroids and nonsteroidal anti-inflammatory drugs increases the success of filtration surgery. Surgery with the patient under subconjunctival anesthesia is safe. Intraoperative application of mitomycin C is state of the art and enhances success rates. Perioperative use of bevacizumab seems to attenuate postoperative fibrosis. Postoperative hypotension is avoided by stable fixation of the scleral flap followed by stepwise controlled suturelysis or release. Transconjunctival flap suturing allows fast and simple treatment of overfiltration. The shorter the time lag between trabeculectomy and subsequent cataract surgery the higher the probability of bleb failure will be. The number of antiglaucomatous drugs and severity of glaucomatous damage before surgery correlate with the probability of failure and blindness.

[Non-penetrating glaucoma surgery]. / Nicht penetrierende Glaukomchirurgie.

Patients at high risk of developing complications (e.g. high myopia, aphakia, advanced visual field defects) benefit from non-penetrating glaucoma surgery (NPGS). Neovascular glaucoma, traumatic glaucoma or patients with a narrow angle (a scleral spur must at least be visible) are not suitable for NPGS. The aim of deep sclerectomy (DS) is mainly external subconjunctival drainage. Modified with mitomycin C and intrascleral implants, intraocular pressure (IOP) and success of DS are comparable to trabeculectomy. Viscocanalostomy and the further development to canaloplasty aim for blebless IOP control. Viscocanalostomy has an extremely low complication profile but only a slight reduction in IOP. Canaloplasty creates much more favourable results. Combined with phacoemulsification canaloplasty appears to lower IOP comparable to phacotrabeculectomy and demonstrates a more sustainable success compared to canaloplasty alone.

[Aphakic and pseudophakic glaucoma following pediatric cataract surgery]. / Aphakie- und Pseudophakieglaukom nach Kataraktoperation im Kindesalter.

Modern surgical techniques allow congenital cataract surgery to be performed much more successfully. The development of a secondary glaucoma is the most dreaded postoperative complication (one third of all pediatric secondary glaucomas). Due to the limited value of the available literature, data on prevalence are unreliable. A 10-year postoperative incidence of 10-25% is given in the literature for developing secondary glaucoma and the frequency increases with the duration of follow-up. A major risk factor seems to be the age at the time of surgery. The younger the patient is at the time of surgery the higher the risk of secondary glaucoma. A microcornea seems to be another risk factor in multivariate analysis. The following postoperative changes might be involved in the pathogenesis: peripheral anterior synechia, high iris insertion and membranous material over the trabecular meshwork. Additionally postoperative inflammation, reaction to lens epithelial cells, perioperative barotrauma and loss of anterior segment architecture might also be responsible. In order to evaluate the optimal age window for congenital cataract surgery and risk factors for the development of secondary glaucoma, a prospective longitudinal study is mandatory.

[Electronic patient records and teleophthalmology. Part 2: concrete projects in ophthalmology]. / Elektronische Patientenakte und Teleophthalmologie. Teil 2: Konkrete ophthalmologische Projekte.

Electronic storage of patient-related data will replace paper-based patient records in the near future. Because of the high visualization needed in ophthalmology integrated electronic data storage and usage will be very useful. Chronic diseases like glaucoma, macular degeneration and diabetic retinopathy would benefit from long-term data storage and analysis. Unfortunately there are nearly no widely accepted systems available providing these options. Another important point is the simplification of existing diagnostic procedures and nomenclature on an international level. Increasing mobility of patients requires a better portability of existing medical examination data between different physicians. This is the only way to provide continuously high levels of quality in patient care and to simultaneously reduce costs and prevent unnecessary secondary examinations.

[Glaucoma surgery in childhood]. / Glaukomchirurgie im Kindesalter.

Technical characteristics and a long-term therapeutic strategy due to a long life expectancy play a key role in pediatric glaucoma surgery. The well-established angle surgery (goniotomy and trabeculotomy) achieves successful results in primary childhood glaucoma. Trabeculectomy seems to have been displaced as a secondary approach by glaucoma drainage devices (GDD) in primary childhood glaucoma due to inferior results, especially for children under 3 years of age. Even for secondary childhood glaucoma the results of GDD are encouraging, especially for therapy refractory aphakic glaucoma. In the first 2 years after GDD surgery success rates are about 80% for pediatric glaucoma and the results appear to be independent of the type of glaucoma and implant used. The complications of GDD are balanced to the faster intraocular pressure (IOP) control during the phase of visual acuity development. Cyclodestructive procedures may be applied as a secondary adjuvant approach but they increase the risk of conjunctival scarring and hypotony for subsequent procedures.

[Electronic patient records and teleophthalmology : part 1: introduction to the various systems and standards]. / Elektronische Patientenakte und Teleophthalmologie : Teil 1: Vorstellung der verschiedenen Systeme und Standards.

Electronic storage of patient-related data will replace paper-based patient records in the near future. Some steps in medical practice can even now not be achieved without electronic data processing. Both systems, conventional paper-based and electronic-based records, have advantages and disadvantages which have to be taken into consideration. The advantages of electronic-based records are e.g. good availability of data, structured storage of data, scientific analysis of long-term data and possible data exchange with colleagues in the context of teleconsultation systems. Problems have to be solved in the field of data security, initial high investment costs and time consumption in learning to use the system as well as in incompatibility of existing IT systems.

[Corneal epitheliopathy following trabeculectomy with postoperative adjunctive 5-fluorouracil]. / Korneale Epitheliopathie nach Trabekulektomie mit postoperativer subkonjunktivaler 5-Fluorouracil-Injektion.

PURPOSE: The success of trabeculectomy in glaucoma not sufficiently controlled by maximal medical therapy substantially depends on postoperative scarring of the filtering bleb. This process of scarring can be inhibited by antimetabolites like mitomycin C (MMC) and 5-fluorouracil (5-FU). The aim of this study is the evaluation of incidence and long-term outcome of corneal surface defects and intraocular pressure following MMC- or 5FU-trabeculectomy using different doses of postoperative 5FU. METHODS: A retrospective, non-randomised comparative study of 381 patients undergoing trabeculectomy with intraoperative application of either 5FU (group A, n = 169) or MMC (group B, n = 212) was performed. Based on the Wuerzburg bleb classification score (WBCS) for postoperative wound healing evaluation, 30 of these operations of group A (group B: n = 26) did not receive 5 FU postoperatively (controls), 67 (93) received up to 7 postoperative injections of 5 mg 5 FU (normal dosage group), and 72 (93) received more than 7 injections (high dosage group). Surface epithelial defects were routinely assessed by slit-lamp microscopy and fluorescein staining. Intraocular pressure (IOP) was measured by Goldmann applanation tonometry. RESULTS: In the normal dosage group the mean total dose of 5 FU was 25.8 ± 9.1 mg in group A (group B: 28.4 ± 7.5 mg) and in the high dosage group 54.2 ± 10.9 mg 5 FU (51.7 ± 11.8 mg), respectively. Increased doses of postoperative 5 FU induced more frequent corneal erosions in both groups. Corneal erosions were seen in controls in 16.7 % (26.9 %), in the normal dosage group in 55.2 % (47.3 %) and in the high dosage group in 77.8 % (59.1 %) in group A and group B, respectively. The incidence of a corneal erosion between group A and group B did not differ significantly (p = 0.074). The mean reduction of intraocular pressure in mmHg did not show a significant difference 12 months after trabeculectomy between controls and postoperative 5-FU operations. CONCLUSION: In eyes with beginning scarring of the filtering bleb after trabeculectomy the subconjunctival injection of 5-FU allows a similar reduction of intraocular pressure as in eyes without scarring. Corneal epitheliopathy following trabeculectomy and postoperative 5 FU is dose-dependent with higher doses leading to a higher incidence of corneal erosions. As serious corneal long-term complications are rare, risk-benefit analysis justifies the application of 5-FU after filtrating glaucoma surgery.

Bleb needling in encapsulated filtering blebs: evaluation by optical coherence tomography.

PURPOSE: To evaluate the role of anterior segment optical coherence tomography (OCT) in describing the morphology and outcome of encapsulated filtering blebs after bleb needling. PROCEDURES: Prospective assessment of 9 patients - before, 2 days and 6 months after filtering bleb needling with 5-FU - using slit-lamp examination, Goldmann tonometry and OCT. RESULTS: Before the needling, the average internal height of the cyst was 1.3 +/- 0.8 mm. Two days after the needling procedure, the cyst collapsed in 5 patients. After 6 months, the average internal cyst height was 0.7 +/- 0.4 mm. All patients with a collapsed cyst at day 2 after needling had controlled regulated IOP without glaucoma medication. CONCLUSIONS: The preoperative internal height of the cyst does not correlate with the outcome of the needling. A collapsed cyst at day 2 after needling is an indicator of controlled intraocular pressure, whereas a prominent cyst after 6 months indicates poor function.

[Antiangiogenic therapy for pterygium recurrence]. / Antiangiogene Therapie bei Pterygiumrezidiven.

PURPOSE: A pterygium is defined as a fibrovascular and hyperplastic proliferative degeneration tissue of the limbus. Although the pathogenesis is not yet clearly understood there are indications that vascular endothelial growth factor (VEGF) may play a significant role in the development. Despite various surgical approaches recurrence remains the major postoperative problem. Bevacizumab is a human monoclonal antibody against VEGF. Its antiangiogenic effect is used in ophthalmology as an off-label treatment for retinal disease. We report about the use of Bevacizumab eye drops to prevent repeated recurrence of pterygia. MATERIALS AND METHODS: In our clinic 5 eyes (4 patients) were treated with topical Bevacizumab eye drops (25 mg/ml) 2-8 times per day for 5-24 weeks as an adjunct after excision of recurrent pterygia and conjunctival autograft. Patients were examined preoperatively and over a follow-up period ranging from 3-14 months (median 12 months). RESULTS: Visual acuity improved in 3 out of 5 eyes and in 1 eye no pterygium recurrence was noted. Two eyes showed conjunctival hyperemia (stage 1 recurrence) and one eye showed fibrosis of the limbus (stage 2 recurrence). In one eye an early recurrence with corneal vascularisation and superficial punctate keratopathy was observed (stage 3 recurrence). No serious permanent complications were observed. CONCLUSIONS: Considering the previously multiple recurrences in our patients we think that these first clinical mid-term follow-up experiences support the use of topical VEGF inhibitors in recurrent pterygia.

[Suture management after trabeculectomy]. / Fadenmanagement nach Trabekulektomie.

The frequency of bleb interventions after trabeculectomy is high. In half of the cases suture manipulation of the scleral flap is needed. Both standard and adjustable sutures are used for outflow adjustment of the scleral flap. The long-term results of both methods are equivalent. Open scleral flap revision and transconjunctival sutures are suitable for the treatment of hypotonia. Postoperative conjunctival suture removal seems to be favourable, improving both intraocular pressure and overall success rate.

[Beyond TGF-beta: wound healing modulation in filtering glaucoma surgery]. / Wundheilungsmodulation nach filtrierenden Glaukomoperationen: Was kommt nach TGF-beta?

Conjunctival scarring remains the major problem in filtering glaucoma surgery. Antimetabolites afford a reduction of scar formation, but considerable side effects limit their application. Here, we review the mechanisms and peculiarities of wound healing following glaucoma surgery and report on new developments in the field of wound healing modulation. The growth factor TGF-beta has a central role in wound healing and scarring. Therefore, novel concepts of wound healing modulation comprise scavenging of TGF-beta and specific inhibition of disinct downstream intracellular signalling pathways. Several compounds have entered preclinical evaluation and offer new potential to modulate scarring in future combination therapies.

[Surgery of primary open angle glaucoma]. / Chirurgie des primären Offenwinkelglaukoms.

The selection of the surgical approach to glaucoma depends primarily on the type of glaucoma. Filtration surgery (trabeculectomy) is considered the gold standard for the most common form of glaucoma, primary open angle glaucoma. The technique of surgery has been continuously improved during the past years resulting in less immediate postoperative complications such as flat anterior chamber, choroidal detachment and hypotony. The major problem of glaucoma surgery nowadays is wound healing with scarring of the outflow area. By intensified postoperative care using antimetabolites at the time of surgery and during postoperative care, many problems of scar formation can be managed. The absolute success rate may be doubled by using intensified postoperative care. Non-penetrating surgery such as deep sclerectomy or trabeculotomy are effective; however, the amount of IOP lowering achieved is inferior to that of trabeculectomy. To select a special glaucoma surgical procedure, the individual target pressure for the respective patient has to be defined. Recent large randomised prospective studies have shown that a low target pressure is needed to preserve and stabilise the visual field in advanced cases. Glaucoma filtration surgery is an important mainstay of advanced glaucoma treatment.

Long-term results of Erbium YAG-laser-assisted deep sclerectomy.

PURPOSE: To evaluate the long-term results of Erbium YAG-laser-assisted deep sclerectomy (DS). In this procedure, the delicate dissection of a deep corneoscleral lamella is greatly simplified by using the Erbium YAG-laser. METHODS: Data of 14 consecutive patients (10 male, four female, age 67.7+/-10.4 years), who underwent surgery from 1999 to 2000 were analysed retrospectively. The procedure was begun as a standard DS. The deep corneoscleral lamella was dissected with a pulsed Erbium YAG-laser (energy: 40-100 mJ, frequency: 5-10 Hz). Schlemm's canal was unroofed and the lamella thinned until aqueous percolated continuously through the membrane. RESULTS: The mean follow-up time was 50.4+/-6.8 months. The mean preoperative intraocular pressure (IOP) was 37.7+/-10.5 mmHg. The mean postoperative IOP was 16.1+/-3.9 mmHg at 1 month, 15.1+/-4.3 mmHg at 3 months, 16.4+/-4.5 mmHg at 12 months, and 17.6+/-8.7 mmHg at 50.5 months. The complete success rates (IOP< or =21 mmHg+IOP reduction > or =20% without glaucoma medication) were 83.3% at 3 months and 50% at 12 and 50.5 months. Rates for qualified success (IOP< or =21 mmHg+IOP reduction > or =20% with glaucoma medication) were 91.7% at 3 months, 92.9% at 12 months, and 78.6% at 50.5 months. The number of glaucoma medications was reduced from 3.07+/-0.92 preoperatively to 1.14+/-1.41 at 50.5 months. A single case of anterior-chamber penetration, requiring iridectomy, was the only intraoperative complication. CONCLUSIONS: Erbium YAG-laser-assisted DS has the advantage of a greatly simplified dissection, while offering a successful long-term IOP control comparable to conventional DS.