[Eyelid surgery : Eyelid surgical techniques from a histopathological perspective]. / Lidchirurgie : Lidchirurgische Techniken aus histopathologischer Sicht.

Eyelid surgery and histopathology are closely related, especially in tumor surgery. Based on histological specimens from the archive of the Department of Ophthalmopathology, Eye Centre Freiburg, this article deals with the search for traces following eyelid surgery, and explains the respective clinical relevance for ophthalmologists involved in surgical and conservative treatment. Thermal, electrical and mechanical impacts on the tissue during tumor removal lead to histologically detectable artifacts. These must be kept to a minimum by the surgeon in order to ensure histological assessability and avoid adverse consequences for the patient. During the subsequent eyelid reconstruction, the eyelid architecture is changed depending on the surgical technique. Thus, after Hughes' operation a degeneration of the meibomian glands is histologically noticeable, which should be taken into account in the clinical aftercare of the patients. Suture material can lead to foreign body granulomas, which can be clinically misinterpreted as tumor recurrence. In contrast to foreign material, transplanted autologous tissue, such as cartilage or oral mucosa in the case of eyelid malposition, usually does not lead to chronic inflammation.

[Surgical management of firework-induced eyelid injuries]. / Lidchirurgische Versorgung von Feuerwerksverletzungen.

Fireworks injuries are frequently caused by malfunction or incorrect operation of fireworks. Injuries often affect the eyeball and the periorbit. After treatment of life-threatening bleeding, injuries of the eyeball have priority over the treatment of periorbital lacerations and burns. The aim of eyelid surgery in firework-related injuries is to prevent delayed damage, such as lagophthalmos, symblepharon, entropion with trichiasis, and keratinization of the conjunctiva of the eyelid and eyelid margin. The treatment requires a considerable amount of time and patience both for the elaborate surgical procedures as well as for the necessary healing and rest phases. Many patients, however, are left with serious visual impairments and stressful esthetic deformities, which result in considerable occupational and social impairments.

[Blepharitis component of dry eye syndrome]. / Blepharitiskomponente des trockenen Auges.

This review contains a compilation of long-standing and more recent relevant information on chronic blepharitis, especially in the context of dry eye disease regarding epidemiology, symptoms, clinical findings and pathophysiology. Chronic blepharitis often represents the underlying cause of dry eye disease but remains undetected and untreated in many cases; however, it can be a result of (hypovolemic) dry eye disease and leads to sometimes severe corneal complications, which are illustrated by material from our own patient archives. Recent findings regarding the lipid composition in the tear film in correlation with that of Meibomian gland secretions and the hypothesis of a biofilm as the basis of chronic blepharitis as a theoretical, not yet proven addition to the previously known pathophysiological factors, are discussed.

[Fusarium keratitis with dramatic outcome]. / Fusarienkeratitis mit dramatischem Ausgang.

BACKGROUND: Fungal keratitis is much less common in Europe than in Asia. Antifungal therapy can be applied topically as well as systemically and in advanced situations surgical intervention can become necessary. CASE REPORT: We present the case of a 60-year-old woman who suffered from Fusarium keratitis that showed progression to endophthalmitis following contact lens wearing. Due to numerous resistances against antimycotic drugs the eye had to be enucleated to prevent the pathogens from spreading. Histologically, major inflammatory activity could be detected but no causative organism could be found. The failure to detect a pathogen was in clear contrast to the clinical findings and was interpreted as being an overreaction of the immune response even after the Fusarium had been destroyed. CONCLUSION: If a fungal infection of the cornea is suspected, antimycotic therapy should be initiated as early as possible. In cases involving highly resistant pathogens the eye cannot always be saved.

Pulmonary artery perforation and coronary air embolism-two fatal outcomes in percutaneous left atrial appendage occlusion.

Percutaneous left atrial appendage (LAA) closure is a routinely performed method to reduce the risk of stroke in patients suffering from atrial fibrillation, when an oral anticoagulation is no longer indicated due to relevant bleeding complications. Currently, the Amplatzer Amulet and the Watchman system are two equally used systems. While there is an acute success rate of more than 95 per cent for this intervention, several minor and major complications such as pericardial effusions, air embolism, vascular lesions in proximity to the heart or even death can occur. Here, we report two cases of very rare fatal outcomes in percutaneous LAA occlusion. Eight hours after deployment of an Amplatzer Amulet a patient died, after the pulmonary trunk was perforated by a hook of the occluder device causing pericardial tamponade. In the second case during final radiological position control of the deployed Watchman occluder air was injected accidentally. The patient immediately died due to coronary air embolism. Forensic autopsies are necessary to solve the cause and manner of death, to evaluate and develop medical devices and to rule out medical malpractice. Thus, a close collaboration of legal medicine and the various cardiologic departments is proposed.

[Treatment options for chronic blepharitis considering current evidence]. / Therapeutische Optionen bei chronischer Blepharitis unter Berücksichtigung der Evidenzlage.

The goal of the treatment of chronic blepharitis lies in the reduction of inflammation, which can be achieved by warming, mechanical, and immunomodulatory measures as well as acaricide medication in cases with pathogenetically relevant demodicosis.

[Intraocular Inflammation: Autoimmune or Infectious?]. / Intraokulare Entzündung: autoimmun oder infektiös?

Presentation of 3 cases of intraocular inflammation: 1. 47-year old female patient with severe necrotising scleritis and uveitis with underlying granulomatous polyangiitis (formerly known as Wegener granulomatosis, in honour of the German pathologist Friedrich Wegener), known for 10 years. 2. 48-year old male patient with longstanding bilateral uveitis and granulomatous polyangiitis for 2 years. In the histopathological examination of the enucleation specimen, a retrolental tumour turned out to be a granuloma. 3. 57-year old male patient in status post renal transplantation with intraocular cellular infiltration suspicious for lymphoma, which surprisingly proved to be Toxoplasma gondii-associated uveitis. The clinical course and characteristic histological signs and therapeutic options are discussed.

Rare cause of natural death in forensic setting: hemophagocytic syndrome.

We report about the case of a sudden unexpected death of a 25-year-old male suffering from infectious disease. An autopsy was ordered with no final premortem diagnosis. Microscopic and microbiological examination revealed a pneumococcal bronchopneumonia and hemophagocytic lesions in the bone marrow. After integrating clinical and autopsy reports as well as additional postmortem investigations, the cause of death was found to be infectious-triggered hemophagocytic syndrome (HPS) with a final cytokine storm. This seems to be the first reported fatal case of a reactive form of HPS associated to Streptococcus pneumoniae to the best of our knowledge. HPS is a dangerous hyperinflammation with highly characteristic, but nonspecific, laboratory findings and symptoms. Autopsies in such cases must be carefully performed and include systematic tissue sampling done by an experienced pathologist.

Detection of gamma hydroxybutyrate in emergency department: Nice to have or a valuable diagnostic tool?

BACKGROUND: Many patients present to emergency departments (EDs) with an altered state of consciousness. Fast exclusion of gamma hydroxybutyrate (GHB)-associated intoxication in these patients may optimize diagnostic and therapeutic algorithms and decisions in the ED. METHODS: Between January and March 2014, a novel enzymatic test system was used to quantify GHB in blood and urine samples of suspected intoxicated patients in the ED of the University Hospital. The underlying causes for suspected intoxication and the diagnostic and therapeutic measures were documented and analysed retrospectively. RESULTS: GHB measurements were performed in 13 patients with suspected ingestion during a 3-month study period. GHB was positive in six patients showing serum levels between 61.8 mg/l and 254.8 mg/l, and GHB was tested negative in seven patients with a range of 0.3-6.2 mg/l (upper reference limit 6.1 mg/l). Additional intoxication was found in five of six GHB positive (83%, alcohol n = 2 and other drugs n = 5) and in six of seven negative-tested patients (86%, alcohol n = 5 and other drugs n = 1). CONCLUSION: GHB quantification in the ED provides specific additional information for intoxication, which can lead to more precise diagnostic and therapeutic decisions and may also be important for legal aspects. We believe that GHB analysis in unconscious patients with suspected intoxication may improve the efficient treatment of intoxicated patients.

[Morphological analysis of corneal refractive lenticules--is there a correlation with refractive results?]. / Ultrastrukturelle Analyse von Hornhautlentikeln nach fs-Lentikelextraktion gibt es einen Zusammenhang mit den refraktiven Ergebnissen?

BACKGROUND: ReLEx®flex is a corneal refractive procedure performed by removing corneal lenticules with a femtosecond (fs) laser system. Using electron microscopy, tissue parameters of extracted lenticules were analysed for potential correlations to the refractive results. Furthermore, the effect of previous contact lens (CL) wear on refractive stability (regression) was tested. PATIENTS AND METHODS: 19 lenticules from 11 patients (age 24-56 years, 8 f, 3 m) were prepared for EM. The central areas of the samples were photographed and the distance between the collagen fibres and their diameters were digitally measured. ANOVA analysis was used to correlate postoperative refractional stability with time of preoperative CL use, fibre diameter and the coefficient of variation (CV) of fibre distance. RESULTS: 14 of 19 lenticules were from patients who had worn CL preoperatively. The cumulative duration of CL wear averaged around 31.2 ± 35.5 thousand hours. Preoperative CL use significantly influenced the postoperative regression: the longer time patients had worn CL, the greater was the regression towards myopia (p = 0.01). Additionally, the morphological parameters collagen fibre diameter (p = 0.09) and CV of fibre distance (p = 0.07) had an impact on regression. CONCLUSIONS: Prolonged CL use and alterations in ultrastructural patterns affected the refractive stability after ReLExflex. Although the pathophysiological relationships between CL use, corneal morphological parameters, and refractive stability are still poorly understood, these findings could potentially be used as prognostic markers for postoperative refraction after ReLExflex.

[Update on corneal dystrophies: new insights following first publication of the IC3D classification]. / Update Hornhautdystrophien: Neues nach der Erstveröffentlichung der IC3D-Klassifikation.

In this review we summarise the new insights into corneal dystrophies following publication of the IC3D classification in 2008. Topics covered are new mutations, new clinical/histological phenotypes, first descriptions of known mutations in previously not mentioned ethnic groups, new dystrophic entities after modern corneal surgery and potentially new types of conservative therapy.