[Intraocular lens explantation and secondary implantation of a light-adjustable lens. Video article]. / Intraokularlinsenexplantation und Sekundärimplantation einer lichtadjustierbaren Linse. Videobeitrag.

INDICATIONS: The operation is carried out to exchange previously implanted intraocular lenses (IOL) because of deviation from the target refraction with aniseikonia and anisometropia, in cases of contact lens intolerance, dissatisfaction with the IOL due to side effects and particularly problems with multifocal lenses. OBJECTIVE AND PRINCIPLES: The aim of this surgical approach is to retain the original implantation site of the exchange lens and capsular bag integrity with maximum sparing of the zonular fibers and secondary IOL implantation with stable positioning for fine adjustment of residual refractive errors. OPERATIVE TECHNIQUE: Using a non-astigmatic approach the primary IOL is first mobilized and removed. A light-adjustable IOL is then implanted in the capsular bag and residual refractive errors in the visual axis are adjusted using profiled UV light. The surgical technique is demonstrated in detail with the help of a video of the operation, which is available online. RESULTS: Residual postoperative deviations from the target refraction of sphere and cylinder up to 2 diopters can be precisely adjusted noninvasively. Individual alterations of asphericity can provide stable distance visual acuity while enhancing near and intermediate visual acuity.

[Anterior chamber intraocular lenses for aphakia correction]. / Vorderkammerintraokularlinsen bei Aphakie.

The intraocular correction of aphakia in the anterior chamber currently consists of two options: an angle supported intraocular lens (IOL, Kelman Multiflex) and an iris fixated IOL (Artisan/Verisyse). The angle supported IOL is fixated with four haptic points in the anterior chamber and the iris fixated IOL is enclavated to the anterior iris surface. Acceptable results of both IOLs are reported in the literature; however both IOLs show some long-term complications in some eyes. Alternatives to these anterior chamber IOLs to correct aphakia are the retropupillary fixated Artisan and sclera fixated IOLs.

[Femtosecond laser-assisted lens surgery depending on interface design and laser pulse energy: results of the first 200 cases]. / Femtosekundenlaser-gestützte Linsenchirurgie abhängig von Interfacedesign und Laserpulsenergie : Ergebnisse der ersten 200 Fälle.

BACKGROUND: This study was designed to evaluate the effectiveness and safety of femtosecond laser-assisted lens surgery depending on interface design and laser pulse energy settings. METHODS: In this non-randomized, consecutive case series200 eyes underwent femtosecond laser-assisted (LenSx, Alcon) lens surgery between November 2012 and June 2013. Group 1 consisted of 85 eyes with 60 cataracts and 25 refractive lens exchanges (RLE) which were treated with a curved direct contact interface, and group 2 consisting of 115 eyes with 72 cataracts and 43 RLEs treated with a modified interface using an additional soft contact lens (SoftFit™, Alcon) between the corneal surface and the interface. The degree of opacity of the lens in cataract eyes was measured with a Scheimpflug camera. Afterwards, phacoemulsification was performed with intraocular lens (IOL) implantation in all eyes. Primary endpoints were the effective phacoemulsification time (EPT), the average laser treatment time and the occurrence of intraoperative complications. RESULTS: The mean EPT in group 1 was 1.62 ± 1.12 s (cataract 1.94 ± 1.31 s, RLE 1.29 ± 1.01 s) and in group 2 the mean EPT was 1.66 ± 0.92 s (cataract 1.98 ± 1.28 s, RLE 1.33 ± 1.22 s, p = 0.32 between groups). The laser treatment lasted on average 48.90 ± 2.45 s (group 1) and 49.70 ± 2.87 s (group 2) with an average lens fragmentation thickness of 3401.48 ± 401.12 µm (all groups). In four cases of group 1, a second applanation of the interface was necessary. Furthermore, one anterior capsule tear, 39 cases of intraoperative wrinkling of the corneal surface and 21 cases in which the corneal incision had to be opened manually were documented in group 1. In group 2 no second applanation of the interface, no anterior capsule tears and no corneal wrinkling but 9 cases with a manual opening of corneal incisions were documented (p < 0.01 between groups). CONCLUSION: The minor intraoperative complications of the femtosecond laser technique investigated could be significantly reduced using an optimized interface and reduced laser pulse energy.

[Femtosecond lasers for cataract and refractive lens surgery]. / Femtosekundenlaser für die Katarakt- und refraktive Linsenchirurgie.

The femtosecond laser technology continues its progress in ophthalmology and now also plays an increasingly important role in lens surgery. Using this technology it is possible to create corneal sections and to perform capsulorhexis and lens fragmentation. There are currently four instruments on the market with more to follow. The individual benefits and also critical issues are presented and the results of current studies are discussed.

Orbital haemorrhage associated with orbital fractures in geriatric patients on antiplatelet or anticoagulant therapy.

Retrobulbar haemorrhage is a sight-threatening condition that can occur after orbital trauma. The aim of this study was to evaluate the frequency and outcome of orbital haemorrhages following orbital fractures in geriatric patients receiving anticoagulants. All patients aged 65 years or more suffering from orbital fractures between 2008 and 2009 were included in this study. The mechanism of trauma, underlying diseases, and medication were recorded. In case of a retrobulbar haemorrhage, surgical exploration, the elapsed time between the onset of haemorrhage symptoms and surgical treatment, and the outcome regarding visual acuity were documented. Sixty-eight orbital fractures occurred (31 males, 37 females, age 65-95 years) resulting in six (3%) orbital haemorrhages. Four cases were associated with initial orbital bleeding, two other patients developed orbital haemorrhage as a complication after surgical reconstruction. Anticoagulant therapy, but not aspirin, was associated with a significantly increased risk of retrobulbar haematoma (p=0.02). Two patients permanently lost vision, two partial recoveries and two total recoveries were observed. Patients receiving anticoagulants have a higher risk of orbital haemorrhage after orbital fracture and should be monitored closely. Any evidence of visual impairment should lead to further investigation and prompt treatment.

[Current state of the "light-adjustable lens"]. / Aktueller Stand "light-adjustable lens"

The light-adjustable intraocular lens offers the possibility to correct postoperative residual refractive errors in a non-invasive way. After implantation and healing, a fine-tuning of the refractive power can be performed using ultraviolet light based on the individual requirements of each patient. Up to 2 diopters in sphere, as well as cylinder, can be adjusted in one step. This technology received CE market approval in 2007. This review article summarises published prospective studies on clinical evaluations of the effectiveness, safety and long-term refractive stability of this innovative technique. Moreover, a critical statement about limitations and perspectives will be given and future options will be discussed. For safety reasons, following application of the UV-light during refractive adjustments, examinations of endothelial cell count changes and measurements of corneal thickness have been monitored for 12 months following treatment. Further studies have been performed to evaluate the refractive stability over an 18-month period with a patient population that included average as well as biometrically short and long eyes. An analysis of postoperative refractive data led to optimised constants for preoperative IOL power calculation enabling the surgeon to further enhance visual outcomes with the IOL by using additional nomograms for customised correction of presbyopia, multifocality and increasing depth of focus with individual corrections of asphericity.

[Light adjustable lens. New options for customized correction of presbyopia]. / Lichtadjustierbare Linse. Neue Möglichkeiten zur Presbyopiekorrektur.

PURPOSE: The aim of this study was a prospective evaluation of new algorithms for the treatment of presbyopia using a light-adjustable intraocular lens (LAL). PATIENTS AND METHODS: A total of 15 patients scheduled for routine cataract surgery were included in the study. Following cataract removal a LAL (CalhounVision, Pasadena, CA) was implanted. At approximately 2 weeks after implantation the IOL was adjusted to correct any residual refractive error (sphere and cylinder) followed by the creation of a customized near add (CNA) that was based on the individual patient pupil size in one eye. The fellow eye was corrected for emmetropia. A final lock-in treatment was then performed. RESULTS: There were no complications observed during the surgery or power adjustments. All patients demonstrated an improvement in near vision (0.97 ± 0.18) and distance vision (0.78 ± 0.18) with good intermediate vision (0.92 ± 0.12) months after the final lock-in. CONCLUSION: This preliminary study showed that the creation of a CNA based on the individual patient's pupil size, provided patients with a good range of near, intermediate and distance vision following implantation of the LAL.

[Adjustment of sphero-cylindrical refractive errors in hyperopic eyes: 6-month results after cataract surgery and implantation of a light-adjustable intraocular lens]. / Adjustierung von sphärozylindrischen Refraktionsfehlern bei hyperopen Augen: 6 Monatsergebnisse nach Kataraktchirurgie und Implantation einer lichtadjustierbaren Intraokularlinse.

PURPOSE: The aim of this study was to determine whether residual spherical and cylindrical errors could be corrected postoperatively in a non-invasive manner using ultraviolet irradiation in patients with axial hyperopia undergoing cataract surgery and implantation of a light-adjustable lens, silicone intraocular lens (LAL) (Calhoun Vision, Pasadena, CA). METHODS: In a prospective, non-randomised clinical trial at Center for Vision Science, Ruhr University Eye Clinic, Bochum, Germany, 15 eyes of 15 patients with axial hyperopia (less than 22.2 mm) were studied. The manifest refraction, uncorrected visual acuity (UCVA), and best spectacle-corrected visual acuity (BSCVA) were determined with a follow-up time of six months to determine the achieved refractive corrections and their stability. RESULTS: The adjustment and lock-in procedures were well tolerated by patients. Preoperative refraction was in mean + 2.56 D as spherical equivalent, postoperative before adjustment + 1.01 D, one month after lock-in procedure + 0.03 D, after 3 months + 0.12 D and after 6 months 0.0 D (± 0.21 D). 6 months after lock-in all patients reached an uncorrected visual acuity of 20/30 or better, 10 of 15 patients reached 20/25 and 1 patient 20/20. The data demonstrate the stability of the achieved refractive change after the adjustment and lock-in procedures. CONCLUSION: Postoperative refractive errors were successfully corrected with precision and significant improvement in UCVA and without compromising BSCVA using the light adjustable intraocular lens technology. Our data demonstrate the stability of the achieved refractive change after the adjustment and lock-in procedures. The light-adjustable lens is a promising technology with the potential to eliminate postoperative refractive surprises of up to 2 diopters of refractive and cylindrical error following cataract surgery.

[The light-adjustable lens. Principles and clinical application]. / Die lichtadjustierbare Linse. Grundlagen und klinische Anwendung.

Despite improvements in preoperative lens power calculations many patients are in need of spectacle correction to achieve emmetropia and/or optimal distance vision after cataract surgery. A method to adjust residual spherical and astigmatic errors postoperatively in a predictable and non-invasive way is the implantation of the light-adjustable lens (LAL). Selective irradiation of the LAL with UV light (365 nm) using a digital light delivery device enables a customized light pattern for each patient which produces modifications in the lens curvature and lens power by polymerization of silicon monomers in the lens matrix. In Europe this therapeutic option is currently only available in Spain and Germany, therefore, the number of patients treated is limited. In the future this technique will be available for correction of higher order aberrations and to design individual multifocality.

[Retropupillary fixation of the iris claw lens in aphakia. 1 year outcome of a new implantation techniques]. / Retropupillare Fixation der Irisklauenlinse bei Aphakie. Einjahresergebnisse einer neuen Implantationstechnik.

INTRODUCTION: There are several surgical options available for the correction of aphakia. We investigated if retropupillary fixation of an iris claw lens is a method combining the advantages of posterior chamber implants with a new low-risk method of intervention. PATIENTS AND METHODS: An iris claw lens was implanted in 48 eyes in the plano-convex direction (model 205 Y). For the calculation of the IOL power we estimated an A-constant of 116.8. The lens was pushed via a 5-mm wide corneal incision vertically in the anterior chamber and was fixed in the retropupillary position after turning in the horizontal direction. After aspiration of the viscoelastica the corneal incision was closed by a 10-0 nylon suture. RESULTS: The implantation was successful in all patients. A visual improvement was noted in 27 patients (56.2%), an unchanged visual acuity was seen in 18 patients (37.5%) while 3 patients (6.2%) showed a loss of visual acuity. A cystoid macular edema was found by fluorescein angiography in two cases. Leakages in the area of the enclavation were not seen. SUMMARY: The retropupillary fixation of an iris claw lens seems to have the advantages of a true posterior chamber implantation with a low intra- and postoperative risk profile. The easy implantation process with this technique could replace the normally applied sclera suture fixed implantation of a posterior chamber lens as the method of choice.

Localization of latency-associated transcripts in the uterovaginal plexus of herpes simplex virus type 1 and 2 latently infected mice.

The vagina and medulla of the adrenal gland of mice vaginally infected with herpes simplex virus (HSV) types 1 and 2 were examined in the latent stage of infection (5 to 51 weeks post-infection). RNA in situ hybridization with HSV-1 and -2 latency-associated transcript (LAT) RNA probes resulted in positively stained neuronal cell nuclei in the uterovaginal plexus, but not in the medulla of the adrenal gland. These organs were chosen because HSV antigens can be detected not only in the vaginal epithelium, but also in neurons of the uterovaginal plexus and in the medulla of the adrenal gland at the acute stage of genital infection. To our knowledge, this is the first report describing LATs in neurons of the uterovaginal plexus in the genital tract of latently HSV-infected mice.

Mixed vaginal infections of Balb/c mice with low virulent herpes simplex type 1 strains result in restoration of virulence properties: vaginitis/vulvitis and neuroinvasiveness.

Vaginal infections of BALB/c Ann mice with herpes simplex virus type 1 (HSV-1) were studied. Mice were inoculated with virulent strains ANG path and 17 syn+ or low-virulent recombinant strains 27/III and 17-syn3 that differ from parental strains in their glycoprotein B (gB) gene sequences. When low-virulent strains were inoculated separately, no vaginitis/vulvitis was produced despite replication in the vagina. In contrast, after coinfection of mice with the two low-virulent strains, vaginitis/vulvitis was produced and virus could be recovered from the central nervous system (CNS). Two of the CNS isolates produced vaginitis/vulvitis, neuroinvasiveness and death of mice after vaginal infection. Restriction fragment analysis and sequencing were used to assess recombination events in the gB gene sequence of the CNS isolates. After mixed vaginal infection recombination between non-virulent HSV strains occurs, resulting in vaginitis/vulvitis and neuroinvasiveness. No correlation was detected between the syncytial phenotype and local vaginal virulence. Virulence of HSV is not solely dependent on gB function; it seems to be more probable that several genes act in concert to induce virulence and neuroinvasiveness.

Replication of herpes simplex virus type 1 and 2 in the medulla of the adrenal gland after vaginal infection of mice.

After vaginal infections of mice with neuroinvasive strains of herpes simplex virus type 1 and 2 (HSV-1, HSV-2) virus replicates in the epithelium of the vagina, in the paravaginal ganglia, in the spinal cord and finally in the brain and in the adrenal glands. However, viral antigens could be demonstrated only in the medulla of the adrenal glands but not in the cortex, as assessed by immunohistochemistry (IHC). HSV could not be isolated from liver, spleen, uterus, and ovaries. This contrasts to the intraperitoneal (i.p) route of infection with replication in different visceral organs including the adrenal gland's cortex.

Asymptomatic vaginal herpes simplex virus infections in mice: virology and pathohistology.

One of the causes of genital tract infections in humans are herpes simplex virus types 1 and 2 (HSV-1, HSV-2). Although primary and recurrent infections can be clinically apparent and in part very serious, many infections are asymptomatic and result only in temporary genital shedding of virus (recurrences). During our investigations of vaginitis, strain IES of HSV-1 produced an asymptomatic infection. Replication in the murine vaginal (vag.) epithelium as well as antibody formation after vag. infection was comparable to those of survivors after infection with highly virulent strains. Titration of liver, spleen, ovaries, adrenal glands spinal cord, or brain after vag. IES infection revealed no virus, whereas after i.p. infection virus could be demonstrated in many organs examined. Histological examination with a DNA probe (in situ hybridisation), HSV antibodies (immunohistochemistry), and haematoxylin and eosin (HE) staining showed only small focal HSV lesions of the vaginal epithelium in early stages of the infection, never exceeding to the subepithelial tissue. Severe infiltrations and ulcerations after infection with highly virulent strains (17syn +, ER-) could never be demonstrated after IES vag. infection. Identical replication rates of both groups of HSV despite much greater areas of epithelial necrosis with the virulent strains may be explained by the large number of virus inactivating granulocytes induced by the virulent strains, thus inactivating the hypothetical higher virus load.