[Trabecular micro-invasive glaucoma surgery : Procedures and clinical results]. / Trabekuläre mikroinvasive Glaukomchirurgie : Verfahren und klinische Ergebnisse.

The management of glaucoma therapy to reduce intraocular pressure commonly consists of a gradual approach with local monotherapy, combined therapy, laser surgery and finally filtration surgery. The local side effects of glaucoma medications and the lack of adherence and persistence to the medical therapy as well as the complication profile of the established glaucoma surgical techniques justify the introduction of new surgical procedures. Micro-invasive glaucoma surgery (MIGS) is a promising new surgical approach. Microstents can reduce the medication burden and prolong the need for filtration surgery. This review article presents the different trabecular implants (iStent, iStent inject, HydrusTM Microstent) in detail and discusses the effectiveness and safety of the procedures based on the currently available data.

[Revision after filtration surgery]. / Revision nach Filtrationschirurgie.

BACKGROUND: In contrast to all other glaucoma surgeries, filtration surgery is associated with biomicroscopically visible wound healing, which enables the surgeon to perform revision surgeries if necessary. OBJECTIVES: The aim of this review is to provide general considerations and to give a structured overview about bleb revisions after trabeculectomy. MATERIALS AND METHODS: The different revision techniques are explained in detail and in the context of perioperative management. RESULTS: Preoperative preparation and modifications of the surgical techniques reduce the incidence of postoperative revisions. The site of the fibrosis defines the revision technique (bleb needling, needle revision, bleb revision with reopening). The increased percolation rate of aqueous humor in postoperative hypotony contributes to fibrosis and may lead to maculopathy, choroidal effusion, and suprachoroidal hemorrhage. DISCUSSION: Discontinuing administration of local medication and pretreatment with steroids without preservative for at least one week prior to surgery increase surgical success of trabeculectomy and reduce the incidence of postoperative revisions. Postoperative management after filtration surgery should be performed after consulting the surgeon. The primary endpoint of trabeculectomy is an intraocular pressure between 8 and 12 mm Hg without local antiglaucomatous medication. In postoperative hypotony revisions should be done earlier and based on the pathological findings.

[Dyslipidaemia and glaucoma]. / Fettstoffwechselstörungen und Glaukom.

Endothelial dysfunction and vascular dysregulation play a role in the multifactorial pathogenesis of glaucomatous optic nerve atrophy. Dyslipidaemia as a risk factor for endothelial dysfunction is associated with glaucoma and cardiovascular morbidity and mortality. In additional to a genetic disposition, a potential mechanism for the pathogenesis of endothelial dysfunction could be an additive effect of several risk factors, like dyslipidaemia, smoking, arterial hypertension, diabetes and hyperhomocysteinaemia. This paper reviews the literature concerning the association between dyslipidaemia and glaucomatous disease and explains the possible role of dyslipidaemia for the pathogenesis and progression of glaucoma. The role of exogeneous modifiable risk factors for prevention and therapy of glaucoma and their neutralisation by changing life style like weight reduction, modifications of nutrition and physical activity, are discussed.

[Pigment dispersion syndrome and pigmentary glaucoma. Morphometric analysis of the anterior chamber segment with SL-OCT]. / Melanindispersionssyndrom und -glaukom. Morphometrische Analyse des vorderen Augenabschnittes mittels SL-OCT.

BACKGROUND: The purpose of this study was to analyze if anterior chamber parameters are risk factors for the development of pigment dispersion syndrome (PDS) and/or for the conversion to pigmentary glaucoma (PG). PATIENTS AND METHODS: This study included a total of 63 eyes from 35 patients with PDS and PG and 65 eyes from 49 unaffected volunteers as the control group. The following parameters were measured by slit lamp optical coherence tomography (SL-OCT): anterior chamber volume (ACV) and depth (ACD), angle opening distance (AOD) and the trabecular iris space area (TISA) at 500 µm and 750 µm from the scleral spur. Comparisons between the following groups were performed: between the PDS/PG and the control group, between PDS and PG and between male and female patients. RESULTS: The results of ACV, ACD, AOD and TISA were significantly higher in PDS/PG patients when compared to the control group. There were no significant differences between PDS and PG. The gender-specific comparison also showed no significant differences. CONCLUSIONS: Significantly higher anterior chamber parameters are a possible risk factor for development of PDS; however, a higher risk of conversion to PG does not seem to correlate with increased anterior chamber parameters. The parameters of the anterior chamber are apparently not associated with the male predominance of PDS and PG.

[Medicinal glaucoma therapy. What can we learn from large randomized clinical trials?]. / Medikamentöse Glaukomtherapie. Welche Lehren können wir aus den großen klinischen Studien ziehen?

The prospective multicenter randomized controlled clinical trials (RCTs) Ocular Hypertension Glaucoma Treatment Study (OHTS), Early Manifest Glaucoma Trial (EMGT), Advanced Glaucoma Intervention Study (AGIS), Collaborative Initial Glaucoma Treatment Study (CITGS) and Collaborative Normal Tension Glaucoma Study (CNGTS) are often named as landmarks for glaucoma management as the results of these studies provided the evidence for numerous therapeutic decisions in clinical practice. The studies confirmed the consensus that reduction of intraocular pressure reduces the risk of glaucoma progression covering the whole spectrum of glaucoma from ocular hypertension to advanced glaucoma. Furthermore, the identification of new risk factors allows a higher precision of assessment of the risk of progression. The RCTs achieved the main goal of high level of evidence, thus making progress in the understanding of glaucoma and its treatment and bridging consensus-based and evidence-based decisions. However, the implementation of the results into clinical practice needs adequate and accurate interpretation of the results.

[Diagnosis and therapy of pseudoexfoliation glaucoma]. / Diagnose und Therapie des Pseudoexfoliationsglaukoms.

Pseudoexfoliation (PEX) glaucoma is the most frequent and most important type of secondary glaucoma, accounting for approximately 25% of open angle glaucoma worldwide and currently representing the most common identifiable cause of glaucoma overall. Due to high intraocular pressure levels, marked diurnal pressure fluctuations and spikes, and rapid optic nerve damage and visual field loss, PEX glaucoma represents a relatively severe and progressive type of glaucoma. Therefore, hard and fast lowering of intraocular pressure is necessary. Fixed combinations in medical therapy and early glaucoma surgery are recommended. When considering a surgical procedure (e.g. selective laser trabeculoplasty, bleb-dependent or bleb-independent surgery) the timing of cataract surgery plays a major role. Pathogenesis, clinical characteristics and therapeutic aspects of PEX glaucoma are described in the following article.

[Influence of mode of delivery on pre-existing eye diseases]. / Einfluss des Geburtsmodus auf vorbestehende Augenerkrankungen.

Many ophthalmologists and obstetricians recommend either an assisted vaginal delivery with forceps or vacuum extraction, or a Caesarean section in cases of pre-existing eye diseases, such as myopia, retinal detachment, glaucoma or diabetic retinopathy. This is mainly based on the increase of intraocular pressure during the final stage of labor. These recommendations, however, are not evidence-based. None of the published trials have reported any retinal changes after vaginal delivery. This report provides information on the influence of physiological changes on eye diseases during the final stage of delivery. In general eye disease is not an indication for an instrumental or operative delivery provided regular eye examinations (once each trimester) have been performed.

Frequency doubling technique perimetry and spectral domain optical coherence tomography in patients with early glaucoma.

PURPOSE: To assess the combined diagnostic power of frequency-doubling technique (FDT)-perimetry and retinal nerve fibre layer (RNFL) thickness measurements with spectral domain optical coherence tomography (SDOCT). METHODS: The study included 330 experienced participants in five age-related groups: 77 'preperimetric' open-angle glaucoma (OAG) patients, 52 'early' OAG, 50 'moderate' OAG, 54 ocular hypertensive patients, and 97 healthy subjects. For glaucoma assessment in all subjects conventional perimetry, evaluation of fundus photographs, FDT-perimetry and RNFL thickness measurement with SDOCT was done. Glaucomatous visual field defects were classified using the Glaucoma Staging System. FDT evaluation used a published method with casewise calculation of an 'FDT-score', including all missed localized probability levels. SDOCT evaluation used mean RNFL thickness and a new individual SDOCT-score considering normal confidence limits in 32 sectors of a peripapillary circular scan. To examine the joined value of both methods a combined score was introduced. Significance of the difference between Receiver-operating-characteristic (ROC) curves was calculated for a specificity of 96%. RESULTS: Sensitivity in the preperimetric glaucoma group was 44% for SDOCT-score, 25% for FDT-score, and 44% for combined score, in the early glaucoma group 83, 81, and 89%, respectively, and in the moderate glaucoma group 94, 94, and 98%, respectively, all at a specificity of 96%. ROC performance of the newly developed combined score is significantly above single ROC curves of FDT-score in preperimetric and early OAG and above RNFL thickness in moderate OAG. CONCLUSION: Combination of function and morphology by using the FDT-score and the SDOCT-score performs equal or even better than each single method alone.

[Selective lacrimal sac biopsy for external dacryocystorhinostomy: a clinical pathological study]. / Selektive Tränensackbiopsie bei externer Dakryozystorhinostomie: Eine klinisch-pathologische Studie.

BACKGROUND: Tumors of the lacrimal drainage system are rare but potentially life-threatening. The purpose of this study was to investigate the applicability of selective lacrimal sac biopsy in 500 cases of external dacryocystorhinostomy for acquired dacryostenosis. PATIENTS AND METHODS: Lacrimal sac biopsy was obtained selectively for atypical clinical and/or intraoperative findings. The frequency and spectrum of biopsies were recorded and correlated with the follow-up results. RESULTS: Lacrimal sac biopsy was performed in 19 external dacryocystorhinostomies (3.8%) including non-Hodgkin B-cell lymphoma (3), squamous carcinoma (2), mucoepidermoid carcinoma (1), malignant melanoma (1), oncocytoma (1), pyogenic granuloma (4), Wegener's granulomatosis (4) and sarcoidosis (3). Within 5 years none of the patients without biopsy developed systemic inflammatory diseases or lacrimal neoplasms. The 5-year survival was 87% in patients with significant lacrimal sac pathology and 96% in patients without significant pathology. CONCLUSION: External dacryocystorhinostomy with selective biopsy for atypical clinical and intraoperative findings allows safe diagnosis and management of potentially life-threatening lacrimal lesions.

[Web-based electronic patient record as an instrument for quality assurance within an integrated care concept]. / Webbasierte elektronische Krankenakte im Rahmen eines integrierten Versorgungskonzepts als Instrument der Qualitätssicherung.

OBJECTIVE: A prerequisite for integrated care programmes is the implementation of a communication network meeting quality assurance standards. Against this background the main objective of the integrated care project between the University Eye Hospital Erlangen and the health insurance company AOK Bayern was to evaluate the potential and the acceptance of a web-based electronic patient record in the context of cataract and retinal surgery. METHODS: Standardised modules for capturing pre-, intra- and post-operative data on the basis of clinical pathway guidelines for cataract- and retinal surgery have been developed. There are 6 data sets recorded per patient (1 pre-operative, 1 operative, 4-6 post-operative). For data collection, a web-based communication system (Soarian Integrated Care) has been chosen which meets the high requirements in data security, as well as being easy to handle. This teleconsultation system and the embedded electronic patient record are independent of the software used by respective offices and hospitals. Data transmission and storage were carried out in real-time. RESULTS: At present, 101 private ophthalmologists are taking part in the IGV contract with the University Eye Hospital Erlangen. This corresponds to 52% of all private ophthalmologists in the region. During the period from January 1st 2006 to December 31st 2006, 1844 patients were entered. Complete documentation was achieved in 1390 (75%) of all surgical procedures. For evaluation of this data, a multidimensional report and analysis tool (Cognos) was used. The deviation from target refraction as one quality indicator was in the mean 0.09 diopter. CONCLUSIONS: The web-based patient record used in this project was highly accepted by the private ophthalmologists. However there are still general concerns against the exchange of medical data via the internet. Nevertheless, the web-based patient record is an essential tool for a functional integration between the ambulatory and stationary health-care units. In addition to the telemedicine functions of the system, we achieved the export of the data to a data warehouse system in order to provide a flexible and powerful tool for quality assurance analysis and reporting.

[Peripheral suprathreshold stimulation in preperimetric glaucoma]. / Uberschwellige periphere Stimulation bei präperimetrischen Glaukomen.

BACKGROUND AND PURPOSE: Early glaucomatous visual field defects can occur outside the central 30 degrees , which is usually examined in perimetric tests used for glaucoma diagnosis and screening. This study aimed to evaluate the diagnostic value of peripheral suprathreshold stimulation in open angle glaucoma before the development of reproducible visual field damage in standard 30 degrees automatic white-on-white perimetry. METHODS: A total of 352 eyes of 352 patients (ages 35-69 years; visual acuity 0.8 or better) from the Erlanger Glaucoma Registry were included in this study. They were divided into two groups: normal eyes and preperimetric glaucoma. All patients underwent a standardized glaucoma examination including Octopus 500EZ static perimetry (G1 program, all three phases); 95 eyes of 95 patients also received a 135-point suprathreshold test pattern of the Humphrey Field Analyzer (model 750i) for detecting peripheral visual field defects. Sensitivity and specificity were calculated for any single test point in phase 3 of the G1 test pattern and the Humphrey 135-point pattern. A score was calculated, and cluster analysis was performed. RESULTS: In 33 of 176 (18.8%) eyes with preperimetric glaucoma, the score was 3 or higher in phase 3 of the G1 program (normal eyes: 19 of 196; 9.7%). For both examination modalities, the highest sensitivity was found in test locations in the superior nasal midperiphery, corresponding to neuroretinal rim loss predominantly in the inferotemporal sector in early glaucomatous optic disc atrophy. CONCLUSION: Positive test results using suprathreshold stimulation in the midperiphery can be found in patients with preperimetric glaucoma at a significantly higher frequency than in normal subjects. Longitudinal studies will show whether such tests can be useful for predicting perimetric manifestation of the disease.

Increased homocysteine levels in tear fluid of patients with primary open-angle glaucoma.

AIMS: We assessed homocysteine (Hcy) levels in tear fluid and plasma of patients with primary open-angle glaucoma (POAG). We determined the association between Hcy levels, dry eye syndrome and B vitamin status. METHODS: This prospective case-control study included 36 patients with POAG and 36 controls. Hcy concentrations were measured by high-performance liquid chromatography. RESULTS: Patients with POAG had significantly higher mean Hcy levels both in tear fluid (205 +/- 84 nmol/l; p < 0.001, t test) and in plasma (13.43 +/- 3.53 micromol/l; p = 0.001, t test) than control subjects (130 +/- 53 nmol/l and 10.50 +/- 3.33 micromol/l, respectively). Hcy in tear fluid was significantly correlated with plasma Hcy in POAG patients (r = 0.459; p = 0.005, Pearson's correlation), but not in controls (r = 0.068; p = 0.695). POAG patients with dry eye disease had significantly higher Hcy levels both in tear fluid and plasma than POAG patients without dry eye disease. There was no association between Hcy levels and B vitamin status in subjects with POAG. CONCLUSIONS: The study suggests increased Hcy levels in tear fluid and plasma of patients with POAG. Elevated Hcy levels might be a risk factor for POAG and dry eye syndrome in subjects with glaucoma.

[Eye disease and mode of delivery]. / Geburtsmodus bei präexistenten Augenerkrankungen.

Many ophthalmologists and obstetricians recommend either an assisted vaginal delivery with forceps or vacuum extraction or a Caesarean section in cases of pre-existing eye diseases such as severe myopia, retinal detachment, diabetic retinopathy, or glaucoma. These recommendations, however, are not evidence-based. None of the published trials have reported any retinal changes after vaginal delivery. In general, eye disease is not an indication for an instrumental or operative delivery provided that regular eye examinations (once each trimester) have been performed.

Vitamin deficiency and hyperhomocysteinemia in pseudoexfoliation glaucoma.

Pseudoexfoliation syndrome (PEX) is a systemic disorder characterized by the deposition of an abnormal fibrillar material in ocular and various extraocular tissues. It represents the most common identifiable cause of glaucoma (PEX glaucoma = PEXG). Due to similar pathogenetic mechanisms, glaucoma has been called "ocular Alzheimer's disease". PEXG and Alzheimer's disease share common associations such as the higher prevalence of hyperhomocysteinemia in both disorders. In order to investigate the cause of hyperhomocysteinemia in PEXG, we evaluated B-vitamin levels (folate, B12, B6) and their associations with homocysteine (Hcy) in plasma of 70 PEXG patients and 70 control subjects. Folate, vitamin B12 and B6 levels were significantly decreased and associated with elevated Hcy levels in PEXG. Low B-vitamin levels in PEX might also help explain, at least in part, the higher prevalence of B-vitamin deficiency in disorders associated with PEX such as Alzhemier's disease.

Homocysteine levels in aqueous humor and plasma of patients with primary open-angle glaucoma.

We determined homocysteine (Hcy) levels in aqueous humor (AH) and plasma and their association with B-vitamin levels in patients with primary open-angle glaucoma (POAG) and controls. Both AH Hcy and plasma Hcy levels were significantly increased in POAG, and elevation of AH Hcy and plasma Hcy was a significant risk factor for POAG. In contrast to controls, neither plasma nor AH Hcy of POAG patients demonstrated a significant association with important non-genetic determinants of elevated Hcy such as low B-vitamin levels, increasing age and caffeine consumption. Considering that Hcy is a neurotoxin that induces apoptotic retinal ganglion cell death via stimulation of the N-methyl-D-asparate (NMDA) receptor, increased Hcy concentrations in AH and plasma might contribute to the optic nerve damage in POAG.

[Flicker provocation with LED full-field stimulation in normals and glaucoma patients]. / Flimmerprovokation im LED-Ganzfeld bei Gesunden und Glaukompatienten.

BACKGROUND: Flicker light is an easy method to test sensory function after stress. The aim of this study was to determine the influence of flicker stress on temporal contrast sensitivity in healthy controls and patients with glaucomatous alteration of the optic disk. METHODS: A commercially available full-field stimulator (Retiport, Roland Consult) equipped with white LEDs was modified to perform psychophysical tests. The patients underwent measurements of the recovery time interval from cessation of flicker stress until recognition of a pregiven flicker contrast after photo stress. In addition, we studied contrast sensitivity with a continuous flickering target and with a flicker burst protocol avoiding adaptation to prevailing flicker. All tests were performed at a constant retinal illumination and at a frequency of 37 Hz for provocation as well as for contrast sensitivity tests. SUBJECTS: Normal healthy controls (40), "preperimetric" (62), and "perimetric" (52) open-angle glaucoma patients were studied. Exclusion criteria were age lower than 31 years, visual acuity under 0.6, and perimetric mean defect more than 9.5 dB. RESULTS: Recovery time after flicker stress was significantly longer in patients than in normals and longer in perimetric than in preperimetric patients. Analysis in perimetric patients revealed a larger area under ROC for the provocation test (0.95) than in contrast sensitivity tests (continuous flicker method: 0.90, flicker burst mode: 0.84). CONCLUSION: High-power LEDs which are installed in modern full-field devices can be used as a helpful tool to study psychophysical properties. In the present study it could be shown that threshold, adaptation, and recovery of temporal transfer characteristics are impaired in many patients with glaucoma.

Laser scanning tomography of the optic nerve vs CSF opening pressure in idiopathic intracranial hypertension.

The authors investigated 17 patients with idiopathic intracranial hypertension (IIH), correlating laser scanning tomography of the optic nerve with CSF opening pressure. The decrease in papilla volume and papilla height showed a linear correlation with the opening pressure of the CSF (r = 0.59, p < 0.001; r = 0.63, p < 0.001). If the CSF opening pressure is higher than 20 cm water, an increase of 5 cm water CSF pressure corresponds to a papilla volume increase of 0.95 mm3 as well as a papilla height increase of 0.34 mm.

Two methods of lens opacity measurements in glaucomas.

PURPOSE: Determination of lens opacity is important in aging glaucoma patients, because sensory testing may be influenced by increasing lens opacity. Purpose of this study was to measure lens opacity in normals and glaucoma patients using two different techniques, to compare both methods, and to correlate the results with contrast sensitivity testing. METHODS: 94 glaucomatous eyes, 47 ocular hypertensive eyes, and 79 control eyes were studied using the following devices: opacity lens meter (OLM, objective back scatter method), stray light meter (SLM, subjective forward scatter using flicker light), and temporal contrast sensitivity (full-field flicker test). SLM results were separately analyzed at the lower and upper flicker disappearance. All subjects were younger than 66 years and had no significant cataracts. RESULTS: In patients and in normal subjects OLM readings and SLM findings elicited at the upper disappearance point are significantly correlated with age and with each other (R >0.45, P<0.001), while SLM at the lower disappearance point shows no such correlation. In normals, but not in patients, SLM at the lower disappearance point is significantly correlated with temporal contrast sensitivity. CONCLUSIONS: Both devices can be used for quantifying lens opacity in glaucoma. SLM readings with increasing light intensity at the lower disappearance point seems to be more influenced by the individual flicker sensitivity than determination of the upper flicker disappearance. Therefore, using the SLM in glaucoma patients, the threshold measurements based on the upper disappearance of the flicker should be used instead of the suggested mean threshold measurements.

[Early childhood cataract in hereditary UDP-galactose-4-epimerase deficiency--a case report]. / Frühkindliche Katarakt bei familiärem UDP-Galaktose-4-Epimerase-Mangel--eine Kasuistik.

BACKGROUND: Increased plasma galactitol levels may lead to development of bilateral pediatric cataract. PATIENT: A 3-year-old boy was found to suffer from a bilateral zonular cataract. Extracapsular lensectomy with posterior capsulotomy, transpupillar anterior vitrectomy and posterior chamber lens implantation were performed during a 4-month-interval. RESULTS: The epimerase-activity in red cells of the index patient was found to be significantly decreased (11.2 mumol/h/g Hb; normal range; 19-35). From other family members, such as the brother (16.8), the father (16.0) and the grandfather (15.6), a diminished red cell activity was observed. The mother whose epimerase activity was considerably lower than that of the above mentioned family members (13.3) showed also a zonular bilateral cataract. CONCLUSIONS: Investigation of enzymes and polyols of galactose metabolism as well as consultation of the concerned families are recommended for clarification of cataract development.

The diagnostic value of optic nerve imaging in early glaucoma.

In the last decade, new imaging techniques have been added to conventional fundus photography and have been evaluated for use in early glaucoma. They all measure the loss of neuroretinal rim or retinal nerve fiber layer as a correlate to glaucomatous ganglion cell and axon loss. The value of optic disc photography, planimetry, laser scanning tomography, laser scanning polarimetry, and optical coherence tomography for the diagnosis of glaucomatous eyes in a preperimetric or early perimetric stage is analyzed on the basis of sensitivity, specificity, and receiver operating characteristics (ROC) curves. It becomes clear that all these techniques allow a more or less semi-automated evaluation of the optic disc and retinal nerve fiber layer but still have their limitations in the diagnosis of a very early, preperimetric stage of the glaucoma disease.