[Rebound tonometry and applanation tonometry during narcosis investigation of pediatric glaucoma]. / Reboundtonometrie und Applanationstonometrie während einer Narkoseuntersuchung beim kindlichen Glaukom.

BACKGROUND: A comparison of intraocular pressure (IOP) in cases of infantile glaucoma during general anesthesia was carried out by measurement with the iCare rebound tonometer (RBT) and a handheld applanation tonometer (Perkins). METHODS: A total of 45 eyes from pediatric patients with childhood glaucoma were included in this prospective trial. Bland-Altman plots and linear regression were used for statistical analysis. RESULTS: In almost two thirds of the eyes the difference between RBT and Perkins was 2 mmHg or less. A systemic bias of 1.96 mmHg and a 95% confidence interval of -3.35 to 7.26 was detected. Linear regression of the Bland-Altman data showed a proportional error (gradient=0.16; r(2)=0.23; p<0.01). CONCLUSIONS: The iCare rebound tonometer is useful during general anesthesia in cases of childhood glaucoma. It provides comparable IOP values to applanation tonometry with a tendency to record higher values.

A prospective randomised trial of trabeculectomy using mitomycin C vs an ologen implant in open angle glaucoma.

PURPOSE: The aim of this study is to assess the efficacy and complications of trabeculectomy with a biodegradable implant (ologen implant) vs trabeculectomy using mitomycin C (MMC) in patients with medically uncontrolled open-angle glaucoma in a prospective randomised clinical trial. METHODS: In the MMC group (10 patients), trabeculectomy was performed according to standard protocols. In the ologen group (10 patients) after standard trabeculectomy the implant was positioned on top of the scleral flap and no MMC was applied. Follow-up was continued for 12 months after surgery and included testing of intraocular pressure (IOP), visual acuity, visual field, ultrasound biomicroscopy, and filtering bleb score. RESULTS: The mean preoperative IOP was 24.8+/-8.9 mm Hg for all patients enrolled. At 1 year after surgery, the mean IOP was 15.6+/-2.4mm Hg in the ologen group (P<0.01, 43% reduction) and 11.5+/-4.1 mm Hg in the MMC group (P<0.01, 50% reduction). No anti-glaucomatous medication was necessary in the MMC group in the first year of follow-up, whereas five patients in the ologen group required topical treatment. The absolute success rate was 100% in the MMC group and 50% in the ologen group (P=0.01). After 1 year, filtering blebs developed significantly more avascular areas in the MMC group (score=1.4) than in the ologen group (score=2.8; P<0.01). CONCLUSION: The complete success rate using trabeculectomy with the ologen implant is lower than that achieved by trabeculectomy with MMC. However, the bleb morphology caused more problems in the MMC group (avascularity score).

[Trabecular meshwork bypass surgery for glaucoma]. / Trabekuläre Bypasschirurgie beim Glaukom.

The outflow facility of the glaucomatous eye can be significantly enhanced by opening Schlemm's canal to the anterior chamber. Surgical options for this approach include mechanical procedures, laser surgery, microbipolar cauterization and intracanalicular microstents. Especially in the area of combined cataract-glaucoma surgery these procedures are valuable options owing to their limited intraoperative and postoperative risk profiles. However, trabeculectomy with mitomycin C must still be regarded as the superior surgical option for glaucoma, which requires a low target pressure if combined surgery is unnecessary.

Modern concepts in antiglaucomatous implant surgery.

BACKGROUND: Antiglaucomatous implant surgery is a continously evolving field in glaucoma treatment. METHODS: A literature search with the terms "glaucoma implant surgery", "aqueous shunts" and "glaucoma drainage devices" was carried out, especially giving prominence to innovative surgical developments in glaucoma implant surgery and to recently established clinical evidence on traditional shunt surgery. RESULTS: Episcleral glaucoma drainage devices have recently proven their efficacy in large studies. Longterm data about their clinical efficacy and their risk/safety profile are sufficiently available. New antiglaucomatous devices try to target alternative drainage routes, for example trabecular or uveoscleral outflow. Valid longterm data from prospective randomized clinical trials are not available for these devices as yet. CONCLUSIONS: Although valid data on clinical application of the new glaucoma implants are not available as yet, profound knowledge about their theoretical concept and their practical management is obligatory for all glaucoma clinicians.

[Midterm patient satisfaction following mitomycin C-assisted trabeculectomy]. / Patientenzufriedenheit nach filtrierender Glaukomchirurgie mit Mitomycin C.

BACKGROUND: There are few published data on patient satisfaction following glaucoma surgery. The aim of our study was to investigate factors influencing patient satisfaction more than one year after trabeculectomy with mitomycin C. MATERIAL AND METHODS: We sent a two-page questionnaire to 61 female glaucoma patients who had consecutively undergone filtering surgery with MMC at the Department of Ophthalmology, University of Cologne, requesting anonymous replies (mean follow-up 19.2+/-2.5 months). RESULTS: The response rate was 79%. There was no significant inverse correlation between patient satisfaction and recent IOP values, redness of the eye, local irritation or foreign body sensation. There was a significant correlation between patient satisfaction and visual function, a significant inverse correlation between frequency of visits to the ophthalmologist and frequency of eye drop application. A weak, insignificant inverse correlation was found between satisfaction and number of topical medications. CONCLUSIONS: Patient satisfaction seems to correlate primarily with practical impact on everyday life, visual function, frequency of eye drop application and visits to the eye doctor being identified as the major issues. Local symptoms related to the filtering bleb seem to have a minor influence on patient satisfaction.

[Lateral tube repositioning following a Baerveldt glaucoma implant. An alternative surgical procedure in the case of repeated conjunctival arrosion]. / Seitliche Schlauchverlagerung beim Baerveldt-Implantat. Eine chirurgische Alternative bei rezidivierender Bindehautarrosion.

Conjunctival arrosion of the silicone tube following glaucoma implant surgery is a postoperative complication that generally requires surgical revision by means of a sclera or dura patch with mobilization of adjacent conjunctiva. We present a case of repeated conjunctival arrosion following Baerveldt implant surgery, in which successful revision was achieved over the course of a year by changing the insertion site of the silicone tube into the anterior chamber without touching the plate of the glaucoma implant. However, a long enough silicone tube is absolutely essential if this strategy is to work.

[High-dose intravenous immunoglobulins for treatment of optic neuritis in Guillain-Barré syndrome]. / Intravenöse Hochdosisimmunglobulintherapie zur Behandlung der Neuritis nervi optici beim Guillain-Barré-Syndrom.

BACKGROUND: Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating disease of the peripheral nervous system. Treatment strategies include systemic steroids, immune adsorption, plasmapheresis, and intravenous immunoglobulins. Optic neuritis as an affectation of the central nervous system does not belong to the normal spectrum of neurological symptoms in GBS, which is thought to be restricted to the peripheral nervous system. CASE REPORT: A 55-year-old female patient with unilateral optic neuritis secondary to GBS was referred to our department. Visual acuity was 0.04 in the affected left eye, L. E. and 1.25 in the right eye, R. E. Visual field testing revealed a large centrocecal scotoma. Ophthalmoscopy disclosed a slight oedema of the left optic disc. High-dose steroid treatment based on the diagnosis of optic neuritis secondary to GBS could not improve vision in the patient's left eye. Therefore, a repetitive treatment with high-dose intravenous immunoglobulins (IVIg) was initiated. The patient underwent three treatment cycles - 0.4 g per kg daily for 5 days - with intervals of two weeks between each cycle. Visual acuity and visual field improved gradually after the initiation of the immunoglobulin treatment. At the end of the last treatment course - 7 weeks after the begin of ocular symptoms - visual acuity had recovered to 0.8. A small residual paracentral scotoma resolved completely within the following weeks. Further follow-up examinations revealed a complete recovery of visual acuity to 1.0. Side effects of the immunoglobulin treatment were not observed throughout the treatment period. CONCLUSIONS: Based on the observation that the clinical improvement in our patient coincided with the initiation of the IVIg treatment after steroid treatment had failed, we feel justified in drawing attention to IVIg as a potential treatment option in patients with GBS and involvement of the optic nerve.

[Bilateral anterior panuveitis as early manifestation of syphilis in a patient with HIV infection]. / Beidseitige Panuveitis als okuläre Frühmanifestation einer Lues bei einem Patienten mit HIV-1-Infektion.

INTRODUCTION: Syphilis is a dangerous sexually transmitted infection which can be effectively treated with penicillin to avoid late-onset diseases. Even if syphilis is diagnosed an HIV infection should be excluded. PATIENT: A 32-year-old homosexual man complained about a decreased bilateral visual acuity after a feverish infection with lymphadenitis colli. With slit-lamp biomicroscopy a bilateral panuveitis with papillary edema, endothelial cells and episcleritis was found. After antimycotic and antiviral therapy, his visual acuity decreased and symptoms progressed. In the lab routine we found lues and HIV infections and started an intravenous penicillin therapy immediately. A few days later the symptoms improved and visual acuity increased. CONCLUSION: Lues serology should be incorporated into routine lab diagnostics to aid the detection and to start the right therapy as soon as possible.

[Early postoperative spikes of the intraocular pressure (IOP) following phacoemulsification in late-stage glaucoma]. / Frühe postoperative Augeninnendruckspitzen nach Phakoemulsifikation bei terminalen Glaukomen.

BACKGROUND: Modern cataract surgery with use of viscoelastics can induce remarkable early spikes of the intraocular pressure (IOP) in patients with glaucoma. PATIENTS AND METHODS: The purpose of this prospective study was to investigate risk factors for an early increase of the IOP following cataract surgery in eyes with end-stage glaucoma. Clear cornea phacoemulsification with implantation of a foldable acrylic lens was performed in 25 eyes with end-stage glaucoma (primary open-angle glaucoma including normal tension glaucoma or exfoliative glaucoma) either under topical anesthesia or under general anesthesia. In eyes with exfoliative glaucoma, trabecular aspiration was performed additionally. IOP measurements were conducted at the day before surgery, 4 hours following surgery and on the first morning following surgery. RESULTS: Cataract surgery was performed without complications. The mean IOP was 18.5 +/- 4.2 mm Hg with 2.1 +/- 1.0 topical medications. 4 hours postoperatively, mean IOP was 31.3 +/- 11.9 mm Hg. In eyes with exfoliative glaucoma (n = 12) the early postoperative IOP was 28.5 +/- 12.0 mm Hg, but without significant difference compared to eyes with POAG (n = 13). The early postoperative IOP showed significant correlation with the maximum IOP in patient's history (p = 0.014). CONCLUSIONS: Patients with late-stage glaucoma can experience considerable early IOP spikes following uneventful cataract surgery, although preoperatively IOP is controlled by topical medications. Postoperative IOP monitoring is recommended at the day of surgery, especially if high IOP values are reported in patient's history.

[New aspects of corneal pachymetry in congenital glaucoma and pediatric aphakic glaucoma]. / Neue Aspekte der Hornhautpachymetrie beim kongenitalen Glaukom und kindlichen Aphakieglaukom.

BACKGROUND: Knowledge of individual corneal thickness in individual eyes is proving to be more and more crucial for correcting Goldmann applanation tonometry, as well as to assess its predictive value regarding the possible progression of glaucomatous damage. It has become an important factor in determining appropriate glaucoma therapy. Only few pachymetric data exist about eyes with congenital or secondary pediatric aphakic glaucoma. METHODS: 12 eyes with congenital glaucoma (6 patients, mean age 3.3 years, mean 3.9 previous operations) and 7 eyes with secondary pediatric aphakic glaucoma (4 patients, mean age 14.8 years, mean 3 previous operations) without clinical signs of corneal decompensation were investigated by ultrasound pachymetry. RESULTS: Eyes with glaucoma due to aphakia had a mean corneal thickness of 708 +/- 77.3 microm. Mean corneal thickness of the eyes with congenital glaucoma was 688.1 +/- 115.9 microm, which is far above the values known from the literature. Two eyes, which had a central corneal thickness of 646 microm and 640 microm, presented with a localised paracentral corneal thickness of only 402 microm and 405 microm, respectively, correlating with microscopic descemet scars. CONCLUSIONS: Congenital glaucoma and the pediatric aphakic glaucoma present with very heterogeneous clinical pictures. Especially for congenital glaucoma, this is confirmed by the high interindividual, but also intraindividual, variability of corneal pachymetry.

[The effect of brimonidine on the pupillary reflex. A pupillographic study in healthy volunteers]. / Beeinflussung der Pupillenreaktion durch Brimonidin. Eine pupillographische Studie an Normalpersonen.

PURPOSE: The effect of brimonidine in comparison with acetazolamide on pupillary reflex was investigated in 18 volunteers. METHODS: Infrared pupillography was performed with white diode light of 200 ms duration to measure pupil diameter, constriction latency, reaction time, constriction amplitude, and relative constriction amplitude. The measurements were performed according to a fixed schedule including a phase without medication to determine the baseline level. Data were analyzed by Student's paired t-test. RESULTS: Application of brimonidine and acetazolamide led to a significantly reduced intraocular pressure as well as static and dynamic differences in the pupillary reflex. The pupil diameter measurements were significantly smaller after both medications in comparison to baseline. The reduction of pupil diameter after brimonidine led to significantly reduced contraction amplitude and prolonged latency. CONCLUSION: Application of brimonidine leads to significant miosis, which might due to the affinity to alpha(2)-receptors with reduction of noradrenaline release in the synapse. This effect may play a role in a higher decrease of intraocular pressure by increasing aqueous humor outflow in comparison to clonidine and apraclonidine, but further investigations are required.

[Patient characteristics in a tertiary glaucoma center. Circumstances of treatment and attitudes of patients]. / Profil einer universitären Glaukomsprechstunde. Objektive Behandlungsumstände und subjektive Einstellungen der Patienten.

BACKGROUND: In order to look for conceptual improvements in the practical management of patients sent to our glaucoma department, we analyzed the structures, behaviour, and knowledge about the disease in this patient group. METHODS: Glaucoma patients who were sent for the first time to our department were included prospectively. Before being examined 129 patients were asked to answer a questionnaire concerning their individual characteristics, their behaviour, and patterns of treatment. RESULTS: Of the patients 74% had open-angle glaucoma (including normal tension, exfoliative, and pigment glaucoma), 22% had secondary glaucoma (including neovascular, congenital, and chronic closed-angle glaucoma), and 4% had suspected glaucoma. Written documentation of previously performed intraocular pressure measurements was not available for 84% of the patients. Younger patients had significantly more knowledge about glaucoma and used more possibilities to get information about the disease than elder patients. CONCLUSION: Education about glaucoma disease should be optimized especially for elder glaucoma patients. Documentation of intraocular pressure measurements is insufficient in our patient group.

[Implant exposure after viscocanalostomy with reticulated hyaluronic acid (SK-GEL)]. / Implantatexposition nach Viskokanalostomie mit hochvernetzter Hyaluronsäure (SK-GEL).

BACKGROUND: Lately, the application of intrascleral implants has been increasingly discussed to improve success rates of nonpenetrating surgery for the treatment of open-angle glaucoma. PATIENTS AND METHODS: A 36-year-old male patient with medically uncontrolled pigmentary glaucoma underwent viscocanalostomy with intrascleral implantation of reticulated hyaluronic acid (SK-GEL) in his right eye. RESULTS: The immediate postoperative course was unremarkable with control of intraocular pressure without additional glaucoma medications. At first follow-up, 2 weeks post surgery, conjunctival dehiscence with partial extrusion and exposure of the reticulated hyaluronic acid implant was observed. Under topical tobramycin ointment a gradual limbal readaptation of the conjunctiva over the surface of the exposed parts of the implant with formation of a filtration bleb was noted. Therefore, surgical revision remained unnecessary. CONCLUSIONS: Implant exposure following nonpenetrating antiglaucomatous surgery is a specific complication, which can appear whenever intrascleral implants are used. Depending on the local situation nonsurgical treatment may be successful.

Reproducibility of circadian retinal and optic nerve head blood flow measurements by Heidelberg retina flowmetry.

BACKGROUND/AIM: The Heidelberg retina flowmeter (HRF) is designed to measure retinal capillary blood flow. Previous studies however showed weak reproducibility of data. The intraindividual reproducibility of circadian HRF measurements was examined in healthy subjects in three locations of the retina. METHODS: 36 healthy volunteers (27.3 (SD 4.3) years) were examined by HRF seven times a day (t0-t6). Using a default window of 10 x 10 pixels, three consecutive measurements were performed in three precise focusing planes: superficial, intermediate and deep layer, peripapillary retina, neuroretinal rim and cup, respectively. Images of identical tissue locations identified by capillary landmarks of each layer were selected to quantify the retinal microcirculation of each volunteer. Means and standard deviations of all flow results of a given subject were calculated, at t0-t6 and the coefficients of variation as a measure of reproducibility. RESULTS: The coefficients of variation ranged between 8.4% and 41.0% in the superficial layer (mean 19.8% (SD 8.4%)), 10.6%, and 43.0% in the intermediate layer (mean 24.0% (SD 8.4%)), and 9.9% and 84.0% (mean 29.6% (SD 15.8%)) in the deep layer. CONCLUSIONS: These data show the best reproducibility of measurements in the superficial layer followed by the intermediate and the deep layer. Clinically, this is an unsatisfactory intraindividual reproducibility of flow values in each studied layer.

Retinectomy for treatment of intractable glaucoma: long term results.

AIM: To report long term efficacy and complications of retinectomy as an intraocular pressure lowering procedure for intractable glaucoma. METHODS: This was a consecutive interventional case series. In 44 consecutive eyes (39 patients, 22 men and 17 women) retinectomy was performed to lower the intraocular pressure (IOP) in patients with uncontrolled IOP (>35 mm Hg for more than 4 months) despite conventional filtering surgery and drug treatment. Pars plana vitrectomy was performed and the peripheral retina was surgically excised to various degrees. The procedure was concluded by an intraocular gas tamponade of 20% C(3)F(8). Included were patients with neovascular glaucoma (12 eyes), infantile and juvenile glaucoma (three eyes), secondary glaucoma due to aphakia (13 eyes), severe ocular trauma (seven eyes), uveitis (seven eyes), and glaucoma in Ehlers-Danlos syndrome (two). RESULTS: All patients underwent successful surgical retinectomy. All patients were followed for 5 years. Mean postoperative IOP after 4 years was 15.7 (SD 9.4) mm Hg, representing a decrease of IOP by 61% compared to the preoperative level (41.2 (9.4) mm Hg). In 52.3% of eyes long term regulation of IOP could be achieved without complications. Retinectomy was least effective in neovascular glaucoma because of central retinal vein occlusion (CRVO). Eyes with glaucoma secondary to uveitis showed a tendency towards low IOP levels with subsequent phthisis bulbi. The initial visual acuity of all patients was lower than 20/50 (mean 1.8 (0.8) logMAR) in the treated eye. Final visual acuity was 2.3 (0.6) logMAR. 21 out of 44 cases developed retinal complications (retinal detachment or proliferative vitreoretinopathy (PVR)) after surgery, requiring silicone tamponade in 11 eyes (52%) either for persistent low IOP or for PVR. Nine eyes developed phthisis, seven of which were enucleated during the follow up. CONCLUSIONS: Long term results after retinectomy demonstrate its efficacy in otherwise intractable glaucoma. Efficacy and safety of retinectomy are dependent on the underlying disease.

Photodynamic modulation of wound healing in glaucoma filtration surgery.

AIM: To report a clinical pilot study investigating photodynamic therapy (PDT) in combination with glaucoma filtration surgery. BCECF-AM was used as the photosensitising substance. The clinical safety and tolerability of BCECF-AM, and its efficacy in controlling postoperative intraocular pressure (IOP) were assessed. METHODS: Before trabeculectomy (TE), 42 consecutive eyes of 36 glaucoma patients received one subconjunctival injection of 80 micro g BCECF-AM (2,7,-bis- (2-carboxyethyl) -5- (and-6) -carboxy-fluorescein, acetoxymethyl-ester) followed by an intraoperative illumination with blue light (lambda = 450-490 nm) for 8 minutes. Antifibrotic efficacy was established as postoperative IOP reduction of >20% and/or an IOP constantly < 21 mm Hg without antiglaucomatous medication. Follow up of the filtering bleb was documented by slit lamp examination. RESULTS: Eyes had mean 1.1 preoperative surgical interventions (filtration and non-filtration glaucoma surgery). Mean preoperative IOP was 31.6 (SD 9.7) mm Hg. Patients were followed for mean 496 days (range 3.5-31.8 months). Of the 42 eyes, 25 eyes had an IOP decreased to 15.8 (3.4) mm Hg without medication (complete success: 59.5%; p<0.001; t test). Seven eyes showed good IOP reduction < 21 mm Hg under topical antiglaucomatous medication (qualified success: 16.7%). 10 eyes failed because of scarring within 2-67 weeks (23.8%). Clinical follow up examinations revealed no local toxicity, no uveitis, and no endophthalmitis. CONCLUSIONS: This method is a new approach in modulating postoperative wound healing in human eyes undergoing glaucoma filtration surgery. The data of the first human eyes combining TE with PDT underline the clinical safety of this method and its possible potential to prolong bleb survival.