CONTEMPORARY PRACTICES IN CATARACT SURGERY - SUBJECTIVE PREFERENCES OF CZECH CATARACT SURGEONS.

AIMS: The aim of the work was to find out the current subjective preferences of Czech cataract surgeons in terms of individual procedures, techniques and materials used during cataract surgery. MATERIAL AND METHODS: This study was conducted in the form of a questionnaire (online, a total of 44 questions). The survey respondents were members of the Czech Society of Refractive and Cataract Surgery. Questions 1-10 concerned the characteristics of the respondent (age, number of operations performed, type of workplace, etc.). Questions 11-20 focused on the surgical procedure used by the specific surgeon (anaesthesia, viscomaterial, position of the main incision, use of antibiotics at the end of the operation, etc.). Questions 21-34 concerned the type of intraocular lens used. Lastly, in questions 35-44, respondents were asked about their individual preferences if cataract surgery were to be performed on them. RESULTS: The questionnaire was fully or partially completed by 72 surgeons (26% of the originally approached subjects). Most of the respondents were experienced surgeons, 74.5% of them have been performing surgeries for more than 10 years, out of which 55.5% perform more than 500 operations per year. The average age of the respondents was 50 years. 65.3% of surgeons use hydroxypropylmethylcellulose during surgery, 74% do not use a femtosecond laser for surgery, 50% never perform posterior circular capsulorhexia, and 98% apply antibiotics to the anterior chamber at the end of surgery. Surgeons predominantly use hydrophobic (80.8%), aspherical (72.3%), clear (54.3%), single-focal (97.9%) and non-preloaded (78.3%) lenses. However, if they were not limited or restricted in any way in their choice, they would prefer aspherical lenses (94.6%), multifocal or extended-focus lenses (78%) and preloaded lenses (96.8%). CONCLUSION: The subjective preferences of Czech cataract surgeons are relatively variable regarding the individual steps. Often the procedures used do not always correspond with the actual preferences of the surgeon. On the contrary, there is almost complete unity in the steps recommended by professional societies (intracameral antibiotics at the end of the operation).

Plasma osteopontin levels, but not its myocardial expression, reflect heart failure severity in recently diagnosed dilated cardiomyopathy.

BACKGROUND: Elevated levels of the extracellular matrix glycoprotein osteopontin (OPN) may be detected in both myocardium and plasma under various pathological conditions affecting the heart. Several studies demonstrated increased plasma OPN levels in patients with heart failure due to dilated cardiomyopathy (DCM), while other studies showed high OPN expression levels in the myocardium of such patients. However, very little is known about OPN levels in both plasma and myocardium of the same individual with DCM. Therefore, we aimed to compare plasma OPN levels and levels of myocardial OPN expression in patients with recent-onset DCM (Ro-DCM). METHODS: We examined plasma OPN as well as creatinine, C­reactive protein (CRP), brain natriuretic peptide (BNP), and troponin I levels in 25 patients with Ro-DCM. Furthermore, all subjects underwent transthoracic echocardiography, selective coronary angiography, and endomyocardial biopsy (EMB) for the assessment of myocardial OPN expression. RESULTS: No significant correlation between myocardial OPN expression and clinical, biochemical, or echocardiographic parameters was found. In log transformation analysis, plasma OPN levels correlated significantly with BNP levels (r = 0.46, p = 0.031), with CRP levels (r = 0.52, p = 0.015), and with early diastolic mitral annular velocity (r = -0.57, p = 0.009). There was a borderline association between the plasma OPN log value and New York Heart Association class (p = 0.053). CONCLUSION: Plasma OPN levels reflect heart failure severity in patients with Ro-DCM. Myocardial OPN expression is not associated with either plasma OPN levels or markers of heart failure in these individuals.

Plasma osteopontin levels in patients with dilated and hypertrophic cardiomyopathy.

BACKGROUND: Osteopontin (OPN) is an extracellular matrix glycoprotein that plays a role in a variety of cellular activities associated with inflammatory and fibrotic responses. Increased OPN levels in myocardium and plasma have been demonstrated in patients with dilated cardiomyopathy (DCM). However, nothing is known about OPN levels in patients with hypertrophic cardiomyopathy (HCM). Therefore, the aim of our study was to compare plasma OPN levels in patients with these two most common cardiomyopathies. PATIENTS AND METHODS: We examined plasma OPN as well as creatinine, C­reactive protein (CRP), brain-type natriuretic peptide (BNP), and troponin I levels in 64 patients with DCM, 43 patients with HCM, and 75 control subjects. Transthoracic echocardiography was also performed on all cardiomyopathy patients. RESULTS: Plasma OPN levels were significantly elevated in patients with DCM compared with HCM patients (95 ± 43 vs. 57 ± 21 ng/ml; p < 0.001) and control subjects (54 ± 19 ng/ml; p < 0.001); however, there was no difference between HCM patients and control subjects. New York Heart Association (NYHA) class III or IV disease was more frequently present in DCM patients than in HCM subjects (44 % vs. 2 %, p < 0.0001). In multivariate analysis, BNP and CRP levels together with NYHA class were found to be significant predictors of plasma OPN levels in DCM patients (p = 0.002, p = 0.029, and p < 0.001 for BNP, CRP, and NYHA, respectively). CONCLUSION: Plasma OPN levels were associated with overall heart failure severity rather than with specific cardiomyopathy subtype in patients suffering from DCM or HCM, respectively.

Utility of cardiac CT for evaluating delayed contrast enhancement in dilated cardiomyopathy.

BACKGROUND: The presence of myocardial fibrosis is associated with adverse outcome in dilated cardiomyopathy (DCM). Delayed contrast-enhanced cardiac magnetic resonance (DE-CMR) currently represents the gold standard in noninvasive evaluation of myocardial scarring. However, a significant number of patients are unable to undergo DE-CMR study for various reasons. We sought to determine the diagnostic accuracy of cardiac CT (CCT) compared with CMR in the investigation of the presence of delayed contrast enhancement (DCE) in subjects with DCM. METHODS: We prospectively enrolled 17 consecutive patients with DCM, who were initially referred to our institution because of recently manifested heart failure due to unexplained left ventricular systolic dysfunction. In all subjects, CCT and DE-CMR were performed within 1 week. RESULTS: CCT and DE-CMR showed satisfactory agreement in detecting DCE (agreement in 82% cases, κ = 0.56) with 50% sensitivity, 100% specificity, and a positive predictive value of 100%. CONCLUSION: CCT may be a valuable method for detecting DCE in patients with DCM. CCT thus might be considered as an alternative method to DE-CMR in the assessment of the presence and extent of myocardial fibrosis in subjects who are not suitable for DE-CMR examination.

[Historic Survey of Posterior Lamellar Keratoplasty Techniques - an Overview]. / Historický prehled technik zadní lamelární keratoplastiky.

Some of the modifications of posterior lamellar keratoplasty is at the present considered by most of the corneal surgeons as method of choice in case of patients corneal endothelium damage. However, this surgical technique undergoes in the last 20 years relatively rapid development. Even in the current time, there exist side by side and are used different types and modifications of this sort of transplantation. Because of this reason, differences among individual methods are sometimes not accurately understood and the terminology may be used not exactly as well. The authors specify all until now described surgical methods, describe differences among single surgical procedures, and point out their advantages and disadvantages. The methods are described in the same order as they were historically introduced into the literature.Key words: posterior lamellar keratoplasty, surgical methods.

[Clinical Results after Continuous Corneal ring (MyoRing) Implantation in Keratoconus Patients]. / Výsledky implantace plného rohovkového krouzku (MyoRing) v lécbe keratokonu.

PURPOSE: to present one and two years clinical results after intrastromal continuous corneal ring implantation in keratoconus patients. METHODS: Retrospective evaluation of the results of patients with keratoconus, after MyoRing implantation for improving of visual functions. The uncorrected distance visual acuity (UDVA), best corrected distance visual acuity (CDVA), the residual subjective refractive error, pachymetry, keratometry and the size of corneal astigmatismus were evaluated. Peroperative and postoperative complications were investigated. The minimal follow-up time was 12 months. RESULTS: The study included 32 eyes of 30 patients with mean age of 30.08 (± 11.56) years. UDVA improved from 1.03 (± 0.41) logMAR to 0.36 (± 0.25) logMAR 12 months and 0.31 (± 0.27) logMAR 24 months after surgery. These changes were stastistically significant. The maxima value of corneal curvature (Kmax) was preoperatively 52.48 (± 6.35) D, 46.08 (± 4.44) D 12 months and 45.53 (± 5.52) D 24 months after surgery. Both changes were statistically significant (P ˂ 0,00000). The mean value of corneal curvature (K mean) was preoperatively 50.10 (± 4.96) D, 44.25 (± 4.40) D 12 months and 44.11 (± 5.38) D 24 months after surgery. Both changes were statistically significant. In any of the patients we did not register any severe peroperative or postoperative complication. CONCLUSION: The MyoRing implantation is an effective and safe method in improvement of visual functions in keratoconus patients. Clinical results are stable in one and two years follow-up time.

[Corneal transplantations in the Czech Republic in 2012]. / Transplantace rohovek v Ceské republice v roce 2012.

OBJECTIVE: To determine the frequency of corneal transplantations in the Czech Republic in 2012, the percentage representations of the different types of surgeries and main indications for corneal transplantation. METHODOLOGY: All clinics performing the corneal transplantations were asked to complete a questionnaire about the number of corneal transplants, types of surgeries and indications for such procedures. The obtained data were compared with the annual report of corneal banks for the year 2012. RESULTS: Data for 465 transplantations were analyzed, it represents 92, 8 % of all corneas issued by the corneal tissue banks. The most common indication for corneal transplantation (regardless of type) was bullous keratopathy (40 % of cases), then keratoconus and other ectatic diseases (19,1 %) and endothelial dystrophy (16,1 %). The most common type of translation was penetrating keratoplasty (50,75 %), then posterior lamellar keratoplasty (44, 95 %) and anterior lamellar keratoplasty (4,3 %). CONCLUSION: Acquired data confirm increasing proportion of lamellar transplantations among all corneal keratoplasties, especially posterior lamellar keratoplasty. This approach probably affects indications, for which keratoplasties are made. Keratoplasties are indicated significantly due to endothelial corneal dystrophies such as bullous keratopathy and other endothelial dystrophies. Keratoconus represents approximately 20 % of indications to corneal transplantation.

Genetic variation screening of TNNT2 gene in a cohort of patients with hypertrophic and dilated cardiomyopathy.

Mutations in troponin T (TNNT2) gene represent the important part of currently identified disease-causing mutations in hypertrophic (HCM) and dilated (DCM) cardiomyopathy. The aim of this study was to analyze TNNT2 gene exons in patients with HCM and DCM diagnosis to improve diagnostic and genetic consultancy in affected families. All 15 exons and their flanking regions of the TNNT2 gene were analyzed by DNA sequence analysis in 174 patients with HCM and DCM diagnosis. We identified genetic variations in TNNT2 exon regions in 56 patients and genetic variations in TNNT2 intron regions in 164 patients. Two patients were found to carry unique mutations in the TNNT2 gene. Limited genetic screening analysis is not suitable for routine testing of disease-causing mutations in patients with HCM and DCM as only individual mutation-positive cases may be identified. Therefore, this approach cannot be recommended for daily clinical practice even though, due to financial constraints, it currently represents the only available strategy in a majority of cardio-centers.

[Long term efficiency of a deep sclerectomy with T-flux implant]. / Efektivita hluboké sklerektomie s implantaci T-Fluxu--dlouhodobé výsledky.

PURPOSE: To evaluate a long term efficiency of a deep sclerectomy with T-Flux implant on intraocular pressure METHODS: Retrospective noncomparative analysis of glaucomatic patients from our ambulance who underwent deep sclerectomy combined with T-flux implantation. The main postoperative outcome measures were intraocular pressure (IOP), number of treatments and Nd:YAG goniopunctures. RESULTS: Mean preoperative IOP was 26.7 (+/- 0.8) mmHg, mean postoperative IOP was 17.4 (+/- 0.8) at month 6, 16.5 (+/- 0.7) at month 12, 16.9 (+/- 0.9) at month 24, 17.2 (+/- 1.0) at month 36, 18.6 (+/- 1,1) at month 48, 17.6 (+/- 1.1) at month 60 and 18.3 (+/- 1.8) at month 72. Mean preoperative number of medications per patient was reduced from 2.5 (+/- 0.13) to 0.73 (+/- 0.13) at month 6, 1.02 (+/- 0,13) at month 12, 1.1 (+/- 0.15) at month 24, 1.0 (+/- 0.18) at month 36, 1.22 (+/- 0.18) at month 48, 1.68 (+/- 0,2) at month 60, 1.8 (+/- 0.3) at month 72. Four patients (10%) underwent early goniopuncture and six patients (15%) late goniopuncture. CONCLUSION: Deep sclerectomy combined with T-Flux implant appears to be a relatively safe antiglaucomatic surgery with a minimum number of complications, high predictability of the result and a very good long term effectivity.

Levels of circulating biomarkers at rest and after exercise in coronary artery disease patients.

As traditional risk factors are unable to fully explain the pathogenesis of coronary artery disease (CAD), novel mechanisms became a target of many investigations. Our aim was to study the response of selected markers to physical exercise. High-sensitive C-reactive protein (hs-CRP), matrix metalloproteinases 2 and 9 (MMP-2, MMP-9), advanced oxidation protein products (AOPP), soluble receptor for advanced glycation end-products (sRAGE), pregnancy-associated plasma protein A (PAPP-A), E-selectin, vascular endothelial growth factor (VEGF) and B-type natriuretic peptide (BNP) levels were measured in serum of 21 CAD patients and in 22 healthy controls at rest and after exercise bicycle stress test performed up to the maximal tolerated effort. At rest, hs-CRP, AOPP, MMP-9 and BNP were significantly elevated in the CAD patients as compared with controls. In contrast, P-selectin was significantly lower in CAD patients and a tendency to lower levels of sRAGE was noted. After exercise MMP-9 and BNP, increased significantly in both groups. In conclusions, CAD patients have elevated hs-CRP, AOPP, MMP-9 and BNP--novel markers related to cardiovascular risk or left ventricular overload. MMP-9 and BNP increase significantly with exercise in both healthy individuals and CAD patients.

[The follow up of prognostic important factors and analysis of five years survival rate in patients with uveal melanoma at the Department of Ophthalmology, 3rd Medical Faculty Charles University in Prague and the Faculty Hospital Královské Vinohrady in Prague]. / Sledování prognosticky významných faktoru a analýza petiletého prezití pacientu s uveálním melanomem na Ocní klinice 3. LF UK a FNKV.

The analysis of survival and the influence of the followed up prognostic important factors to the duration of survival in 51 patients with uveal melanoma, treated by enucleation of the eyeball was evaluated by means of Kaplan-Meier analysis and Cox regression model. The study was performed at the Department of Ophthalmology of the 3rd Medical Faculty, Charles University in Prague and the Faculty Hospital Královské Vinohrady in Prague, Czech Republic, E.U., during the period 1999 to 2007. The mortality rate with the association to the general diagnosis was 35.5%. By means of the statistical analysis of survival, (Kaplan-Meier analysis) we established that these followed up prognostic factors are important for the duration of the survival period: pTNM (pathologic tumor-node-metastasis) (p = 0.00032), the size of the tumor (p = 0.01603), mitotic activity (p = 0.028889), and the rupture of the Bruch's membrane (p = 0.1446). The Cox regression model specifying which of the independent entry values correlates mostly with the period of survival, or the date of death respectively, showed that the strongest correlations with the period of survival duration had in our group the pTNM classification.

[The isolated form of cardiac amyloidosis in the form of beginning infiltrative cardiomyopathy without restrictive physiology]. / Izolovaná forma srdecní amyloidózy v podobe pocínající infiltrativní kardiomyopatie bez restriktivní fyziologie.

The authors describe an interesting case of isolated cardiac manifestation of AL-amyloidosis manifesting as an incipient infiltrative cardiomyopathy with heart failure symptoms due to moderate left ventricular diastolic dysfunction. Restrictive cardiomyopathy with severe diastolic dysfunction is considered as the characteristic manifestation of fully developed cardiac amyloidosis. However, the organ deposition of amyloid is progressive and left ventricular filling worsens continuously, starting with less advanced forms of diastolic dysfunction; the restrictive physiology is characteristic only for advanced phases of the disease. Therefore, the possibility of the incipient infiltrative cardiomyopathy due to the amyloidosis should be considered in patients with heart failure symptoms and echocardiographic findings of unexplained left ventricular hypertrophy with only mild or moderate diastolic dysfunction.

Intraocular astrocytoma without phacomatosis.

PURPOSE: Astrocytic tumors occur in the retina or in the optic disc usually as a part of tuberous sclerosis complex or other phacomatosis and their isolated occurrence is rare. The authors present two adult patients in whom the diagnosis of intraocular astrocytoma was established but no signs of phacomatosis were revealed.

[Congenital cataract--the growth of the eyeball after the PC IOL implantation]. / Kongenitální katarakta--rust oka po implantaci PC IOL.

The authors followed the influence of PC IOL (posterior chamber intraocular lens) implantation in congenital cataract to the growth of the eyeball (six bilateral cataracts and 6 monolateral cataracts). The development of the eye growth was compared to the 6 healthy eyes of patients of this group. The intraocular lens implantation was performed at the age of 1 to 5.5 year, in average at the age of 3 years. The follow up period was 4 to 7 years, mean 6 years. In operated, as well as in non-operated eyes, an equal average growth of the eyeball 0.2 mm per year was detected. All operated eyes were slightly hypermetropized according to the physiological values of growth of healthy eyes. The absolute mean deviation from emmetropia was 1.8 diopters. The author established the suitability of intraocular lens implantation in small children because of positive influence to the growth as well as to the final visual acuity, which ranged from 0.05 to 1.0, mean 0.4.

[Angiolymphoid hyperplasia with eosinophilia or Kimura disease?]. / Angiolymfoidní hyperplazie s eozinofilií nebo Kimurova choroba?

Angiolymphoid hyperplasia with eosinophilia (ALHE) and Kimur's disease are two rarely occurring and mutually very similar, yet independent nosological units. For the frequency of similar features these diseases were long considered to be modifications of one disease. In the last years most authors considered these diseases to be independent entities with certain specific clinical and morphological features. The case of a 76-year white man, suffering from occurrence of subcutaneous tumor formations in various part of the body for the period of six years, is described. Six years after the first signs of the disease, swelling of eyelids on the right eye with palpable resistance under the upper temporal margin of eye socket developed. A similar finding also developed on the left side eight months later. The tumors were removed by surgery and subjected to histological examination. One year later a unilateral relapse developed to be again subjected to surgical treatment and histological examination. In the first two orbital excisions the tumor infiltrate was in topical connection with structure of the tear gland, the third excision did not contain such structures. The histological diagnosis was established as ALHE in spite of some common features with the Kimur's disease. The diagnosis of ALHE was especially supported by absence of the formation of lymphatic follicles, absent fibrotization in the infiltrate and epithelium-like or even histiocyte-like appearance of proliferating endothelia, which formed minute vascular lumina. A substantial exceptionality in the occurrence of the Kimur's disease in white Europeans further supported the diagnosis of ALHE. Our own experience indicates that both units mutually overlap even in features considered to be of distinctly different character. A question arises, whether the strict division of these two nosological units is really possible in practice with unequivocal certainty.

[Indications for refractive procedures in adult patients with strabismus and results of the subsequent therapeutic procedures]. / Indikace refrakcního výkonu u dospelých pacientu se strabismem a výsledky následného lécebného postupu.

The authors estimated the contribution of the refraction intervention and a possible evolution in the position of eyes in 102 adult individuals considering a refraction intervention. The indications for this intervention were a disorder in eye position or amblyopia in those who were interested in this operation and were examined in the years 1996 to 2002. The basic refraction examination was always supplemented by a detailed orthoptic analysis. Based on this examination the intervention was not recommended in 14 examined subjects (14%). ARK represented the contraindication of the refraction intervention in 9 patients, since subsequent changes in the size of the deviation or operation adjustment of strabismus could result in diplopia. An excessive convergence with a high AC/A in hyperopia was also considered as an unsuitable indication, since a lasting cosmetic and functional significant convergent deviation into near distances could not be excluded. Five patients declined from the refraction intervention on the basis of this explanation. The paper is mainly dealing with an analysis of the development of position of the eyes and binocular functions in 46 adult patients, who decided to undergo a refraction intervention and further orthoptic care after a complex stroboscopic and refraction examination. The adjustment of refractive error was made by the LASIK methods (Laser in Situ Keratomileusis) on 69 eyes (80%) and CLE (Cleans Lens Extraction) on 17 eyes (20%). The orthoptic analyses before and the refraction intervention revealed that in all 29 even only partially accommodating esotropia, the deviation was diminished after the refraction intervention on the average by +11.2 degrees (in the rage of +2 degrees to +30 degrees) to 5.4 degrees (in the range of parallel position to +20 degrees) in the predominantly represented hyperopia, but also in 6 myopias. The improved position of the bulbs was not directly associated with the degree of hyperopia with the original deviation. The deviation after the refraction intervention in 23 patients (79%) with esotropia was not higher than degrees. The cosmetic position of the eyes was completely satisfactory and did not therefore represent even indication for the operation. The 9 patients (35%) with esotropia and hyperopia there were an improvement of binocular functions. It could be theoretically due to the newly developed emetropia making permanent optimal sensory information possible. In all 17 exotropias there were not any significant changes in the size of deviation and the binocular functions were not reestablished, if they were not retained before. The position of eyes was solved surgically in 12 patients, while exotropia predominated in two thirds of them. The weakening or strengthening interventions on horizontal straight muscles were selected according to character of strabismus in 11 patients. Recession of the lower oblique muscle was indicated one case only for the simultaneously present torticollis with exotropia. The residual deviation was not greater than 5 degrees immediately after the operation or during the following months. Binocular functions were not reestablished in any patients. A alternate suppression or suppression of perception on one eye were proved.

[Spontaneous reduction and absorption of cataracts in childhood]. / Spontánní redukce a absorpce katarakt v detském veku.

The authors give an account on spontaneous reduction and absorption of cataracts in nine children. The initial symptom where leukocoria predominated was as a rule detected already in infant age. In one case the affection was bilateral and was manifested by partial pseudoaphakia. The observation comprised also classical secondary aphakia in a 4-year-old girl. Resorption of lenticular masses of cataracts into the shape of membranous discs or reduced masses of a fibrous character took on average 18 months on seven eyes and this process was associated with vascular activity in four lenses. In two of these patients during resorption panuveitis was observed with a hyperergic response in humoral and cellular immunity without obvious general antigenic action which caused atrophy of the optic nerve. Surgical solution of cataract was used in four eyes, PC IOL was implanted in one patient which had a favourable effect on visual function. Histological examination was successful of the extracted reduced lens only in one case. Inside the lenticular capsule was a mixture of the original fibrotically altered cataract masses with ingrowing vascular tissue.

[Implantation of the AcrySof MA30BA lens using the Monarch system]. / Implantace cocky AcrySof MA30BA systémem Monarch.

The authors describe experiences with implantation of the intraocular lens AcrySof MA30BA by the Monarch IOL delivery system. They consider the facility of Monarch's system completion, the location of the lens in the cartridge and its folding, lens passage through the cartridge and its expansion intraocculary. The authors evaluate the width of incision necessary for the conduction of injector, preoperative and postoperative course, final visual acuity and inducted astigmatism. The results of the work show that implantation of the lens AcrySof MA30BA by the IOL Monarch delivery system is easy and safe. The width of incision after implantation performs criterion of the no stitch technique and corresponds contemporary requirements of the modern cataract surgery of small incision.