[Possibilities and limitations of eye drops for glaucoma therapy]. / Möglichkeiten und Grenzen der medikamentösen Glaukomtherapie.

BACKGROUND: In Germany, chronic open-angle glaucoma is mostly treated by daily eye drop application. The possibilities and limitations of this form of therapy are presented. Reasons for the change in the selection of the preferred substances over time are also discussed and the limits of local drug therapy are described. OBJECTIVES: What effects can be expected of the available drugs? MATERIALS AND METHODS: The article provides a review of the literature from PubMed and clinical experience. RESULTS: In chronic open-angle glaucoma, eye drops containing a single agent can achieve an intraocular pressure decrease of 15-35 % compared to the initial pressure level. This is dependent on the substance and is achievable when used as directed. Difficulties in administration are often observed in older patients where regular use over extended periods of time is required. In addition, there are limits in the achievable pressure reduction by combining several active ingredients. Novel systems are being developed for future applications. The idea is to achieve a continuous slow release of the active substance by surgical application of a biodegradable carrier. CONCLUSION: A treatment regimen which is individually tailored to the individual patient's needs should be developed by the attending physician and the achievement of the set objectives should be monitored at regular intervals. However, restrictions induced by patients due to inadequate adherence or by the drug due to limited efficacy of the drug have to be considered. Therefore, eye drop therapy in open-angle glaucoma is not always sufficient. It should be supplemented in due time by laser or filtering surgery before the affected patients and their optic nerves suffer advanced glaucomatous damage.

[Possibilities and limitations of glaucoma surgery]. / Möglichkeiten und Grenzen der operativen Glaukomtherapie.

BACKGROUND: Glaucoma is the second leading cause of blindness worldwide and in many cases cannot be adequately controlled with conservative treatment. MATERIALS AND METHODS: Schematic evaluation of various surgical techniques. RESULTS: Trabeculectomy is the gold standard of glaucoma surgery and requires close follow-up care. Novel, minimally invasive procedures are suitable for patients with moderately advanced, uncomplicated stages of the disease, whereas filtrating tube implants or cyclodestructive techniques are required in patients with complex glaucoma. CONCLUSION: Various surgical techniques are available and have their specific indication window for the glaucoma surgeon, depending on the severity, progression, and risk factors of the disease.

[Mastered with statistics: perfect eye drops and ideal screening test : Possibilities and limits of statistical methods for glaucoma]. / Mit Statistik gemeistert: perfekte Augentropfen und idealer Screeningtest : Möglichkeiten und Grenzen statistischer Methoden beim Glaukom.

BACKGROUND: The use and the understanding of statistics are very important for biomedical research and for the clinical practice. This is particularly true for estimation of the possibilities for different diagnostic and therapy options in the field of glaucoma. The apparent complexity and contraintuitiveness of statistics along with a cautious acceptance by many physicians, might be the cause of conscious and unconscious manipulation with data representation and interpretation. OBJECTIVES: Comprehendable clarification of some typical errors in the handling of medical statistical data. MATERIALS AND METHODS: Using two hypothetical examples from glaucoma diagnostics the presentation of the effect of a hypotensive drug and interpretation of the results of a diagnostic test and typical statistical applications and sources of error are analyzed in detail and discussed. RESULTS: Mechanisms of data manipulation and incorrect data interpretation are elucidated. Typical sources of error in the statistical analysis and data presentation are explained. CONCLUSION: The practical examples analyzed demonstrate the need to understand the basics of statistics and to be able to apply them correctly. The lack of basic knowledge or half-knowledge in medical statistics can lead to misunderstandings, confusion and wrong decisions in medical research and also in clinical practice.

[Spontaneous closure of traumatic macular holes. Two cases]. / Spontanverschluss traumatischer Makulaforamina: Zwei Fälle.

The optimal treatment approach for traumatic macular holes (TMH) is still controversial. We report two cases of spontaneous closure of TMH. In the first patient, closure resulted in an increase in visual acuity from 0.2 to 0.8. In the second case, no increase in visual acuity was detectable despite spontaneous closure of the TMH within a few days after the trauma. This may be explained by an irreversible damage of the photoreceptors and retinal pigment epithelium. In patients with TMH, a waiting approach should be considered because of the possibility of spontaneous closure of TMHs.

[Diffuse stromal corneal opacity and alterations of the hands]. / Diffuse stromale Hornhauttrübungen und Veränderungen der Hände.

Bilateral stromal corneal opacity is a differential diagnostic challenge for ophthalmologists. In this article 2 female patients aged 30 and 36 years old, respectively, with different degrees of expression of stromal diffuse corneal opacity will be presented. Patient 1 was of short stature (114 cm) and patient 2 was 172 cm in size. Both patients exhibited altered joint structures of the hands and feet and diffuse stromal corneal opacity. Furthermore, patient 1 had both mitral and aortal insufficiencies and patient 2 an aorta insufficiency. The stromal diffuse corneal opacity was indicative of Schleie syndrome. For patients with reduced vision a lamellary keratoplasty is to be recommended.

[Temporal oscillations of retinal vessel diameter in healthy volunteers of different age]. / Zeitliche Schwingungen retinaler Gefässdurchmesser bei Gesunden unterschiedlichen Alters. Kreuz- und Autokorrelation für dynamische Gefässanalyse.

PURPOSE: We investigated whether temporal oscillations of the retinal vessel diameter, as measured with the dynamic vessel analyzer (DVA), undergo age-related changes. METHODS: Vessel diameters of retinal arterial and venous segments were examined with the DVA in 28 medically healthy volunteers divided into two age groups of 14 persons each: young subjects (21-32 years) and seniors (52-70 years). Continuous temporal records of vessel diameter were mathematically evaluated and divided into high-frequency (period <1.5 s) and low-frequency (period > or =1.5 s) oscillations. RESULTS: The phase difference between temporal arterial and venous vessel diameter records was higher in the young group [0.6 (0.1, 3.3)] s [median (1st quartile, 3rd quartile)] compared with the seniors [0.1 (-0.4, 0.3) s]. There was a difference in the periodicity in veins between the groups and, in seniors, between the arteries and the veins. CONCLUSIONS: High-frequency oscillations of vessel diameter correspond to the heartbeat. These were expressed more in seniors. Low-frequency oscillations were well expressed in young subjects. Our results show significant age-related alterations in retinal vessel regulation.

[Anisocoria and nausea]. / Anisokorie und Ubelkeit.

We present the case of a 40-year-old female patient with sudden onset of anisocoria and unilateral ptosis of the left eye. With the exception of several previous episodes of nausea and vomiting, mild headache and tiredness, combined with the early death of the patient's mother following aortic rupture, patient history and clinical condition showed no pathological findings. Following indicative findings on duplex sonography, a dissection of the left internal carotid artery from its origin to its distal section was detected on CT angiography of the brain vessels and the diagnosis of Horner syndrome due to internal carotid artery dissection was made. Since this condition is associated with serious embolic complications, prompt treatment following diagnosis is of utmost importance. Our patient was treated conservatively using PTT (partial thromboplastin time)-effective heparinisation. Regular checks including kidney ultrasound, blood pressure measurement, imaging and continuous therapy with acetylsalicylic acid are recommended.

[Botulinum toxin injection for production of ptosis]. / Botulinumtoxin-Injektionen zur Erzeugung einer Ptosis.

Selective muscles can be paralysed or weakened for a limited time period using botulinum toxin type A. The upper eyelid muscles can be a target, leading to a temporary protective ptosis. In this report we discuss indications for this application, describe how to perform the injection, and present results. The procedure is safe and effective.

Retinal vessel reaction to short-term IOP elevation in ocular hypertensive and glaucoma patients.

PURPOSE: Regulation of ocular blood flow might be impaired in glaucoma patients. We compared the reaction of retinal vessels to a short-term increase of intraocular pressure (IOP), using a retinal vessel analyzer (RVA), in normal volunteers, ocular hypertensive patients (OH) and primary open angle glaucoma patients (POAG). METHODS: Ten healthy subjects (56+/-8 years, IOP 13.7+/-1.6 mmHg), 10 OH patients (55+/-12 years, IOD 23.4+/-4.1 mmHg) and 11 POAG patients (60+/-11 years, IOP 23.3+/-1.95 mmHg) were evaluated. Arterial and venous retinal vessel diameter was measured continuously before, during and after raising IOP to suprasystolic values by the suction cup method, described as ocular oscillo-dynamography. RESULTS: The change in vessel diameter after the IOP rise differed in its temporal sequence and in absolute values depending on the group examined. In the retinal branch veins the reduction of vessel diameter during the IOP rise was significantly different in POAG (0%+/-6.7) and volunteers (-6.7%+/-8.5; p = 0.06) and in POAG and OH (-6.7%+/-7.0; p = 0.04). At 70-130 sec after IOP increase a dilatation occurred, again differing significantly in POAG (+5.8%+/-3.9) and volunteers (+9.7%+/-4.3; p = 0.03). Systemic blood pressure did not show any significant differences between groups or during the course of the examination. DISCUSSION: At short-term rise in IOP leads to less retinal vessel reaction in POAG patients than in volunteers and OH. This might be due to impaired autoregulation to ocular perfusion changes in POAG patients.

[Retinal vessel reaction to 100% O2-breathing--functional imaging using the retinal vessel analyzer with 10 volunteers]. / Reaktion retinaler Gefässdurchmesser auf 100% O2-Atmung--funktionelle Messung mit dem Retinal Vessel Analyzer an 10 Probanden.

BACKGROUND: Retinal vessel diameter assessment is complicated by various components among them dynamic changes due to vasomotoric effects. Measurement of these diameters was usually obtained from fundus photographs. Functional diameter changes induced by external stimuli were difficult to evaluate because of their dynamic nature. The Retinal Vessel Analyzer (RVA) allows continuous on-line measurement of those dynamic changes. Whether functional changes due to 100% O2 breathing can be assessed by RVA is investigated in this study. MATERIALS AND METHODS: Continuous on-line registration of retinal arterial and venous branch vessels was obtained in 10 healthy volunteers. A baseline was taken during the first minute. Then for 5 minutes 100% O2 was delivered by mask. Further recording ensued for 4 minutes, while breathing room air. Vessel diameter change in percent to baseline was calculated for each individual and for a mean of the group. RESULTS: Each individual demonstrated vasoconstriction. The mean diameter reduction for the group was 6.5% for arteries and 15% for veins. CONCLUSIONS: RVA allows assessment of functional retinal branch vessel reactions. Retinal branch vessels diameters are denominators for capillary perfusion. RVA might be able to demonstrate an individual vessel's regulation potential by purposeful stimulation to constrict and dilate. This property could be helpful in understanding pathophysiologic processes as well as improving diagnosis and therapeutic effects in diseases influencing ocular perfusion such as diabetes, retinal vessel occlusion or even glaucoma. Further evaluation of effects of systemic diseases might be an additional application of functional retinal vessel diameter assessment by RVA.

Does head positioning influence anterior chamber depth in pseudoexfoliation syndrome?

PURPOSE: Phacodonesis can occur in pseudoexfoliation syndrome because of impaired zonular support. This study investigates whether the increased mobility of the lens influences anterior chamber depth in patients with pseudoexfoliation while assuming a prone position. METHODS: Central anterior chamber depth was measured in 39 patients with clinically apparent unilateral pseudoexfoliation and elevated intraocular pressure. Patients were placed in a face-up position for 5 minutes, at which time anterior chamber depth and axial length were measured by A scan, and intraocular pressure was measured by Tonopen (Oculab, La Jolla, CA) in both eyes. The measurements were repeated on both eyes after 5 minutes in a face-down position. RESULTS: No significant differences in intraocular pressure or axial length between the prone and supine positions were found in either eye. Anterior chamber depth in eyes with pseudoexfoliation decreased from a mean of 3.08 mm in the supine position to a mean of 2.95 mm in the prone position, whereas mean anterior chamber depth in the fellow eyes decreased from 3.01 mm to 2.97 mm. The decrease in anterior chamber depth when facing down in the eyes with pseudoexfoliation was significantly greater than in the fellow eyes. CONCLUSIONS: In patients with clinically apparent unilateral pseudoexfoliation, the lens seems to be more mobile in the affected eye. This results in a shallower anterior chamber when the head is placed in a prone position. Whether this fact might potentially lead to transient pupillary block when engaging in activities such as facing down while reading warrants further study.

Outcome of trabeculectomy with mitomycin-C in the iridocorneal endothelial syndrome.

PURPOSE: Eyes with iridocorneal endothelial (ICE) syndrome have a high risk of failure in glaucoma filtering surgery failing. We investigated the efficacy of trabeculectomy with intraoperative mitomycin-C application in these patients. DESIGN: Retrospective nonrandomized comparative trial with historical controls. PARTICIPANTS AND CONTROLS: Ten patients with unilateral iridocorneal endothelial (ICE) syndrome were reviewed. Their intraocular pressures could not be controlled medically. In five eyes, this was the primary surgery performed. Five of the patients had undergone prior intraocular pressure-(IOP) lowering surgery that had failed at the time enrolled. Results were compared with previously published case series of similar patients treated with trabeculectomy alone or trabeculectomy and subconjunctival 5-fluorouracil injections. INTERVENTION: Intervention consisted of trabeculectomy with a limbus-based conjunctival flap and mitomycin-C application. The dosage of mitomycin-C was 0.4 mg/ml for 1 to 4 minutes (mean, 1.9 min). MAIN OUTCOME MEASURES: Adequate control of IOP (without medication lower than 21 mm Hg). RESULTS: In eight eyes the IOP remained well controlled (mean IOP, 12.1 mm Hg) over the entire length of available of follow-up (mean, 14.9 months). Two eyes required implantation of an aqueous tube shunt at 4 and 11 months, respectively, after trabeculectomy with mitomycin-C. One eye experienced visual loss of 3 Snellen lines because of hypotony maculopathy. CONCLUSIONS: Trabeculectomy with mitomycin-C application offers a reasonable intermediate-term success rate in ICE patients, who are otherwise at high risk for failure of filtering surgery.

Detection of changes of the optic disc in glaucomatous eyes: clinical examination and image analysis with the Topcon Imagenet system.

PURPOSE: This study was designed to evaluate the clinical agreement in the detection of optic disc changes and the ability of computerized image analysis to detect glaucomatous deterioration of the optic disc. METHODS: Pairs of stereophotographs of 35 glaucomatous optic discs taken 5 years apart and of 5 glaucomatous discs photographed twice on the same day. Two glaucoma specialists examined the pairs of stereophotographs (35 cases and 5 controls) in a masked manner and judged whether the optic disc showed changes in the optic disc compatible with progression of glaucomatous damage. The stereophotographs of the five optic discs photographed twice on the same day (which by definition did not change) and of five cases judged to have deteriorated by both glaucoma specialists were analyzed by computerized image analysis with the Topcon ImageNet system. Intra- and inter-observer agreement in the detection of optic disc changes (evaluated using kappa statistic), and changes in the rim area to disc area ratio (evaluated using descriptive statistics and paired t-test). RESULTS: Intra-observer agreement had a kappa value of 0.75 for observer 1 and 0.60 for the observer 2. Inter-observer agreement between the glaucoma specialists had a kappa value of 0.60. The image analyzer did not discriminate between controls and cases with clinically apparent glaucomatous change of the optic disc. CONCLUSION: Clinical agreement in detecting changes in the optic disc was moderate to substantial. Computerized image analysis with the Topcon ImageNet system appeared not to be useful in detecting glaucomatous changes of the optic disc.

Autologous patch graft in tube shunt surgery.

PURPOSE: To evaluate an alternate method of covering the subconjunctival portion of the tube in aqueous shunt surgery. Evidence of tube erosion, graft-related infection, graft melting, or other associated intraocular complications were evaluated. METHODS: A retrospective study of 16 patients (17 eyes) who underwent tube shunt surgery at Wills Eye Hospital between July 1991 and October 1996 was conducted. An autologous either "free" or "rotating" scleral lamellar graft was created to cover the subconjunctival portion of the tube shunt. RESULTS: All patients were evaluated for at least 6 months, with a mean follow-up of 14.8 months (range 6-62 months). All eyes tolerated the autologous graft well, with no clinical evidence of tube erosion, or graft-related or intraocular complications. CONCLUSION: Autologous patch graft in tube shunt surgery appears--in selected cases--to be an effective, safe and inexpensive surgical alternative to allogenic graft materials. It also offers ease of availability, and eliminates the risk of transmitting infectious disease.

Ciliary body detachment caused by capsule contraction.

A 74-year-old woman developed capsule contraction associated with hypotony and choroidal effusion 18 months after uneventful phacoemulsification with 3-piece poly(methyl methacrylate) intraocular lens implantation. Ultrasound biomicroscopy revealed ciliary body detachment and stretched zonules. A radial neodymium: YAG anterior capsulotomy was performed, resulting in the resolution of the ciliary body detachment and choroidal effusion as well as in normal intraocular pressure over 4 days.

Surgical management of the symptomatic overhanging filtering bleb.

PURPOSE: Large filtering blebs that evolve after trabeculectomies can be bothersome to the patient, especially when overhanging the cornea. Partial bleb excision is warranted to relieve the patient from discomfort or even visual impairment. METHODS: Surgical partial excision of the overhanging corneal part of the bleb was performed in four patients who had undergone earlier trabeculectomy without application of antimetabolites. Duration of follow-up after excision ranged from 9 months to 4 years. RESULTS: Successful reduction of the excessive bleb and continued satisfactory control of intraocular pressure (IOP) were achieved in all four cases. Partial excision of the corneal part of the bleb did not lead to bleb leakage in any of the cases. CONCLUSION: Surgical blunt dissection of the overhanging the morphologic features of the bleb and ensuring continued control of IOP and relief of symptoms. Alternative methods, such as autologous blood injection, cryoapplication, application of trichloracetic acid, or application of Nd:YAG laser, are noninvasive but do not allow precise rearrangement of bleb architecture.