[Cataract surgery 220 years ago]. / Staroperationen vor 220 Jahren.

The author reports on the first 14 cataract extractions performed by Karl Kaspar von Siebold, a Würzburg surgeon, in 1766/67. He used Daviel's method. At that time there was no anesthesia, no sterility or even antisepsis, and no optical correction of aphakia for his patients. Four eyes were lost due to infection and another four had much poorer vision after surgery due to irregular corneal scarring. In six cases both patient and physician were satisfied with the result. Siebold's case reports exhibit a fascinating degree of self-criticism and frankness.

[Pallor of the optic papilla--an early sign of glaucoma. A clinical controlled study of optic disk pallor and papillar cupping in glaucoma simplex, ocular hypertension and normal eyes with the optic nerve head analyzer]. / Papillenabblassung--ein Frühzeichen des Glaukoms. Eine klinisch kontrollierte Untersuchung von Papillenblässe und Papillenexkavation bei Glaucoma simplex, okulärer Hypertension und gesunden Augen mit dem Optic Nerve Head Analyzer.

Double examinations of 99 eyes (34 healthy, 12 with ocular hypertension, 53 with primary open-angle glaucoma) were performed with the Optic Nerve Head Analyzer to evaluate whether an increase in disk pallor or in the cup-disk ratio (CDR) is the earlier sign of glaucoma. In eyes with primary open-angle glaucoma the CDR and the mean optic disk pallor value are significantly higher than in healthy eyes. There is no significant difference in the CDR of patients with ocular hypertension as compared to normals. However, the mean pallor value is significantly higher in eyes with ocular hypertension than in healthy eyes. Therefore, an increase in pallor may precede a significant increase in the CDR or detectable visual field defects.

Long-term studies of visual field changes by means of computerized perimetry (Octopus 201) in eyes with glaucomatous field defects after normalization of the intra-ocular pressure.

UNLABELLED: 126 eyes with open-angle glaucoma and defects of the visual field were studied over five years (+/-1.3) by repeated perimetries with Octopus Perimeter, Program 31, after the IOP had been normalized from 26.49 mm Hg to 19 mm Hg. All patients had suffered visual field defects in the period with increased pressure preceding our study and had many perimetric examinations before. The aim of the study was to check the behaviour of the visual field defects after pressure normalization. For evaluation of the visual fields, the upper most line of the test-points and the 6 test-points surrounding the blind spot were disregarded. The evaluation of each field and the comparison with preceding fields (no change, better, or worse) were done by the symmetry test of Bowker instead of the Delta Program, taking into account each of the 61 test-points with a significance level of 5%. In each patient the eye with the heavier field loss was evaluated. RESULTS: 67% of all eyes had no change during the observation time, 12% became better, and 21% worse. Improvement of the visual fields occurred even in old age: 10% became better in the age-group over 70 years. The total loss decreased in the 15 eyes which improved by 269 dB. In eyes which deteriorated, the total loss increased by 282 dB. The good news of this study is that normalization of IOP can stop the further decay of the visual-field in 67% and an improvement of the field loss is possible even in old age of with heavy field loss.(ABSTRACT TRUNCATED AT 250 WORDS)

[Optic papilla parameters in healthy subjects--quantified with the optic nerve head analyzer]. / Papillenparameter bei Gesunden--quantifiziert mit dem Optic Nerve Head Analyzer.

The cup-disk ratio (CDR), the size of the neuroretinal rim area as well as the other disk parameters investigated with the Optic Nerve Head Analyzer (ONHA) were measured in double examinations of 32 healthy eyes in 32 patients. Thus, "normal" values were determined for the various disk parameters. A new method is presented for calculating one average pallor value for the disk. The mean value for disk pallor in healthy eyes is determined. Examination of the CDR in the quadrants of the disk reveals significant differences. According to the results of a multi-regressional analysis of the various disk parameters, the size of the neuroretinal rim area in healthy eyes is influenced by the size of the disk, the disk volume and the elevation volume. The correlation between the size of the neuroretinal rim area and the size of the disk reveals a significant interdependence: a larger disk also has a greater neuroretinal rim area as compared to a smaller disk. This means that sizes of neuroretinal rim areas of different disk should only be compared when the disks are the same size. Relative values, such as the CDR or the ratio between the size of the neuroretinal rim area and disk size (rim area/disk area), are therefore better suited for comparison.

Successful goniotomy in hemophilia A.

An infant of 8 months with congenital glaucoma and hemophilia A lost one eye due to haemorrhages after trabeculotomy in an eye hospital. Only thereafter, the hemophilia A was discovered. We did a goniotomy of the fellow eye in November 1971 after normalization of the factor VIII activity. The intervention was without complications; now, 16 years later, the visual field is completely normal (Octopus), the visual acuity is 1.6, the intraocular pressure oscillates between 18 and 21 mm Hg. This report shows that it is possible to operate upon children with hemophilia A successfully, and that children must be checked before the first intervention for hemophilia A because of the severe consequences if it is not discovered or treated, although the condition is rare.

[Site and depth of glaucomatous visual field defects in relation to the size of the neuroretinal edge zone of the optic disk in glaucoma without hypertension, simple glaucoma, pigmentary glaucoma. A clinical study with the Octopus perimeter 201 and the optic nerve head analyzer]. / Lage und Tiefe glaukomatöser Gesichtsfeldausfälle in Abhängigkeit von der Fläche der neuroretinalen Randzone der Papille bei Glaukom ohne Hochdruck, Glaucoma simplex, Pigmentglaukom. Eine klinische Studie mit dem Octopus-Perimeter 201 und dem Optic Nerve Head Analyzer.

The size of the neuroretinal rim area of the disk was measured with the Optic Nerve Head Analyzer in 57 eyes of 57 patients with low-tension glaucoma (LTG), glaucoma simplex (POAG), and pigmentary glaucoma. The visual fields were examined with Program 33 or 31 (30 degrees eccentricity, 6 degrees grid) of the Octopus 201 Perimeter. The mean sensitivity loss per test point in the central field, in the field quadrants, and in the ranges from 0 degrees-10 degrees, 10 degrees-20 degrees, and 20 degrees-30 degrees were calculated with the Delta program. In addition, the mean loss per disturbed point, which gives the mean depth of scotomata, was calculated. In LTG a larger vertical cup/disk ratio (CDR) was found than in POAG for the same amount of total loss. The comparison of eyes with neuroretinal rim areas of equal size revealed that in contrast to POAG and pigmentary glaucoma, eyes with LTG had a smaller mean sensitivity loss; deeper, more localized scotomata; more visual field defects in the lower field in the initial stages; more scotomata in the area up to 20 degrees. The differences between glaucoma with and without high intraocular pressure were found to be most pronounced in the initial stages of the disease. These differences appear to be caused by the varying amounts of vascular pathogenesis involved. Therefore, at least two pathomechanisms have to be considered in glaucoma.

[Acupuncture for pain in the cranial region and for blepharospasm without organic cause]. / Akupunktur bei Schmerzen im Kopfbereich sowie bei Blepharospasmus ohne organische Ursache.

In patients with functional ophthalmological disturbances classical acupuncture therapy was compared to a technique of inserting the needles close to superficial nerves. Seventy-five patients with migraine, 47 patients with functional blepharospasm, 18 with trigeminal neuralgia, and 9 with posttraumatic pain syndromes were treated. Treatment comprised seven sessions at four-day intervals. Of 62 patients undergoing classical acupuncture, 21 (33.9%) were subsequently free of complaints and 33 (53.2%) felt a great improvement. Nerve points were stimulated in 83 patients, 31 (38%) of whom were completely free of symptoms after treatment, and 45 of whom (54%) felt much better. Hence, there was no marked difference between the two methods as regards therapeutic effect. These results support the concept of acupuncture therapy being a combination of dermal stimulation and suggestion. The therapeutic approach to pain or blepharospasm by use of the mainly suggestive effects of acupuncture is recommended only if underlying organic diseases can be ruled out.

[Effect of neodymium YAG laser treatment of glaucoma on endothelial cell density of the cornea]. / Die Auswirkung der Neodym-YAG-Laserbehandlung des Glaukoms auf die Endothelzelldichte der Hornhaut.

In a prospective clinical study corneal endothelium cell density was measured by means of contact specular microscopy prior to and 2, 4 and 12 weeks after Nd-YAG laser treatment. Two different laser techniques were applied: 19 eyes with narrow-angle glaucoma were treated by laser iridotomy, 21 eyes with open-angle glaucoma underwent laser treatment of the trabecular meshwork. The Nd-YAG laser was driven in Q-switched mode (nanosecond range) for iridotomy and in free-running mode (millisecond range) to treat the trabecular meshwork. A mechanical effect (iridotomy) as well as a thermal effect (LTP) of the Nd-YAG laser source was used. The morphometric study of the corneal endothelium revealed a variable increase in cell size, occasional cell loss, and an increase in polymorphism after Nd-YAG laser treatment. The decrease in endothelial cell density was not statistically significant (p = 0.01) for either laser technique. Possible mechanisms and risk factors responsible for endothelial cell loss are discussed.

[Demonstration of the tonographic effect in YAG laser trabeculoplasty in chronic glaucoma]. / Zum tonographischen Wirkungsnachweis der YAG-Laser-Trabekuloplastik beim chronischen Glaukom.

In a pilot study comprising 16 eyes of 16 patients with chronic open-angle glaucoma the tonographic outflow facility was examined before and after Nd-YAG laser treatment of the trabecular meshwork. For evaluation of the facility effect of laser trabeculoplasty, the tonographic record between the third and seventh minute according to the tonography test of Leydhecker was used. An improvement in outflow facility was established which correlated with the postoperative fall in IOP.

[Glaucoma without ocular hypertension. A clinical study]. / Glaukom ohne Hochdruck. Eine klinische Studie.

One hundred eighty-four glaucomatous eyes (125 patients) with visual field defects of Stage I and II in the central visual field were examined with the Octopus perimeter 201, Program 31 or 33, and were divided into 3 groups according to maximum intraocular pressures: (1) low-tension glaucoma (21 mm Hg), (2) glaucoma simplex (22-29 mm Hg), (3) glaucoma simplex (30-39 mm Hg). In these three groups of glaucomatous eyes the cupping of the optic disk, vision and blood pressure were examined and a further check for cardiovascular risk factors was carried out by the internist. All three groups proved to have an equally high incidence of cardiac insufficiency, abnormal EKG changes and diabetes. However, a low systolic blood pressure was found to be the risk factor more often in patients with low-tension glaucoma than with glaucoma simplex. Furthermore, intraocular pressures in the low-tension glaucoma group were higher than those in the normal population. The occurrence of cupping of the optic disk, which is not present with purely vascular optic nerve diseases, and the location of visual field defects in low-tension glaucoma, which is similar to that in glaucoma simplex but different from vascular diseases, as well as the increased diurnal tension variations of diurnal tension curves compared to the normal population are all factors which indicate that low-tension glaucoma is not a purely vascular optic nerve disease, and that pressure-lowering therapy is necessary.(ABSTRACT TRUNCATED AT 250 WORDS)

[Fibrin adhesion and postoperative anti-fibrinolytic care of conjunctival wounds]. / Fibrinklebung und antifibrinolytische Nachbehandlung von Bindehautwunden.

The closure of conjunctival wounds by means of the fibrin adhesive technique has been reported by several authors; however, the clinical results were only partially satisfactory. Premature clot lysis resulted in disturbances of wound healing. These observations were corroborated by our the present authors' findings. Investigations of the proteolytic and fibrinolytic activity of aqueous humor and the lacrimal fluid revealed no activity in the aqueous humor, but significant activity in the lacrimal fluid. These findings indicated that proteolytic activity is responsible for the rapid dissolution of the fibrin clot after contact with tears. Stimulated by these findings, the present authors developed a topically applicable antifibrinolytic postoperative treatment based on eye drops containing Aprotinin (Trasylol). This technique has been applied in 3 patients so far and has resulted in stabilization of the fibrin clot until the wound has healed sufficiently. This cure is recommended for closure of conjunctival fistulas following glaucoma surgery, as well as for conjunctival wounds and partially dehiscent corneoscleral sections. It is noted that suturing of the latter is often complicated by scars or atrophy of the tissue.

Perimetry update.

The possible applications of computer-assisted static perimetry are examined after five years of personal controlled studies of different types of computerized perimeters. The common advantage of all computer-assisted perimeters is the elimination of the influence of the perimetrist on the results. However, some perimeters are fully computer-assisted and some are only partially so. Even after complete elimination of the perimetrist's influence, some physiological and psychological influences remain due to the patient and will cause fluctuations of the results. In perimeters, the density of the grid and the adaptive strategy of exact threshold measurement are important in obtaining reproducible results. A compromise between duration of the test and exactness has to be found. The most acceptable compromise seems to be an uneven distribution of stimuli, which form a denser grid in areas of special interest and a wider grid in areas less likely to be involved, combined with exact threshold measurements only in suspicious areas. Multiple stimulus presentation is not adequate. High sensitivity of screening is not a great advantage, unless combined with a high specificity. We have shown that using the same stimulus luminosity for center and periphery (a nonadaptive strategy) produces nonspecific results. Only an adaptive strategy can result in high sensitivity and specificity. Adaptive strategy means that the luminosity of the stimulus is adapted to the individual threshold curve of the visual field. In addition, the exact individual thresholds are bracketed by small up and down steps of variation in luminosity. In some cases, scanning programs with two levels of adaptation can be sufficient. The user of modern perimeters must understand such terms as: asb, dB, presentation time, and diameter of stimuli. Projection of stimuli is preferred to light emitting diodes or glass fiber optics. The programs (software) of the modern instruments are of the greatest importance, because the clinical experience that the perimetrist had to acquire in previous manual perimetry is incorporated in these programs. In the Octopus perimeter a delta program is available that differentiates patient fluctuations that may be insignificant from directed significant alterations of the field which might require alteration of therapy. The programs are listed for different computer-assisted perimeters, and their choice is described. The costs of the perimeters are also given. Many controlled clinical studies are quoted briefly where they are useful for understanding the discussion. A brief chapter deals with the reliability of the perimetric test.(ABSTRACT TRUNCATED AT 400 WORDS)

[The physician's obligation to educate patients - legal aspects - patients' expectations]. / Zur ärztlichen Aufklärungspflicht - juristische Aspekte - Erwartungen der Patienten.

There is some uncertainty among doctors and lawyers about the form and content of presurgical medical enlightenment of the patient. Presurgical enlightenment is of increasing significance with respect to malpractice suits. Current jurisdiction has developed principles of enlightenment that are often difficult for the doctor to handle. For routine procedures in major hospitals a standardized, pragmatically designed consent form is therefore necessary. At Würzburg University Eye Hospital the results of glaucoma and cataract surgery have been documented for years by using computer-readable forms. On the basis of these large-scale results from many thousands of procedures a written consent form was developed and tested for its suitability. Two hundred and twenty-two patients were questioned on their expectations as to proper enlightenment. The results of these broadly scattered interviews are summed up and presented. Especially with glaucoma patients, the best method of enlightenment, satisfying both medical and legal requirements, is an information booklet designed for lay people together with verbal information furnished by the doctor. Nearly all of the patients interviewed found the preoperative enlightenment complete and sufficiently clear. The majority ot them could repeat the contents of the enlightenment form four to six days after the operation. This speaks well for the adequacy of the enlightenment. As a rule, the written consent form was supplemented by verbal enlightenment from the operating physician immediately before hospitalization of the patient. A psychological investigation of preoperative anxiety with enlightened and non-enlightened patients revealed that the enlightenment form did not increase preoperative anxiety. Surgical ophthalmology lends itself to a written consent form more readily then other surgical disciplines, because diseases with poor prognoses for life are fortunately rare.