[iOCT in clinical use : Correlation of intraoperative morphology and postoperative visual outcome in patients with full thickness macular hole]. / iOCT in der klinischen Anwendung : Korrelation von intraoperativer Morphologie und postoperativem Ergebnis bei Patienten mit durchgreifendem Makulaforamen.

BACKGROUND: Due to intraoperative optical coherence tomography (iOCT), observation of retinal morphological changes during surgery has become possible. OBJECTIVE: To analyze the intraoperative morphology of full thickness macular holes (FTMH) and the correlation with the postoperative function, a retrospective, observational clinical study was performed analyzing 32 eyes of patients treated at the hospital of the technical university of Munich. MATERIAL AND METHODS: Using iOCT in 32 eyes of 32 consecutive patients, the operative morphology was analyzed during surgery. These findings were then correlated with the postoperative visual outcome. RESULTS: After posterior vitreous detachment (PVD) the macular hole index (MHI) decreased by -0.05 (p = 0.01) and the base diameter (BD) increased by +99.4 µm (SD = 197.8 µm; p = 0.04). Closure rate was 100% at the first visit after a mean time of 73 days and the postoperative best corrected visual acuity (BCVA) significantly improved (p < 0.05). There were significant correlations between intraoperative morphology and postoperative results indicating a relation between low MHI and better postoperative BCVA (SCC = 0.50; p = 0.02), large BD and better postoperative BCVA (SCC = 0.43; p = 0.05) and large aperture after PVD and higher improvement of BCVA (SCC = 0.44; p = 0.03). CONCLUSION: Flattening and broadening of the FTMH occurred as a result of reduction of vitreoretinal traction. The significant correlation between a large operative BD and improved BCVA reveals the importance of intraoperative retinal relaxation.

Inverted internal limiting membrane flap technique in eyes with large idiopathic full-thickness macular hole: long-term functional and morphological outcomes.

PURPOSE: To investigate morphological and functional outcomes of the inverted internal limiting membrane (I-ILM) flap technique in large (≥ 400 µm) idiopathic full-thickness macular holes (FTMH) over a follow-up period of 12 months. METHODS: In this retrospective study, 55 eyes of 54 consecutive patients were enrolled. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT, Heidelberg, Spectralis) were performed preoperatively as well as 1, 3, 6, 9, and 12 months postoperatively. Special focus was put on the reintegration of outer retinal layers and the different ILM flap appearances. RESULTS: FTMH closure rate was 100% (55/55). BCVA significantly improved over the follow-up period of 12 months from 0.98 ± 0.38 LogMAR preoperatively to 0.42 ± 0.33 LogMAR at 12 months postoperatively (p < 0.001). There was no significant correlation between the three different ILM flap appearances and BCVA. Better preoperative BCVA, complete restoration of the external limiting membrane (ELM), higher macular hole index (MHI), and smaller MH base diameter were associated with higher improvement of BCVA. CONCLUSION: Our study highlights the favorable morphological and functional outcomes of the I-ILM flap technique in the short as well as in the long term. While complete ELM restoration revealed to be an important factor for improvement in BCVA, the different postoperative ILM flap appearances seem not to be related to BCVA.

Changes in the foveal microstructure after intravitreal bevacizumab application in patients with retinal vascular disease.

PURPOSE: To investigate changes in the area of the foveal avascular zone (FAZ) in patients with retinal vascular disease. PATIENTS AND METHODS: This retrospective, consecutive study examined 53 eyes of 53 patients with macular edema due to branch retinal vein occlusion in 25 patients (47.2%) and nonproliferative diabetic retinopathy in 28 patients (52.8%). The macular edema was treated with an intravitreal injection of 0.05 mL equal to 1.25 mg bevacizumab. Before and 6-8 weeks after the injection, best corrected visual acuity, slit lamp biomicroscopy of the anterior segment and fundus, optical coherence tomography, and fluorescein angiography were conducted. The FAZ was manually circumscribed on early-phase angiography images and the area of the FAZ was measured. RESULTS: The preoperative overall mean FAZ area was 0.327 ± 0.126 mm(2) (median 0.310 mm(2)). At the control consultation, the overall mean area was significantly larger (0.422 ± 0.259 mm(2); median 0.380 mm(2); P < 0.001). In the nonproliferative diabetic retinopathy subpopulation, the mean area was 0.361 ± 0.129 mm(2) (median 0.330 mm(2)) before bevacizumab application and 0.434 mm(2) at the follow-up visit (mean increase 0.071 mm(2)/19.7%). In the branch retinal vein occlusion group, the baseline FAZ area was 0.290 ± 0.115 mm(2) and 0.407 ± 0.350 mm(2) at follow-up (median 0.330 mm(2); mean increase 0.117 mm(2)/40.3%). No cases of severe operation-associated complications were observed. CONCLUSION: The results confirm the safety of intravitreal bevacizumab injection in patients with macular edema due to nonproliferative diabetic retinopathy and branch retinal vein occlusion. The enlargement of the FAZ could be equivalent to an increase in retinal ischemia. These results may be transient; a potential vascular risk, however, when applying antivascular endothelial growth factor therapy in eyes with preexistent vascular disease must be considered.

First clinical results of epithelial laser in situ keratomileusis with a 1000 Hz excimer laser.

PURPOSE: To evaluate the safety, stability, and efficacy of the first clinical cases of epithelial laser in situ keratomileusis (epi-LASIK) performed using a 1000 Hz excimer laser system. SETTING: Klinikum Rechts der Isar, Munich, Germany. METHODS: The epi-LASIK procedure was performed using an EpiLift microkeratome and a WaveLight Concept System 1000 laser. Preoperatively and 1, 3, and 6 months postoperatively, a complete ophthalmic examination was performed. The examination included objective and subjective refraction, uncorrected and corrected distance visual acuities, and topography. RESULTS: The study comprised 30 eyes of 17 patients. The mean spherical equivalent was -4.36 diopters (D) +/-1.77 (SD) preoperatively, 0.07 +/- 0.38 D 1 month postoperatively, -0.06 D +/- 0.25 D at 3 months, and -0.05 +/- 0.24 D at 6 months. Six months postoperatively, 90% of patients were within +/-0.50 D of the intended correction and all were within +/-1.00 D. At 3 months, 25 eyes had a clear cornea and 5 eyes had trace haze. CONCLUSIONS: In this pilot series, the use of the 1000 Hz excimer laser did not lead to the clinical side effects that are potentially associated with the use of a high repetition rate. The safety, stability, and efficacy of the laser were high although no adjustments to the nomogram were made.

Critical flicker-fusion frequency in age-related macular degeneration.

PURPOSE: To assess the influence of age-related macular degeneration (AMD) on critical flicker-fusion frequency (CFF). METHODS: CFF was measured centrally for a red, green and blue target, and in 10 degrees excentricity with a red target. Twenty-eight patients with non-exsudative AMD, 12 patients with exsudative AMD and 45 age-matched healthy eyes were included. RESULTS: CFF decreased in eyes with non-exsudative AMD (red 1.3 Hz, p=0.025; green 1.4 Hz, p=0.053; blue 2.1 Hz, p=0.006) and exsudative AMD (red 2.2 Hz, p=0.02; green 3.3 Hz, p=0.001; blue 2.9 Hz, p=0.02). The difference between central and peripheral CFF increased in non-exsudative AMD (red-red 10 degrees, 0.7 Hz, p=0.024), but was not significantly increased in exsudative AMD (1.3 Hz, p=0.059). There was no difference between eyes with non-exsudative AMD with good visual acuity (VA >20/32, n=18) and healthy eyes, nor between eyes with non-exsudative (n=10) and exsudative AMD (n=9) with VA from 20/100 to 20/40. CONCLUSIONS: CFF decreased in non-exsudative and exsudative AMD. CFF is not able to distinguish between AMD eyes and healthy eyes of equal visual acuity, and therefore is not applicable as a possible diagnostic test.

Keratocyte density in the retroablation area after LASEK for the correction of myopia.

PURPOSE: During excimer laser photoablation keratocyte cell death is induced in the retroablation area. Afterwards this area is repopulated by keratocyte mitosis and migration from the adjacent stroma. The aim of this study was to investigate keratocyte density in the retroablation area and in the posterior stroma during the first year after LASEK for the correction of myopia. METHODS: In a prospective study LASEK surgery was performed in 17 eyes of 10 consecutive patients for the correction of myopia (-2.25 D to -9.0 D, mean -5.0 D). Confocal microscopy (Nidek Confoscan 2) was performed before surgery and 1 month, 3 months, 6 months and 12 months after LASEK. Keratocyte density was assessed in the anterior retroablation area at depths of 5 mum and 25 mum and in the posterior stroma at distances of 5 mum and 100 mum from the corneal endothelium and compared with the corresponding area before surgery. RESULTS: Keratocyte density was statistically significant reduced in the retroablation area at all timepoints after LASEK. At a depth of 5 mum, cell densities were decreased by 64%, 47%, 43%, and 28% at 1 month, 3 months, 6 months and 12 months after LASEK compared with preoperative values. At a depth of 25 mum, cell densities were decreased by 51%, 32%, 28%, and 18% at 1 month, 3 months, 6 months and 12 months after LASEK compared with preoperative values. In the posterior stroma no significant change in keratocyte density was observed at any time after LASEK. CONCLUSIONS: Keratocyte density in the anterior retroablation area recovers during the first year after LASEK for the correction of myopia, but does not go back to preoperative values.

Von Willebrand's disease type I as a cause for subvitreal, retinal and subretinal haemorrhages.

BACKGROUND: Young patients with vitreous, retinal and subvitreal haemorrhages without neovascularisation or prior trauma are a diagnostic challenge for the physician. In this case report, a patient is presented who developed unilateral, spontaneous, subvitreal, retinal and subretinal haemorrhages and was diagnosed with von Willebrand's disease. CASE REPORT: A 33-year-old Caucasian woman presented at our clinic with unilateral subvitreal, retinal and subretinal haemorrhages. The haemorrhages occurred spontaneously without prior trauma, and the patient had no history of prior bleeding complications. Analysis of the coagulation-fibrinolysis system and von Willebrand multimer analysis led to the diagnosis von Willebrand's disease type I. CONCLUSIONS: Spontaneous subvitreal, retinal and subretinal haemorrhages may be associated with coagulation disorders. Especially in young patients, von Willebrand's disease should be considered as a possible cause.

Tear film function and corneal sensation in the early postoperative period after LASEK for the correction of myopia.

PURPOSE: Subepithelial nerves and stromal nerves of the cornea are damaged during LASEK surgery for the correction of myopia. This leads to a reduction in corneal sensation and to alterations of the tear film function in the early postoperative period. The aim of this study was to evaluate tear film function, corneal sensation and subjective symptoms of dry eye in the early postoperative period after LASEK for the correction of myopia. METHODS: LASEK surgery was performed in 20 eyes of 10 consecutive patients for the correction of myopia (-1.0 to -9.0 D, mean -4.86 D). Subjective symptoms of a dry eye were evaluated with a standardised questionnaire. Schirmer test with and without local anaesthesia, tear film break-up time, fluorescein staining of the cornea and corneal esthesiometry (Cochet-Bonnet) were performed before surgery and 1 week, 1 month, 2 months and 3 months after LASEK. Additionally corneal staining and subjective symptom severity scores were assessed 3 days after surgery. RESULTS: Corneal sensation was reduced 1 week after LASEK and recovered during the first month after LASEK. The tear film break-up time was reduced 1 week and 1 month after LASEK and reached preoperative values 2 months after surgery. Fluorescein staining was increased 3 days and 1 week after LASEK. Subjective symptom severity scores were increased 3 days, 1 week, 1 month and 2 months after LASEK. Schirmer tests values with local anaesthesia were significantly reduced at 3 months after surgery, but not at 3 days, 1 month, or 2 months. Schirmer test values without local anaesthesia were significantly decreased 2 and 3 months after LASEK, but not after 3 days and 1 month after LASEK. CONCLUSIONS: LASEK alters ocular surface haemostasis and reduces corneal sensation in the early postoperative period. Subjective symptoms of dry eye were described during the first 2 months after surgery.

Corneal sensation after laser epithelial keratomileusis for the correction of myopia.

BACKGROUND: Subepithelial nerve fibre bundles and stromal nerves are damaged during laser epithelial keratomileusis (LASEK). The aim of this study was to investigate the recovery of corneal sensation after LASEK for the correction of myopia. METHODS: Corneal sensation was evaluated in 40 eyes of 20 patients using a Cochet-Bonnet aesthesiometer before surgery and 3 days, 14 days, 1, 3 and 6 months after LASEK for the correction of mild to moderate myopia (range -2.5 D to -8.0 D). At every examination corneal sensation was tested in the apex of the cornea and in one point each at the 12, 3, 6 and 9 o' clock positions 2 mm from the centre of the cornea. RESULTS: Corneal sensation was significantly reduced at 3 days and 14 days after surgery (P<0.01). The loss of corneal sensation was greatest 3 days after surgery and corneal sensation increased during the first month after LASEK. After 1 month, 3 months and 6 months no significant difference was found between preoperative and postoperative sensation. There was no significant difference in sensation between different areas of the cornea after LASEK. CONCLUSIONS: Corneal nerves are disrupted during LASEK surgery and the procedure results in a significant reduction in corneal sensation. During the first month after surgery the depressed corneal sensation improved and subsequently went back to preoperative values, staying stable 3 months and 6 months after surgery.

Confocal microscopy and corneal sensitivity in a patient with corneal manifestations of Tangier disease.

PURPOSE: Tangier disease is an autosomal recessive disorder in which cholesterol-rich lipids are deposited at various tissues of the body including the cornea. In this case report, the corneal changes in a patient with Tangier disease are described. METHODS: A 72-year-old patient who was diagnosed with Tangier disease 25 years before received a complete eye examination including confocal microscopy and Cochet-Bonnet esthesiometry. RESULTS: Slit-lamp biomicroscopy and confocal microscopy showed bilateral corneal opacifications caused by lipid accumulation. Confocal microscopy showed that pathologic changes in the cornea in Tangier disease are limited to the stroma. Neither a reduced corneal sensation nor lid abnormalities as previously described in Tangier disease were found. CONCLUSION: Confocal microscopy helps to identify corneal changes in the stroma caused by Tangier disease easily missed in a slit-lamp examination. The ocular manifestations of Tangier disease do not necessarily include a reduced corneal sensitivity and lid abnormalities.