[15 years automated perimetry--where does the path lead?]. / 15 Jahre automatisierte Perimetrie--Wohin führt der Weg?

15 years ago the first fully automated perimeter became available, the Octopus 201, developed by Fankhauser in Bern. Some of the objections which were raised in those days against automated perimeters have turned out true, many, however, not. From todays perspective automated perimetry has brought tremendous advantages for clinical routine diagnosis. The essential power of automated perimetry is its ability to obtain quantitative data which can be processed statistically. The examination of the central visual field may be performed in a much more sophisticated way than by manual kinetic testing. Automated perimetry, however, also has its draw-backs, which are mostly due to mistakes or errors by the examiner, not so much to the method itself. For routine light-sense perimetry the upcoming years will give us faster and optimized testing strategies. Procedures for automated interpretation of visual field data will be developed. The interest in more complex perimetric test criteria goes on one hand into the direction of independence of disturbancies of the optical media (e.g. temporal criteria), on the other hand into the differentiation of various cell populations in the visual system (Blue/Yellow-Perimetry; Motion-Defined-Form etc.). For objective perimetry a powerful system for pattern-ERG and pattern-VECP with a spatial resolution comparable to standard perimetric tests is available. Also in these fields of perimetry the coming years will bring interesting and revolutionary new developments which will open new diagnostic dimensions.

Treatment of endogenous uveitis with anti-CD4 monoclonal antibody: first report.

A patient with endogenous uveitis was treated with a chimeric monoclonal anti-CD4 antibody. This patient with long-standing therapy-refractive uveitis did not benefit immediately from antibody infusions, although the frequency of uveitis relapses was sharply reduced after this therapy. After treatment with the monoclonal antibody, this patient's response to conventional immunosuppression improved. The patient had very low CD4+ T-cell counts before the beginning of antibody therapy. In this case, peripheral T-cell counts slowly increased. Antigen-specific T-cell responses to retinal S-antigen in this patient were significantly elevated only just prior to a clinical relapse. The initially high level of spontaneous T-cell proliferation normalized after antibody infusions.

HIV-related ocular microangiopathic syndrome and cognitive functioning.

Ocular microangiopathic syndrome is found frequently in patients with AIDS or severe HIV infection. Symptoms of this microvascular syndrome can include cotton-wool spots, hemorrhages, and Roth's spots. The clinical and functional significance of HIV-related ocular microangiopathic syndrome has not been clarified as yet. The objective of this study was to evaluate a possible association between HIV-related ocular microangiopathic syndrome and cognitive functioning. Thirty-seven patients infected with HIV (24 with AIDS) underwent ophthalmological and neuropsychological examination. HIV-related ocular microangiopathic syndrome was measured by counting the number of cotton-wool spots in both eyes. Neuropsychological examination included five standardized tests, with the first three primarily measuring function of short-term memory; these tests were as follows: the Auditory-Verbal Learning Test, the Benton Test, the Stroop Colour Word Test, the Trail-Making Part B test, and the Vocabulary for Measuring Premorbid Intelligence test. HIV-related ocular microangiopathic syndrome was found in 15 patients with AIDS (62.5%), and in one patient, staged Walter Reed 5. In 10 patients, one eye was affected (mean count of cotton-wool spots 1.5). In six patients, both eyes were affected (mean count of cotton-wool spots 7.0). Univariate correlations between the number of cotton-wool spots in both eyes and test scores were as follows: Auditory-Verbal Learning Test: 0.56 (p < 0.001); Benton Test: 0.51 (p < 0.001); Stroop Colour and Word: 0.50 (p < 0.001); Trail-Making Part B: 0.15 (not significant); Vocabulary for Measuring Premorbid Intelligence: -0.05 (not significant). Multiple correlation between the test scores and the number of cotton-wool spots was 0.70 (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Strategy for examination and therapy of mycotic keratitis]. / Strategie der Untersuchung und Therapie bei mykotischer Keratitis.

BACKGROUND: Keratomycosis still represents a major problem in ophthalmology because of diagnostic and therapeutic difficulties. This is caused by difficult clinical differentiation and problems in microbiological analysis due to pretreatment and lack of sample material in early stages of the infection. MATERIAL AND METHODS: A 16-year-old female contact lens wearer suffered from a monocular central stromal opacification of the cornea. Analysis of the contact lens storage case liquid (CLCL) was based on investigation of the direct sample, Gram and Lactophenol staining and on specific cultures for aerobic bacteria, anaerobic bacteria and fungi. RESULTS: The patient suffered from a mycotic keratitis caused by Acremonium kiliense. First microbiological results were obtained from the CLCL subsequently confirmed from aqueous and from cornea tissue after keratoplasty. Continuation of the systemic Itraconazol therapy resulted in cure and improvement of the visual acuity. CONCLUSION: Success factors for diagnosis and therapy are early detection of the causative agent in the cornea and/or in the contact lens storage case as well as diagnosis related intensive drug therapy and eventually surgical intervention.

Direct identification of herpes simplex virus type-1 in human corneal tissue. Methodology and application of in situ DNA hybridization technique.

The definitive diagnosis and determination of recurrence of herpes simplex keratitis are still difficult in clinical ophthalmology. At present, isolation of virus by tissue culture is perhaps the best method for establishing a specific aetiological diagnosis of viral infection. But due to its complicated and time-consuming procedures, the application of tissue culture for virus isolation in clinical work is still limited. In situ DNA hybridization is a specific and quick technique for directly detecting genetic materials, DNA and RNA, of viruses. In this study, this technique was used to identify herpes simplex virus type 1 from a patient's cornea suffered from recurrent herpetic keratitis. The technique offers a convenient and specific method for clinicians to make a definitive diagnosis and differential diagnosis of viral infectious diseases. The advantages and disadvantages of other different methods available for viral diagnosis, such as light and electron microscopy and immunohistochemistry were discussed with an emphasis on in situ DNA hybridization.

Fluorescein and indocyanine green angiographies of central serous choroidopathy by scanning laser ophthalmoscopy.

We examined 19 patients (41 +/- 7.5 years old) with central serous chorioretinopathy and symptoms that ranged from one day to 24 months. Fluorescein and indocyanine green angiographies were performed with a scanning laser ophthalmoscope. Focal exudation was found in all patients with fluorescein and in 15 patients (79%) with indocyanine green. We found a more widespread exudation of indocyanine green into the choroid around the focal hyperfluorescent spot in seven patients (37%). Perfusion with fluorescein was delayed in the area of focal exudation in two patients (11%) and with indocyanine green in 12 patients (63%). Exudation of both dyes stopped with clinical improvement, whereas the perfusion deficits remained unchanged. These results further indicate that central serous chorioretinopathy is primarily a choroidal disease.

[Differences in detectability of human immunodeficiency virus type 1 in tears and blood lymphocytes]. / Unterschiede in der Nachweisbarkeit von Humanem Immunschwäche Virus Typ 1 in Tränenflüssigkeit und Blutlymphozyten.

Reported data on the isolation of the human immunodeficiency virus type 1 (HIV-1) from tears are controversial. The purpose of the study was to try to isolate HIV-1 from tears in a large sample of HIV-1-positive patients at different stages of infection. 53 tear samples were obtained from 50 patients. Additionally isolation of HIV-1 from peripheral blood lymphocytes (PBL) was attempted. HIV-1 was isolated from none (= 0%) of the 53 tear samples. Isolation from PBL was successful depending on absolute CD4+ lymphocyte count and Walter Reed staging (Walter Reed stage 6: 83%; stage 2 to 5: 11%; p less than 0.0001). Treatment with zidovudine was not related to the frequency of HIV-1 isolation. These results suggest that tears of patients infected with HIV-1 contain low or no quantities of tissue-culture-infectious units of HIV-1. Nosocomial infection with HIV-1 from tears appears to be unlikely. The known precautions for the prevention of spread of viral disease in ophthalmological practice are sufficient and should be strictly followed.

Quantitative color Doppler imaging in untreated and irradiated choroidal melanoma.

Histological data indicate the importance of tumor vascularization as a determinant of the biological behavior and the response to radiotherapy in choroidal melanoma. Duplex ultrasound and color Doppler imaging, the combination of B-mode ultrasound and pulse-waved Doppler analysis, were used to measure quantitatively neovascular blood flow in 31 patients with choroidal melanoma. Follow-up studies (20 patients) were performed to investigate the change of tumor blood flow in choroidal melanomas after radiotherapy. Blood flow was detected in 30 out of 31 melanomas (size 3.1-17.8 mm) within the tumor and at the tumor base with a mean peak systolic frequency of 1.0 kHz (range 0.3-2.7 kHz), a mean end diastolic frequency of 0.3 kHz (range 0.1-1.0 kHz), and a mean frequency of 0.7 kHz (range 0.2-1.3 kHz). Two and six months after 106Ru/106Rh beta-ray application, 19 patients showed a significant decrease in peak systolic frequency. This occurred with and in advance of the decrease in the tumor size. In one patient, a rising maximum systolic frequency after radiotherapy marked a recurrent tumor growth. Results indicate that the quantitative measurement of tumor blood flow by duplex ultrasound and color Doppler imaging may be a new diagnostic modality for monitoring the effectiveness of radiotherapy in choroidal melanoma.

Argon laser trabeculoplasty: long-term follow-up of at least 5 years.

This retrospective study evaluates the long-term follow-up of 331 eyes of 219 patients treated with argon laser trabeculoplasty (ALT). A total of 258 eyes were included with a follow-up of at least 5 years. Success was defined as an intraocular pressure of under 22 mm Hg with a stable visual field and optic nerve head. Overall, 22% (58/258) were regulated after 5 years (glaucoma chronicum simplex 26%, pigment dispersion glaucoma 31%, pseudoexfoliation glaucoma 19%, angle-closure glaucoma 14%, secondary glaucoma 7%). Filtration surgery was performed in 13% (33/258) mainly (73%) in the first 3 years after ALT. Repeat ALT was done in 43% of the eyes, and 60% of these eyes with repeat ALT underwent filtration surgery in the first year. With repeat ALT the overall success rate increased to 38%. High initial intraocular pressure and the stage of glaucoma documented by the visual field loss correlated with the failure of ALT. These results indicate that ALT and re-ALT were effective in glaucomatous eyes, yet there was a substantial diminishing effect as time progressed. Therefore, close follow-up on ALT-treated patients is necessary.

Lymphocytes, macrophages and HLA-DR expression in vitreal and epiretinal membranes of proliferative vitreoretinopathy. An immunohistochemical study.

Proliferative vitreoretinopathy (PVR) as a severe complication of retinal detachment and also the main cause of failure in its treatments is not yet completely understood. In the present study, we examined 16 PVR epiretinal membrane specimens removed during vitrectomy from 16 patients with complicated rhegmatogenous retinal detachment by immunostaining of cryosections. We looked for the presence of lymphocytes and detected helper/inducer T lymphocytes (CD4+), suppressor/cytotoxic T lymphocytes (CD8+), B lymphocytes (CD22+), macrophages (CD68+), and HLA-DR expression. The results showed that 6 out of 16 specimens reacted positively with monoclonal antibody against the helper/inducer T cell subset (38%), 5 out of 16 reacted positively with a suppressor/cytotoxic T cell-specific monoclonal antibody (31%), 7 out of 16 reacted with B cell-specific monoclonal antibody (44%), and 14 out of 16 were positive for macrophages and HLA-DR (88%). Nevertheless, we think that the invasion of macrophages and lymphocytes into the membranes is not the cause for the pathogenesis, but a secondary event that might further complicate the course of the disease.

Diplophthalmia versus cyclopia and synophthalmia. Mechanisms of doubling of the eye.

In historical and many scientific papers of the 20th century double formation of eyes has been described as cyclopia, which develops as a variably marked fusion of both eye anlagen into a single eye in median position. In contrast with mythology, no cases were viable, as cyclopia is always accompanied by other severe deformities, such as cerebral defects and proboscis. For the first time a double eye on one side - a unilateral diplophthalmia - in a viable child born in Austria is presented after a reviewal of fundamentals of general and experimental embryology, cyclopia and unilateral synophthalmia. Unlike cases of cyclopia with two fused eyes from two anlagen in one single orbit, we found a total of three eyes from two anlagen in two orbits; a normally developed eye in the right orbit and a double eye in the left with no proboscis. In addition porencephaly, a double canine tooth, and a lateral branchial cyst were also present on the left side. An examination of this unique case partially corroberated the findings of experimental embryology as to the normal formation of the lens and brought to light new findings concerning the formation of the vitreous body and the retina, because in the 'extra' left eye a hyaloid artery did not develop. There was only one optic nerve with a normal optic disc as a guiding structure for this artery in the 'normal' left eye.

Unilateral diplophthalmos.

In a child born of a full-term pregnancy, unilateral diplophthalmos without proboscis was observed along with other craniocervical abnormalities (ipsilateral temporoparietal porencephaly, supernumerary teeth, and cervical cyst). A globe almost normal in shape and size was observed within the left orbit. The upper quadrant of this globe was attached to a smaller, pear-shaped, supernumerary eye containing a small lens, normal vitreous humor, ciliary body structures, avascular retina, choroid, and a rudimentary optic disk. When a two-peaked and enlarging intraocular mass was observed clinically, the eye was enucleated because of suspected neoplasm. The enlarging prominence had been caused by the growing second globe. Our findings indicated that a single primary optic vesicle was formed (globe I with an optic fasciculus), and some unknown damage was caused when this single primary optic vesicle induced the lens formation by contacting the ectoderm. Although the conception and early embryonal life of this child had taken place during a period of increased radiation exposure caused by the explosion of the nuclear plant at Chernobyl, U.S.S.R., in the spring of 1986, it seemed unlikely that the abnormality could have been caused by radioactive fallout in the mountains of Austria.

[Vision test device: possibilities and limits of LCD technique]. / Visustestgerät: Möglichkeiten und Grenzen der LCD-Technik.

An automatic visual acuity test examining visual acuity at 5 m distance is presented. An LCD screen with 400 x 640 pixel is used for graphic display. The Landolt rings are selected randomly. The test presented here complies well with the criteria of DIN 58220. Accuracy estimates for representation of the Landolt rings in raster graphics are discussed. With the method suggested, the testing of visual acuity, one of the most important tests in ophthalmological practice, is simplified and its reliability and results are improved. The method allows tests at short time intervals to trace the time dependency of visual acuity. Furthermore, the test may be delegated to support personnel.

[Is endothelial microscopy necessary before cataract surgery?]. / Ist die Endothelmikroskopie vor Katarakt-Chirurgie notwendig?

Specular microscopy was performed before cataract surgery in approximately 3,500 patients. In 127 cases (approx. 4%), implantation of an intraocular lens (IOL) did not appear appropriate, in view of the condition of the cornea. Many of these patients had additional ocular pathology, such as retinal detachment, glaucoma, and intraocular inflammation. In 40 of the patients, IOLs were implanted in spite of the results of specular microscopy, while 48 patients underwent surgery without lens implantation. The incidence of postoperative corneal complications in the two groups was the same. The main problems were caused by cell polymorphism and severe cornea guttata. It is extremely difficult to assess cell polymorphism at the slitlamp. Especially in patients with other ocular diseases and corneal lesions visible at the slitlamp, it is recommended that specular microscopy be performed prior to cataract surgery with implantation of an IOL.

Intravitreal silicone oil injection: complications and treatment of 415 consecutive patients.

Silicone oil injection in conjunction with pars plana vitrectomy was carried out by five surgeons in 415 consecutive patients using the same surgical equipment, the same surgical techniques and the same highly purified silicone oil (viscosity, 5000 mPa.s). Indications for silicone oil injection after vitrectomy included advanced stages of proliferative vitreoretinopathy following rhegmatogenous retinal detachment (49%), severe proliferative diabetic retinopathy (38%), and proliferative vitreoretinopathy following retinal detachment due to ocular trauma (13%). Postoperative complications were noted in a 6- to 30-month follow-up period. Cataractous changes of varying degree were seen in all phakic eyes. Silicone oil entered the anterior chamber in 6% of all phakic and pseudophakic eyes. Subretinal silicone oil was noted in 4%. Other complications associated with the use of intravitreal silicone oil included biomicroscopically visible silicone oil emulsification (0.7%), keratopathy (5.5%), glaucoma (6%), closure of the inferior iridectomy (6%), and reproliferation of epiretinal and subretinal fibrous membranes (40%). We anticipate that the physico-chemical characteristics of the highly purified silicone oil (viscosity, 5000 mPa.s) and the routine performance of an inferior iridectomy in all aphakic eyes had a positive impact on the low incidence of silicone-oil-related complications such as emulsification, keratopathy and secondary glaucoma.

Epithelial tumors of the lacrimal gland: clinico-pathologic correlation and management.

Between 1960 and 1987 29 patients underwent surgery at the Munich University Eye Hospital for benign and malignant tumors of the lacrimal gland. Fifteen tumors were classified as pleomorphic adenomas (three of them with malignant transformation), nine as adenoid cystic carcinomas, two as adenocarcinomas, two as oxyphilic adenomas, and one as oxyphilic adenocarcinoma. The clinico-pathologic correlation of these tumors is described. All age groups were involved in both benign and malignant epithelial gland tumors. A fast growing lesion with bone destruction of the lacrimal fossa in association with pain was found to be highly suspicious of a malignant epithelial tumor. Prior to surgery, inflammatory lesions and lymphomas should be ruled out by clinical history, examination, diagnostic imaging techniques, and, occasionally, by a short course of oral corticosteroids. A diagnostic biopsy prior to tumor excision and a transfrontal surgical approach via craniotomy has a negative impact on the prognosis. Thus it is mandatory to remove epithelial lacrimal gland tumors completely at the time of the initial surgical procedure. Craniotomies facilitate recurrences of lacrimal gland tumors by infiltration into the central nervous system. Lateral orbitotomies using the Krönlein technique are the best surgical approach for successful removal of these unusual tumors.

[AIDS and the eye]. / Aids und Auge.

Seventy percent of patients with AIDS have AIDS-related ocular involvement. This is a special challenge for the ophthalmologist which requires specific knowledge. The nature and frequency of the ocular involvement as well as the time of manifestation during the HIV-disease are discussed. The potential therapy for such opportunistic infections is discussed. Furthermore, the HIV-specific aspects for disinfection procedures in the office (tonometry, three-mirror lens, contact lenses) are also elucidated.

[Long-term results following argon laser trabeculoplasty]. / Langzeitresultate nach Argonlaser-Trabekuloplastik (ALT).

Long-term follow-up findings after argon laser trabeculoplasty are communicated. The coagulation technique employed was that described by Wise and Witter (1979). The circumference of the chamber angle was coagulated over 360 degrees. The indications were chronic open-angle glaucoma, pseudoexfoliation glaucoma, pigmentdispersion glaucoma, glaucoma in aphakia, and glaucoma after ALT or fistulizing surgery with uncontrolled IOP. Glaucoma cases in which IOP exceeded 35 mm Hg were not treated by this method. Therapy was considered successful if a decrease in IOP to below 20 mm Hg was achieved. The difficulties of finding appropriate parameters for the success of glaucoma therapy are discussed. The percentages of normotonic eyes after ALT with a follow-up period of one to four years are reported and compared with results obtained by other authors. After one year, IOP was normal in 89.9% of 881 eyes (chronic open-angle glaucoma 94%, pigment-dispersion glaucoma 91%, pseudoexfoliation glaucoma 86%, glaucoma in aphakia 88%). After two years, it was normal in 72.6% of 237 eyes (chronic open-angle glaucoma 82%, pigment-dispersion glaucoma 50%, pseudoexfoliation glaucoma 53%, glaucoma in aphakia 75%). After three years, it was normal in 60.5% of 76 eyes (chronic open-angle glaucoma 72%, pigment-dispersion glaucoma 25%, pseudoexfoliation glaucoma 37%, glaucoma in aphakia 66%). After four years, it was normal in 95.4% of 128 eyes (chronic open-angle glaucoma 82%, pseudoexfoliation glaucoma 50%). The results of ALT therapy reported by other authors are similar. A decrease in efficiency, initially of 5% to 10% per year, is seen in eyes thus treated, which may necessitate fistulizing surgery.(ABSTRACT TRUNCATED AT 250 WORDS)