Diode laser transscleral cyclophotocoagulation for refractory glaucoma.

PURPOSE: To evaluate the efficacy of contact diode laser transscleral cyclophotocoagulation using different treatment parameters. METHODS: All eyes undergoing contact diode laser transscleral cyclophotocoagulation between April 1991 and September 1997 at our two institutions were enrolled. Success was defined as an intraocular pressure less than or equal to 22 mm Hg or absence of pain for poorly sighted and blind eyes. RESULTS: Two hundred six eyes of 204 patients (Salzburg, 117 eyes; New York, 89 eyes) were enrolled. Mean patient age was 65.8 +/- 18.7 years (range, 4-96 years). Mean follow-up was 9.2 +/- 11.2 months (range, 3-56 months). Mean preoperative and postoperative IOPs were 42.1 +/- 11.0 mm Hg (range, 24-76 mm Hg) and 17.3 +/- 10.9 mm Hg (P < 0.001) and 20.3 +/- 13.2 mm Hg (P < 0.001) at 12 and 24 months, respectively. The number of laser applications (mean, 18.6 +/- 4.2; range, 10-40) and maximal laser power (mean, 2,352 +/- 408.5 mW; range, 1,500-3,000) were not associated with a lower postoperative IOP. An IOP less than or equal to 22 mm Hg was achieved in 72.7% of eyes at the mean follow-up of 9 months. Thirty-three (16.0%) eyes required at least one retreatment. Phthisis occurred in four (1.9%) eyes. CONCLUSION: Contact diode laser transscleral cyclophotocoagulation is useful in eyes with refractory glaucoma in which the risks of outflow surgery are deemed unacceptable.

Repair of a late-onset filtering bleb leak using a corneal graft shaped with an excimer laser.

A new method for repairing an area of late scleral necrosis and bleb leak after glaucoma-filtering surgery using mitomycin C (MMC) is described. In a 33-year-old female patient diagnosed with bilateral juvenile glaucoma, a bleb leak occurred 41 months after trabeculectomy with MMC in the left eye. A corneal stromal patch-graft shaped to the desired size using an excimer laser (Excimer-Laser-Corneal-Shaping-System, ELCS-S) was used to cover the scleral defect. This step was followed by water-tight closure of the conjunctiva. During the follow-up period of 12 months the leak remained successfully repaired and the intraocular pressure stayed between 8 and 14 mm Hg without medication. This technique that uses lamellar grafts of very large size should be considered when a surgical repair of a large leaking bleb is required, especially in cases with scleral tissue necrosis.

Central retinal vessel trunk exit and location of glaucomatous parapapillary atrophy in glaucoma.

OBJECTIVE: To evaluate whether the position of the central retinal vessel trunk exit on the lamina cribrosa spatially correlates with the location of parapapillary atrophy in glaucoma. DESIGN: Clinic-based, observational, cross-sectional study. PATIENTS: Color stereo optic disc photographs of 95 patients with primary or secondary open-angle glaucoma and 65 healthy persons were morphometrically evaluated. The intrapapillary and parapapillary region was divided into four quadrants. We determined the position of the central retinal vessel trunk exit on the lamina cribrosa surface and measured the area of parapapillary atrophy and neuroretinal rim in the four quadrants. MAIN OUTCOME MEASURES: The area of neuroretinal rim and parapapillary atrophy and the position of the central retinal vessel trunk exit. RESULTS: Comparing measurements between opposite disc quadrants showed that beta zone of parapapillary atrophy was significantly (P < 0.05) larger and that the neuroretinal rim was significantly smaller when beta zone and neuroretinal rim were measured in the disc quadrant most distant to the central retinal vessel trunk exit, than if the beta zone and neuroretinal rim were measured in the quadrant containing the vessel trunk exit. Comparing measurements in the disc quadrants between eyes with different positions of the central retinal vessel trunk exit revealed that, in the respective disc quadrant, the beta zone was significantly larger and the neuroretinal rim was smaller in eyes with the vessel trunk exiting in the opposite disc quadrant than in eyes with the vessel trunk exit located in the respective disc quadrant where the measurements were obtained. CONCLUSIONS: Position of the central retinal vessel trunk exit on the lamina cribrosa influences the location of parapapillary atrophy in glaucoma. The longer the distance to the central retinal vessel trunk exit, the more enlarged is parapapillary atrophy and the smaller is the neuroretinal rim. This relationship agrees with the spatial relationship between glaucomatous neuroretinal rim loss and enlarged parapapillary atrophy in glaucoma. Diagnostically, it may indicate that, in eyes with an abnormal configuration of parapapillary atrophy or with an abnormal position of the central retinal vessel trunk exit, early glaucomatous rim changes should be looked for in the disc sector that is most distant to the central retinal vessel trunk exit and where parapapillary atrophy may be relatively large.

Scanning laser polarimetry (SLP) for optic nerve head drusen.

Optic nerve head drusen (ONHD) are either clinically invisible or clearly protruding from the disc, in the later case leading to the condition of an irregular, indistinct disc margin or a swollen disc on biomicroscopy. They also may cause visual field defects, even with slow progression. Scanning laser polarimetry (SLP) has been proposed as a rapid, objective and reproducible technology for retinal nerve fiber layer (RNFL) assessment and clinical studies have demonstrated that SLP can help to distinguish between normal and glaucomatous eyes, identify glaucoma suspects and correlates well with visual field defects. The purpose of this study was to evaluate the potential applicability of SLP in 20 consecutive patients with optic nerve head drusen (18 bilateral) that were clinically visible (22 eyes) and invisible (16 eyes). RNFL thickness was studied in patients with and without visual field defects. Patients with visual field defects and ONHD were significantly older and had a small, but significant reduction of visual acuity. Some global SLP parameters (average thickness, ellipse average) were significantly different between subjects with normal and abnormal visual fields. The comparison of the groups with visible and invisible drusen showed that there was no difference in demographic or perimetric data. RNFL thickness measurements were also very similar in both groups. Clinical visibility of drusen was not correlated with RNFL thinning as measured with the GDxTM. SLP assessment, however, was well correlated with functional loss. This objective, non-invasive technology may be an additional option for RNFL evaluation in this condition and an especially useful tool for long-term follow-up.

Pulsatile ocular blood flow in patients with pseudoexfoliation.

PURPOSE: Pseudoexfoliation syndrome is one of the most frequent causes of open-angle glaucoma and is statistically significant associated with a high risk of hypertension, angina, myocardial infarction or stroke and retinal vein thrombosis. The aim of this study was to evaluate the pulsatile ocular blood flow (POBF) in pseudoexfoliation syndrome without (PEX) and with glaucoma (PEG). METHODS: Seventeen eyes with PEX, 17 with PEG and 11 normal eyes of age-matched patients were enrolled. A complete ophthalmological examination included measuring the POBF with the Langham Pneumotonometer as well as the nerve fiber layer thickness by scanning laser polarimetry (GDx). RESULTS: The blood flow parameters, pulse volume and POBF, were statistically significant different between normals and patients with PEG (p < 0.003, t-test). A negative correlation between the intraocular pressure and the POBF was found for all eyes tested. Analysis of GDx? parameters showed a negative correlation for the "number" with the POBF and a positive one for ellipse modulation. CONCLUSION: Although pseudoexfoliation is reported to be a systemic disease measurement of the POBF could not detect any difference between normals and PEX, but was statistically significant different in PEG. Assessments of nerve fiber layer thickness as determined by scanning laser polarimetry also showed a correlation with POBF in some parameters tested.

Optical coherence tomography and scanning laser polarimetry in normal, ocular hypertensive, and glaucomatous eyes.

PURPOSE: To evaluate the relationship between visual function and retinal nerve fiber layer measurements obtained with scanning laser polarimetry and optical coherence tomography in a masked, prospective trial. METHODS: Consecutive normal, ocular hypertensive, and glaucomatous subjects who met inclusion and exclusion criteria were evaluated. Complete ophthalmologic examination, disk photography, scanning laser polarimetry, optical coherence tomography, and automated achromatic perimetry were performed. RESULTS: Seventy-eight eyes of 78 patients (17 normal, 23 ocular hypertensive, and 38 glaucomatous) were enrolled (mean age, 56.8+/-11.5 years; range, 26 to 75 years). Eyes with glaucoma had significantly greater neural network scores on scanning laser polarimetry and lower maximum modulation, ellipse modulation, and mean retinal nerve fiber layer thickness measured with optical coherence tomography compared with normal and ocular hypertensive eyes, respectively (all P<.005). Significant associations were observed between neural network number (r = -.51, r = .03), maximum modulation (r = .39, r = -.32), ellipse modulation (r = .36, r = -.28), and optical coherence tomography-generated retinal nerve fiber layer thickness (r = .68, r = -.59) and visual field mean deviation and corrected pattern standard deviation, respectively. All scanning laser polarimetry parameters were significantly associated with optical coherence tomography-generated retinal nerve fiber layer thickness. CONCLUSION: Optical coherence tomography and scanning laser polarimetry were capable of differentiating glaucomatous from nonglaucomatous populations in this cohort; however considerable measurement overlap was observed among normal, ocular hypertensive, and glaucomatous eyes. Retinal nerve fiber layer structural measurements demonstrated good correlation with visual function, and retinal nerve fiber layer thickness by optical coherence tomography correlated with retardation measurements by scanning laser polarimetry.

Heidelberg retina tomography and optical coherence tomography in normal, ocular-hypertensive, and glaucomatous eyes.

PURPOSE: To evaluate optic disc and retinal nerve fiber layer (RNFL) appearance in normal, ocular-hypertensive, and glaucomatous eyes undergoing confocal scanning laser ophthalmoscopy and optical coherence tomography (OCT). DESIGN: Prospective, cross-sectional study. PARTICIPANTS: Seventy-eight eyes of 78 consecutive normal (n = 17), ocular-hypertensive (n = 23), and glaucomatous subjects (n = 38) were enrolled. METHODS: Each patient underwent complete ophthalmic examination, achromatic automated perimetry, confocal scanning laser ophthalmoscopy (Heidelberg Retinal Tomography [HRT]), and OCT. Topographic HRT parameters (disc area, cup-disc ratio, rim area, rim volume, cup shape measure, mean RNFL thickness, and cross-sectional area) and mean OCT-generated RNFL thickness were evaluated in each group. MAIN OUTCOME MEASURES: OCT and HRT assessment of optic disc and RNFL anatomy. RESULTS: OCT RNFL thickness showed no difference between normal and ocular-hypertensive eyes (P = 0.15) but was significantly less in glaucomatous eyes (P < 0.001). HRT measurements of rim area, cup-disc ratio, cup shape measure, RNFL thickness, and RNFL cross-sectional area were significantly less in glaucomatous eyes (all P < 0.005) and were correlated with mean OCT RNFL thickness (all P < 0.02). RNFL thickness using OCT or HRT was highly correlated with visual field mean defect during achromatic perimetry (P < 0.0001). CONCLUSION: Both HRT and OCT can differentiate glaucomatous from nonglaucomatous eyes. RNFL thickness measurements using OCT correspond to disc topographic parameters using HRT.

Increasing sampling density improves reproducibility of optical coherence tomography measurements.

PURPOSE: Published series of peripapillary retinal nerve fiber layer (RNFL) measurements using optical coherence tomography (OCT) have sampled 100 evenly distributed points on a 360 degrees peripapillary circular scan. The goal of this study was to determine whether a four-fold increase in sampling density improves the reproducibility of OCT measurements. METHODS: Complete ophthalmic examinations, achromatic automated perimetry, and OCT imaging were performed in all patients. The OCT scanning consisted of three superior and inferior quadrantic scans (100 sampling points/quadrant) and three circular scans (25 points/quadrant). The RNFL thickness measurements and coefficient of variation (CV) were calculated for the superior and inferior quadrants for each sampling density technique. RESULTS: The study included 22 eyes of 22 patients (3 control subjects; 2 patients with ocular hypertension; and 17 patients with glaucoma). Quadrants with associated glaucomatous visual field loss on automated achromatic perimetry had thinner RNFLs than quadrants without functional defects for both the 25- and 100-points/quadrant scans. For quadrants associated with normal visual hemifields (n = 22), there was no difference between the 25- and 100-points/quadrant scans in mean RNFL thickness and CV. Among quadrants with visual field defects (n = 22), RNFL thickness measurements were thinner in the 25-points/quadrant scans than in the 100-points/quadrant scans. The CV for the 25-points/quadrant scans (25.9%) was significantly higher than that for the 100-points/quadrant scans (11.9%). CONCLUSION: Increasing the sampling density of OCT scans provides less variable representation of RNFL thickness. The optimal sampling density to achieve maximal reliability of OCT scans remains to be determined.

Effect of pupillary dilation on retinal nerve fiber layer thickness as measured by scanning laser polarimetry in eyes with and without cataract.

PURPOSE: This study was conducted to evaluate the effect of pupillary dilation on retinal nerve fiber layer (RNFL) thickness as measured by scanning laser polarimetry (SLP) in cataractous and noncataractous eyes. METHODS: The study included 31 eyes of 31 consecutive patients (mean age, 62.5 +/- 14.0 years; range, 30-76 years). Eyes with refractive error exceeding 5.0 D sphere or 2.0 D cylinder, nonlenticular media opacity, cup-to-disc ratio > 0.9, corneal disease, ocular inflammation, or previous intraocular surgery were excluded. A standard reticule was used to measure pupillary diameter. Cataract grade was evaluated by a single observer using the Lens Opacities Classification System (LOCS III). RNFL thickness measurements were obtained by means of SLP before and after pupillary dilation. RESULTS: Of the patients, 10 had clear lenses and 21 had variable degrees of lenticular opacification. In four eyes, imaging could not be performed because of dense cataracts. Mean pupillary diameters before and after dilation were 2.5 +/- 0.7 mm and 7.3 +/- 1.1 mm, respectively. There were no significant differences in global RNFL thickness before and after dilation in noncataractous and cataractous eyes. Among cataractous eyes in which imaging was possible, there was no correlation between difference in RNFL thickness before and after dilation and nuclear opalescence, nuclear color, and cortical and posterior subcapsular grading of the LOCS III score. Six of 27 eyes (22.2%) had a change of more than 10% in RNFL thickness after pupillary dilation. CONCLUSION: Although pharmacologic mydriasis does not statistically alter RNFL thickness as measured by SLP, approximately one fifth of such eyes will have a change of more than 10% in retardation. Uniformity in pupil size is recommended when longitudinally evaluating RNFL measurements.

A slit-lamp needling filtration procedure for uncontrolled glaucoma in pseudophakic and aphakic eyes.

In one aphakic and one pseudophakic patient without previous filtration surgery, a transconjunctival needling procedure similar to that used for failed filtration procedures was performed to create a filtering bleb. In both cases, intraocular pressure was successfully lowered for 6 months until the occurrence of bleb encapsulation, which was relieved by transconjunctival needling. There were no complications. In selected cases, this minimally invasive slit-lamp needling procedure provides successful filtration.

Anterior chamber contamination during cataract surgery with intraocular lens implantation.

PURPOSE: To measure anterior chamber bacterial and fungal contamination at the beginning and end of cataract surgery with intraocular lens (IOL) implantation in a large series of patients and to determine the influence of preoperative treatment and operative technique on contamination. SETTING: Department of Ophthalmology, County Hospital of Salzburg, Austria. METHODS: This prospective study comprised 700 consecutive patients having planned cataract extraction (511 phacoemulsification, 189 extracapsular cataract extraction [ECCE]). Thirty-four patients required an anterior vitrectomy; 8 myopic patients did not receive an IOL. A preoperative smear and two intraoperative (at the beginning and end of surgery) anterior chamber aspirates were obtained from each patient. Postoperative smears were obtained at discharge. Three preoperative treatments were evaluated: no lacrimal system irrigation, no topical antibiotic (n = 282); lacrimal system irrigation with balanced saline solution, no topical antibiotic (n = 243); lacrimal system irrigation, antibiotic (neomycin) eyedrops (n = 175). All patients received topical indomethacin twice a day preoperatively. RESULTS: Preoperative conjunctival smears showed bacterial growth in 76.6% of eyes, with coagulase-negative staphylococci (75%) the most common bacteria. Anterior chamber aspirates were culture positive in 14.1% at the beginning and in 13.7% at the end of surgery, with coagulase-negative staphylococci and corynebacteria the most common. Contamination rates of conjunctival smears taken at discharge were significantly lower (35%) than those taken preoperatively. There was no statistically significantly higher risk of anterior chamber contamination in eyes having ECCE than in those having phacoemulsification. Preoperative treatment did not statistically significantly influence intraoperative aqueous humor contamination rates. There were no cases of acute postoperative endophthalmitis. CONCLUSION: Bacteria entered the anterior chamber during cataract extraction and remained there at the end of surgery in a significant percentage of patients. Surgical technique, preoperative antibiotics, and preoperative lacrimal system irrigation had no statistically significant effect on contamination.

[Endogenous candida endophthalmitis: a new therapy]. / Endogene Candida-Endophthalmitis: eine neue Therapie.

A thirty-year-old patient underwent an extensive abdominal surgery because of a precancerosis due to a colitis ulcerosa. An accompanying smoldering panuveitis led under immunosuppressive therapy to the loss of sight of one eye. Only an increasing vitritis of the second eye allowed the diagnosis of an endogenous Candida endophthalmitis (ECE) following a vitrectomy. A systemic administration of the common antifungal medications was impossible because of the patient's pathological blood-picture and a severe cholestasis. We report the successful use of Fluconazol (Diflucan), an antimycotic agent we never used before in this connection.