[Eyelid surgery : Eyelid surgical techniques from a histopathological perspective]. / Lidchirurgie : Lidchirurgische Techniken aus histopathologischer Sicht.

Eyelid surgery and histopathology are closely related, especially in tumor surgery. Based on histological specimens from the archive of the Department of Ophthalmopathology, Eye Centre Freiburg, this article deals with the search for traces following eyelid surgery, and explains the respective clinical relevance for ophthalmologists involved in surgical and conservative treatment. Thermal, electrical and mechanical impacts on the tissue during tumor removal lead to histologically detectable artifacts. These must be kept to a minimum by the surgeon in order to ensure histological assessability and avoid adverse consequences for the patient. During the subsequent eyelid reconstruction, the eyelid architecture is changed depending on the surgical technique. Thus, after Hughes' operation a degeneration of the meibomian glands is histologically noticeable, which should be taken into account in the clinical aftercare of the patients. Suture material can lead to foreign body granulomas, which can be clinically misinterpreted as tumor recurrence. In contrast to foreign material, transplanted autologous tissue, such as cartilage or oral mucosa in the case of eyelid malposition, usually does not lead to chronic inflammation.

[Surgical management of firework-induced eyelid injuries]. / Lidchirurgische Versorgung von Feuerwerksverletzungen.

Fireworks injuries are frequently caused by malfunction or incorrect operation of fireworks. Injuries often affect the eyeball and the periorbit. After treatment of life-threatening bleeding, injuries of the eyeball have priority over the treatment of periorbital lacerations and burns. The aim of eyelid surgery in firework-related injuries is to prevent delayed damage, such as lagophthalmos, symblepharon, entropion with trichiasis, and keratinization of the conjunctiva of the eyelid and eyelid margin. The treatment requires a considerable amount of time and patience both for the elaborate surgical procedures as well as for the necessary healing and rest phases. Many patients, however, are left with serious visual impairments and stressful esthetic deformities, which result in considerable occupational and social impairments.

[The underestimated depth of tissue invasion of xanthelasma--a histological study]. / Die oft unterschätzte Tiefenausdehnung von Xanthelasmen--eine histologische Studie.

BACKGROUND: The depth of tissue invasion of xanthelasma is of major importance in selecting the most suitable surgical procedure. Intraoperative findings let one assume, that despite the common presumption, xanthelasma are not limited to the superior dermis but that they may penetrate the entire dermis and reach into the orbicularis muscle. In this study the depth of tissue invasion of xanthelasma was measured in histological specimens. MATERIALS AND METHODS: Between 1993 and 2006 100 xanthelasmata of 78 patients were surgically removed and analysed. Histological specimens were examined by light microscopy and the depth of tissue invasion by fat-containing macrophages was measured using the digital picture analysis system AnalySIS® of Soft Imaging System Inc. The distance from the epidermis/dermis junction to the deepest "xanthelasma" cell (fat-containing macrophage) was measured. In addition, we classified the cases into 3 categories: 1) invasion into the dermis, 2) invasion adjacent to and 3) invasion into the stratum musculare. RESULTS: The thickness of the xanthelasmata ranged between 502.9 µm und 4429.5 µm (m = 1443.6 µm, M = 1333.6 µm, SD 716.1). In 58 % of specimens lipid-containing macrophages infiltrated the dermis (m = 1275.9 µm, SD 571.0), in 15 % of specimens they touched the stratum musculare (m = 1426.2 µm, SD 534.8) and in 27 % of specimens they even infiltrated this layer (m = 1813.4 µm, SD 937.6). CONCLUSIONS: This study confirms our hypothesis that a significant part, namely 42 % of the xanthelasmata, infiltrates the entire dermis and reaches the stratum musculare or even invades into this layer. These xanthelasmata should not be treated by superficial laser therapy but should be better excised surgically.

[Chronic dacryocystitis 24 years after dacryocystorhinostomy?]. / Chronische Dakryozystitis 24 Jahre nach Dakryozystorhinostomie? Diagnose: Extraorbital gelegenes Hämangioperizytom (solitärer fibröser Tumor bzw. SFT nach WHO).

A 50-year-old woman suffered from recurrent swelling and inflammation in the region of the medial portion of the lower eyelid 24 years after right-sided dacryocystorhinostomy. The tumor was removed in two stages under histological control of the excision margins. No evidence for malignancy was found. During the follow-up period of 4 years the patient remained recurrence free and without complaints. The diagnosis reached was an extraorbital hemangiopericytoma.

[Corneal complications after hematopoietic stem cell transplantation]. / Hornhautkomplikationen nach hämatopoetischer Stammzelltransplantation.

AIM: To evaluate the incidence and clinical course of corneal complications in patients with severe dry eye syndrome after hematopoietic stem cell transplantation (HSCT). PATIENTS AND METHODS: 50 consecutive patients (aged 9-65 years; average=42+/-11 years) with Sjögren-like syndrome after hematopoietic stem cell transplantation were examined. In order to assess the severity of the dry eye syndrome, the frequency of blinking and break-up time were determined and Schirmer-I, fluorescein,and rose bengal tests were carried out. Biopsy and histological examination were performed in cases with suspected conjunctival graft-versus-host reaction. RESULTS: Patients with Sjögren-like dry eye syndrome were referred within an average of 13 months after HSCT (SD+/-20 months).The follow-up was up to 83 months (mean: 10.2 months,SD+/-14.97). Of the 50 patients 15 developed severe corneal complications with significant loss of vision which resulted in enucleation of the eye in 1 patient. Of these 15 patients 4 had a viral and 2 a bacterial keratitis,7 had trophic corneal thinning and sterile ulcers. Two patients had limbal stem cell insufficiency or pseudomembranous conjunctivitis, both due to conjunctival graft-versus-host reaction. Another patient developed a toxic keratopathy, probably induced by cyclosporin A eye drops. Of 50 patients 35 presented with signs of an inactive or active conjunctival graft-versus-host reaction which could be proven histologically in 26 patients. DISCUSSION: Patients with Sjögren-like dry eye syndrome after hematopoietic stem cell transplantation are at high risk to develop corneal complications.These complications may result from an aggressive extension of the graft-versus-host reaction towards the conjunctiva and/or the lacrimal gland and seem to occur more often during the period of reduction of systemic immunosuppressive therapy.Furthermore, infectious as well as trophic or toxic corneal complications may be supported by local immunosuppressive therapy. We suggest frequent ophthalmological checks of patients receiving hematopoietic stem cell transplantation who need local immunosuppressive therapy or are in the phase of reduction of systemic immunosuppressive therapy

[Astigmatism after trans-scleral posterior chamber lens implantation in young children]. / Astigmatismus nach transskleraler Hinterkammerlinsenimplantation bei Kleinkindern.

BACKGROUND: The purpose of this study was to evaluate the postoperative astigmatism after trans-scleral fixation of intraocular lenses in children and to develop a strategy for amblyopia prophylaxis. PATIENTS AND METHODS: In eight eyes with lentectomy, posterior chamber intraocular lenses were fixed in the ciliary sulcus by trans-scleral sutures. The postoperative astigmatism was measured by retinoscopy every 1 to 2 weeks in the first 2 months, followed by monthly intervals thereafter. Keratometry was performed with an automated hand keratometer. RESULTS: Postoperative astigmatism was 2.5 to 8.0 D. The astigmatism regressed to 0.75 D in half the eyes within 4 weeks and in five of the eyes within 16 weeks. In one of the eight eyes, the astigmatism decreased to 2.0 D and in two it remained unchanged. The astigmatism did not change any more after 16 weeks postoperatively. Visual acuity was 0.016 to 1.0. CONCLUSIONS: Our study shows that the postoperative astigmatism regresses soon and does not seriously interfere with amblyopia therapy. If greater than 2 D, half of the astigmatism should be corrected with glasses, even in the early postoperative period. After 16 weeks, full correction is recommended.

[Errors in keratometry for intraocular lens implantation in infants]. / Messungenauigkeiten der Keratometrie bei der Intraokularlinsenberechnung für Säuglinge.

UNLABELLED: To evaluate investigator- and instrument-dependent errors of keratometry in children and their possible influence on the predicted postoperative refraction after intraocular lens implantation. METHODS: Keratometry readings of five children with congenital cataract were taken preoperatively under general anesthesia (age 1.5-7.5 months, mean = 4.4 months). Both eyes were measured by two investigators with a manual Zeiss keratometer and an Alcon portable automated keratometer. Three measurements were performed with each instrument. Axial length was determined with ultrasound and the SRK II-formula was used for intraocular lens calculation. RESULTS: The investigator-dependent variability was 0.22 mm +/- 0.07 SEM for the manual keratometer and 0.20 mm +/- 0.07 SEM for the automated keratometer. The instrument-dependent variability was 0.44 mm +/- 0.12 SEM for investigator A and 0.34 mm +/- 0.09 SEM for investigator B. These results suggest that deviation from the required postoperative refraction of up to 6.0 D has to be expected in individual cases if intraocular lenses are implanted. CONCLUSIONS: The lack of fixation in children who have keratometry under general anesthesia leads to inaccurate keratometry readings, which will cause rather high deviations of the precalculated postoperative refraction. Our results explain the high rate of residual refractive errors reported in the literature after intraocular lens implantation in children. In order to improve the accuracy of keratometry multiple measurements of corneal curvature should be taken.

Transscleral suture fixation of posterior chamber intraocular lenses in children under 3 years.

BACKGROUND: Children who have undergone lentectomy for congenital or traumatic cataract do not have adequate capsular support for secondary posterior chamber intraocular lens (PC-IOL) implantation and thus will become severely amblyopic if contact lens intolerance occurs. In order to prevent amblyopia we fixed PC-IOLs by transscleral sutures in three children younger than 3 years. Clinical outcome, visual acuity and course of refraction were studied. METHODS: Four eyes of three children with contact lens intolerance were operated. Posterior chamber lenses (PC-IOL) were sutured in the ciliary sulcus by transscleral sutures. Two children had monocular traumatic cataract and one child underwent surgery on both eyes for congenital cataract. To allow adjustment of refraction in situ without removing the primarily implanted and transsclerally fixed PC-IOL we used the piggyback intraocular lens system for implantation. RESULTS: Visual acuity improved in all four eyes. The two children with traumatic cataract achieved visual acuity of 0.7 and 1.0, respectively, and stereopsis. No complications related to the technique of transscleral suture fixation of the PC-IOL were observed. Postoperative changes in refractive power were caused by a myopic shift between -1.0 D and -9.0 D. Follow-up was 25-70 months. CONCLUSION: Transscleral suture fixation of PC-IOLs did not cause specific complications during follow-up of up to 70 months. This technique offers an important option for the correction of an aphakic refractive error which cannot be corrected otherwise. In future the piggyback intraocular lens system may help to rather atraumatically correct postoperative changes in refractive power.

[Etiology of contact lens failure in pediatric aphakia. Indications for intraocular lenses?]. / Ursachen des Kontaktlinsen-Abbruchs bei kindlichen Aphakien. Indikation für Intraokularlinsen?

UNLABELLED: Due to the low rate of complications, lentectomy and contact lens fitting is the standard treatment for congenital cataract. However, contact lens fitting is not possible in all children. The authors report the main reasons for discontinuation of contact lenses in their patients. METHOD: In 134 consecutive lentectomies of 90 children, the underlying eye diseases and general diseases, the age at operation, compliance of parents and children, and social background were analyzed. RESULTS: Twenty of the 90 children had to discontinue contact lens wearing. Twelve of these children were operated on one eye and 8 on both eyes. Only 2 children showed signs of contact lens complications. In 2 children treatment was stopped because of the poor visual prognosis and in 10 children the parents discontinued contact lens treatment because of a severe handicap of the child (n = 2) or due to misunderstanding and parental noncompliance (n = 8). Six children refused contact lenses without obvious reasons. Among the latter, children 2-4 years of age were at the greatest risk. Children with additional systemic abnormalities frequently developed contact lens intolerance. CONCLUSION: In children with systemic abnormalities and in the case of parental communication and compliance problems, discontinuation of contact lenses has to be expected in up to 30% of cases. In these children and in children who object to contact lenses at the age of 2-4 years, intraocular lens implantation should be considered, especially in unilateral cataract, if successful contact lens treatment is not achievable within 8-12 weeks.

Piggyback intraocular lens with exchangeable optic.

The exchange of a posterior chamber intraocular lens (IOL) is difficult if the lens is transsclerally or iris fixated or if a large posterior capsulotomy exists. A piggyback IOL system was developed that allows adjustment of refraction in situ without removing the primarily implanted IOL. The system comprises a posterior chamber IOL and a separate, exchangeable optic. Three succeeding designs were implanted in human, donor eyes. The piggyback system's optical performance exceeded the requirements for conventional posterior chamber IOLs. Thus, the lens could be used in eyes in which postoperative refraction is likely to change or is incorrect (e.g., in children or cases of combined cataract extraction and corneal implantation.

[Early management of scrape and denuding injuries of the face after bicycle accidents. Prevention of scar ectropion]. / Frühbehandlung von Abschürfungs und Ablederungsverletzungen des Gesichts nach Fahrradunfällen. Vorbeugung von Narbenektropien.

Bicycle accidents may cause typical skin defects in the maxillary area if the unprotected face of the bicyclist hits the ground. Cicatricial ectropion is a frequent result. We report on 22 patients with facial skin defects after bicycle accidents and demonstrate a new concept for early treatment of facial skin abrasions and skin defects. Transtarsal traction sutures, temporary closure of skin defects by synthetic skin, and delayed free-skin grafting can prevent cicatricial ectropion even in large skin defects extending beyond the orbital margin. The overall time for treatment is significantly reduced.

Transscleral suture fixation of posterior-chamber lenses after cataract extraction associated with vitreous loss.

From 1987 to 1993, 21 patients who had undergone complicated cataract extraction that was associated with vitreous loss and transscleral suture fixation of the posterior-chamber lens (PC-IOL) in one eye (group A) and uncomplicated in-the-bag implantation of the PC-IOL in the fellow eye (group B) were followed prospectively. The follow-up period was 29.5 months (SD, +/- 17.0 months) in group A and 36.6 months (+/- 24.0 months) in group B. Visual acuity did not differ significantly between the two groups (P = 0.60, Wilcoxon test). In all, 17/21 patients in group A and 16/21 patients in group B achieved a visual acuity of > or = 20/40. Postoperative refractions measured in group A were +0.68 D more hyperopic than those measured in group B (P < 0.04). This result was consistent with the postoperative finding of a significantly deeper anterior chamber in group A (mean, 0.44 mm; P < 0.03). The accuracy of the desired postoperative refraction was poorer in group A. The risk for retinal detachment, cystoid macular edema, and intraocular pressure elevation was increased in patients who had had capsular defects and vitreous loss during cataract extraction. Nevertheless, transscleral suture fixation of PC-IOLs in patients with complicated cataract extractions associated with vitreous loss can give acceptable visual results. We recommend that +0.5 D be added to the calculated IOL power when severe complications require transscleral suture fixation of the PC-IOL during cataract extraction.