[Dural carotid-cavernous sinus fistulas: clinical aspects, diagnosis and therapeutic intervention]. / Durale Carotis-Sinus-cavernosus-Fisteln: Klinik, Diagnostik und therapeutische Intervention.

BACKGROUND: Carotid cavernous fistulas are cerebral artenovenous shunts which may present with ocular or orbital signs. Direct fistulas are distinguished from dural shunts with respect to the anatomical situation. PATIENTS: We report on two patients with spontaneous dural carotid cavernous fistulas with multiple feeding vessels. Both patients required endovascular embolization. RESULTS: Therapy was successful in both patients. We present an overview of the clinical picture, the diagnostic procedure, the differential diagnosis and the therapeutic possibilities in this clinical entity. CONCLUSION: Both patients prove the importance of an immediate differential diagnostical classification so that a specific neuroradiological diagnostic can be ensured. Today's advanced endovascular technology offers therapeutic options with less risk for the patient than in recent years.

Severe ocular trauma managed with primary pars plana vitrectomy and silicone oil.

PURPOSE: This study evaluated the outcome of severely injured eyes treated with early primary vitrectomy with silicone oil filling. METHODS: A total of 435 eye injuries, which required surgical intervention, were reviewed retrospectively. In 13 eyes (3%) pars plana vitrectomy and silicone oil filling were performed as primary surgical repair. Silicone oil filling was restricted to cases with laceration of the retina larger than 4 disc diameters (nine eyes), primary retinal detachment larger than two quadrants (two eyes) and/or persistent intrasurgical hemorrhage (12 eyes). All patients underwent surgery within 24 hours. RESULTS: After a mean follow-up period of 28.7 months (range, 9-70 months), 11 eyes achieved a visual acuity ranging from 20/25 to 20/200. Silicone oil was removed in 11 of 13 eyes after 5.8 +/- 4.6 months. Recurrent proliferative vitreoretinopathy developed in two eyes. CONCLUSIONS: Silicone oil tamponade after early primary pars plana vitrectomy may be an alternative for primary repair after trauma, especially in severely injured eyes with retinal lacerations larger than 4 disc diameters, persistent intrasurgical bleeding, and/or primary retinal detachments.

Evaluation of atherosclerosis in patients with central retinal vein occlusion by carotid artery duplex scanning and echocardiography: a prospective case-control study.

BACKGROUND AND PURPOSE: Central retinal vein occlusion (CRVO) is a common cause of retinal vascular visual loss second to diabetic retinopathy. Atherosclerotic risk factors are thought to affect vascular flow or cause retinal vascular wall abnormalities, thereby contributing to development of CRVO. Previous studies did not fully evaluate the degree of atherosclerotic disease. The purpose of this study was to determine the degree of atherosclerosis of the carotid artery by duplex scanning and to investigate cardiac manifestations of atherosclerotic risk factors by echocardiography in patients with CRVO. MATERIAL AND METHODS: 39 patients (age 63.1 years [50-84 years], 21 men, 18 women) with CRVO were compared with a control group consisting of 39 individuals (age 59.3 years [49-81 years], 19 men, 20 women) in whom echocardiography was performed to rule out endocarditis. Clinical examination, laboratory testing, carotid artery duplex scanning and echocardiography were performed in all patients. RESULTS: Echocardiography revealed significantly increased prevalence of left ventricular hypertrophy (30.8% in CRVO patients, 5.1% in controls) as a typical sign of hypertensive heart disease in CRVO patients, which is consistent with the increased prevalence of hypertension (HTN) (46.2% in CRVO patients, 15.4% in controls). The prevalence of atherosclerosis of carotid artery and ascending aorta, and all other echocardiographic findings were comparable in CRVO patients and controls: regional wall motion abnormality, left ventricular dilatation, aortic valve calcification, and mitral valve calcification. CONCLUSION: Our study demonstrates that CRVO is not associated with atherosclerosis of large arteries, such as the carotid artery and the ascending aorta. We propose that the retinal artery atherosclerosis seen in most CRVO patients is caused by HTN.

[Idiopathic juxtafoveolar telangiectasis. Long-term follow-up of visual acuity]. / Idiopathische juxtafoveoläre Teleangiektasien. Langzeitverlauf des Sehvermögens.

The beneficial effect of laser therapy on idiopathic juxtafoveolar telangiectasis is questionable. We therefore studied retrospectively the spontaneous course of the disease and tried to show a correlation between the initial angiographic findings and visual outcome. In addition, the results after laser therapy were compared with untreated patients. Thirteen patients (24 eyes) with idiopathic juxtafoveolar telangiectasis diagnosed by fluorescein angiography were reexamined after a mean time interval of 38 months. Argon laser coagulation had been performed in 6 patients. The initial extension of fluorescein leakage was divided angiographically into three different stages. The existence of secondary macular changes and peripheral involvement was noted. The mean visual acuity decreased from 0.71 to 0.62 over the follow-up period. No correlation could be found between the final visual outcome and initial extension of telangiectasis or existence of secondary changes. After laser coagulation the patients did not show a better visual outcome. Due to the relatively benign spontaneous course of idiopathic juxtafoveolar telangiectasis laser coagulation cannot be recommended in general. Only in exceptional cases (e.g., development of subretinal neovascularization) can laser coagulation be of benefit.

[Incidence of ophthalmologic complications in acute intracranial hypertension]. / Inzidenz ophthalmologischer Komplikationen bei akuter intrakranieller Drucksteigerung.

Although Terson's syndrome has been diagnosed more frequently since the early 1960s because of improved intensive-care facilities, these reports are single case reports or retrospective studies. Therefore, we examined prospectively 20 patients (11 male, 9 female), aged between 23 and 77 years, with subarachnoid hemorrhages or rapid increase in intracranial pressure (ICP) of other origin (tumor-associated, post-traumatic) to evaluate ocular changes. In all patients the increase in ICP was confirmed by computed tomography. Additionally, in 16 patients permanent monitoring of ICP was performed. Twelve patients presented with subarachnoid hemorrhage, 6 had a post-traumatic increase in ICP, and 2 more presented with a tumor-associated intracranial hemorrhage. A total of 8 patients (40%) presented with intraocular changes; 6 presented with uni- or bilateral intraretinal hemorrhage, 1 patient had a bilateral papilledema and 1 more patient had bilateral vitreal hemorrhage. When ocular hemorrhage occurred, the mortality was 2.5 times as high as in patients without ocular hemorrhage. For this prognostic feature of the ophthalmological status all patients with rapid increase in ICP should be monitored early for intraocular hemorrhage. The possibility of intraocular hemorrhage is elevated in high-degree subarachnoid hemorrhage, whereas a rapid increase in ICP also found when the pressure has other causes (tumor-associated, posttraumatic).

[Systemic perfusion times in non-arteritic anterior ischemic optic neuropathy]. / Systemische Perfusionszeiten bei nicht-arteriitischer anteriorer ischämischer Optikusneuropathie.

The pathogenesis of non-arteritic anterior ischemic optic neuropathy (AION) is not well understood. Local factors like elevated IOP or a low C/D ratio may play a role, as may systemic arteriosclerosis or reduced perfusion pressure. Reduced cardiac output may also contribute to the pathogenesis of the disease. We therefore investigated 17 healthy young persons, 9 patients with non-arteritic AION, and 10 age-matched controls using fluorescence perfusion scintigraphy, a technique that allows subclavia carotid time to be determined. Subclavia carotid time measures the circulation time of the heart and lung and is proportional to cardiac output. The mean subclavia carotid time of healthy young persons was 9.1 +/- 1.6 s, 9.9 +/- 1.9 for AION patients, and 9.9 +/- 1.2 s for age-matched controls. The differences were statistically not significant. The correlation of perfusion times with blood pressure values showed, however, that systemic hypertension is accompanied by a relatively slow systemic perfusion time. In conclusion, it was not possible to demonstrate an absolutely reduced cardiac output in patients with non-arteritic AION during the day. Nevertheless, a drop in systemic blood pressure during the night may be responsible for a reduction in the blood supply to the optic nerve.

[Outer retinitis as an early symptom of subacute sclerosing panencephalitis]. / Aussere Retinitis als Frühsymptom bei subakut sklerosierender Panencephalitis (SSPE).

BACKGROUND: A primary ocular manifestation of subacute sclerosing panencephalitis is known and can progress to severe visual deterioration. The rare occurrence of the disease makes diagnosis often difficult. CASE REPORT: The lethal clinical course of a patient with subacute sclerosing panencephalitis (SSPE) is presented. The disease manifested itself with severe ophthalmic symptoms preceding clinical and neurological signs and leading to bilateral blindness. The dramatic drop of visual acuity was due to a unilateral and later in the course bilateral pigmentepitheliopathy of the posterior pole. Inflammatory signs of retinal vasculature or inner retinal layers were detected neither clinically nor by fluoresceine angiography. A typical blockage of background fluorescence was demonstrated in fluoresceine and indocyanine angiography. Within two weeks after initial symptoms optic atrophy developed in both eyes. CONCLUSION: The primary lesion of retinal pigment epithelium and outer retinal layer were the prominent findings in this case. The presence of an outer retinitis of the posterior pole should alert the physician to the possibility of subacute sclerosing panencephalitis.

Early pars plana vitrectomy without buckling procedure in cytomegalovirus retinitis-induced retinal detachment.

BACKGROUND: Retinal detachments induced by cytomegalovirus (CMV) retinitis can often be treated successfully with a buckling procedure combined with vitrectomy and silicone oil instillation, but this technique yields varying visual results. METHODS: To minimize operational trauma, pars plana vitrectomy and silicone oil instillation without additional buckling was performed in a series of 11 consecutive patients with acquired immune deficiency syndrome (AIDS) and CMV-retinitis-induced retinal detachment. Surgery was performed early in the course of the retinal detachment: 6 patients (55%) had an attached macula, and 7 patients (64%) had a visual acuity of 20/200 or better. RESULTS: After a mean follow-up period of 5 months (range, 1-9 months) 9 patients (82%) had a completely reattached retina and 9 patients (82%) had visual acuity of 20/200 or better. The macula was reattached in all patients. A localized detachment of the inferior retina was noted in 2 patients (18%), and a second operation was required in one eye. Significant cataract formation occurred in two patients during the follow-up period. Proliferative vitreoretinopathy and increased intraocular pressure were not observed. CONCLUSION: Early vitrectomy without additional buckling procedures is justified in patients with CMV-associated retinal detachment because it stabilizes the retinal situation without major complications and improves visual function.

[Perfusion time of the central retinal artery in normal pressure glaucoma. Initial results]. / Perfusionszeit der A. centralis retinae bei Normaldruckglaukom. Erste Ergebnisse.

UNLABELLED: A possible explanation for the progressive visual field defects in normal tension glaucoma is reduced ocular blood flow. We have tried to answer this question using fluorescence perfusion scintigraphy that measures the circulation times between the subclavian vein, carotid artery, central retinal artery and central retinal vein. PATIENTS: Eight normal subjects and eight age- and sex-matched normal tension glaucoma patients were compared. Inclusion criteria for NTG patients were an IOP below 23 mmHg, glaucomatous visual field defects, glaucomatous disk cupping, normal chamber angle and no neurologic deficits. The subclavian carotid time, the carotid retina time and the mean retinal perfusion time of the intravenously injected radioactive fluorescein bolus were measured using digitized scanning laser angiography and technetium scintigraphy. RESULTS: Subclavian carotid time and mean retinal perfusion time were not significantly different between groups, whereas the carotid retina time was 1.6 s (min = 0.8, max = 2.6) in normals and 3.3 (min = 2.6, max = 4.2) in normal tension glaucoma. This difference was highly significant (P < 0.001). CONCLUSIONS: The delay of the carotid retina circulation time in normal tension glaucoma patients may reflect a reduced blood flow velocity in the internal carotid artery, the ophthalmic artery and the central retinal artery. The subclavia carotid time and ultrasound investigation of the carotid artery were normal. This suggests that the delayed carotid retina time is an indicator of reduced blood flow velocity in ophthalmic and mainly central retinal artery. The good discrimination between normal subjects and NTG patients must be confirmed in a larger group of patients.

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.

[Comparative study of deep lying drusen of the papilla with the scanning laser ophthalmoscope and fundus camera]. / Vergleichende Untersuchung tiefliegender Drusen der Papille mit Scanning Laser Ophthalmoskop und Funduskamera.

We examined four patients with the suspected diagnosis of optic disc drusen by scanning laser ophthalmoscopy (SLO) and fundus photography. In all four cases the autofluorescence that distinguishes optic disc drusen was observed with the SLO, but not with the fundus camera. Three of the four examined patients, children or adolescents, were spared further diagnostic procedures to clarify the underlying cause of the swollen optic disc.

[Fluorescence angiography image of erythrocytes with the scanning laser ophthalmoscope]. / Fluoreszenzangiographische Abbildung der Erythrozyten mit dem Scanning-Laser-Ophthalmoskop.

Erythrocytes bind fluorescein to their surface, but they do not take up the dye intracellularly during fluorescein angiography. The cells are therefore hypofluorescent compared to blood plasma. Due to the high velocity of red blood cells in retinal vessels, this phenomenon has not been observed during conventional angiography. Scanning laser ophthalmoscopy, however, allows imaging of the retina with a very high temporal resolution. The exposure time of the scanning laser beam for a single erythrocyte is in the range of only 100 ns. Therefore, scanning laser ophthalmoscopy permits imaging of fast-moving red blood cells in large retinal vessels. Pathologically reduced blood flow is clearly visible and can be measured with digital image analysis. The values found in three patients with vascular occlusions were between 0.1 and 1.8 mm/s. In cases with intact circulation, digital image analysis was not sufficient to measure red blood cell velocity. Even if a velocimeter that permits semiquantitative comparison between erythrocytes and moving black dots is used, superimposed on the angiogram, reliable results can only be obtained in cases with reduced red cell velocity. Nevertheless, for the clinician observation of erythrocyte flow during scanning laser angiography is a new and fascinating tool.

[Acute retinal necrosis--a herpetic retinitis?]. / Die akute Retinanekrose--eine herpetische Retinitis?

Acute retinal necrosis (ARN) is characterized by unilateral or bilateral severe vaso-occlusive retinitis. In a large number of cases the patients become blind in the affected eyes as a direct result of the acute inflammation or the subsequent retinal detachment. The etiology is poorly understood; herpesvirus-induced vasculitis is presumed and has been demonstrated by some authors. However, the author's own investigations in seven patients show that even vitreous biopsy reveals a herpetic origin only in a minority of cases. Intravenous treatment with acyclovir and steroids prevented progression of the retinitis but did not reduce the risk of retinal detachment.

Recovery after severe ethambutol intoxication--psychophysical and electrophysiological correlations.

Six patients with severe ocular side effects caused by therapeutical doses of the tuberculostatic drug ethambutol were investigated during the course of recovery with psychophysical and electrophysiological methods. Three patients developed an optic atrophy with permanently reduced vision as a likely consequence of additional risk factors such as diabetes, alcohol abuse, and reduced kidney function. The severity of the neuritis of the optic nerve was not related to the total intake of ethambutol. The likelihood of a permanent ocular damage increased sharply if the visual acuity had dropped below a value of 1/10. permanently prolonged latency of the P-100 component was found in visual evoked potentials even in cases with good recovery from ethambutol-induced damage. The recovery of color vision could be monitored very well with the Farnsworth-Munsell 100-Hue Test which revealed a diffuse impairment of color discrimination with a slight prevalence of the red-green axis. In addition to the known disturbances of the red-green antagonistic neurons, it could be demonstrated by measuring transient tritanopia and spectral sensitivity functions that ethambutol also affects the blue-yellow antagonism at the retinal level.

[Observation of erythrocyte flow in retinal vessels during fluorescein angiography]. / Observation du débit érythrocytaire dans les vaisseaux rétiniens au cours de l'angiographie en fluorescence.

Erythrocytes do not take up fluorescein intracellularly during angiography, they are hypofluorescent compared to blood plasma. This negative staining phenomenon has not been observed in the human retina. Scanning Laser Ophthalmoscopy permits imaging of the retina with a higher temporal and a higher spatial resolution than a conventional funduscamera. Thus, the retinal erythrocyte flow can be observed during fluorescein angiography. The red blood cells are seen as multiple black dots in a superficial layer of the intravasal blood column. A pathologically reduced blood flow can be recognized by simple observation. The velocity of the red blood cells is estimated with an erythrocyte velocimeter, that permits an optical comparison between the velocity of black dots and the velocity of the cells in the retinal vessel. The measured values fit well to the data obtained with the laser doppler technique. Therefore, the negative staining phenomenon in association with scanning laser ophthalmoscopy gives us a new tool in retinal microcirculation research.

[Fluorescence perfusion scintigraphy. A new method for quantifying ocular circulatory disorders]. / Die Fluoreszenz-Perfusions-Szintigraphie. Eine neue Methode zur Quantifizierung okulärer Durchblutungsstörungen.

A new clinical method, fluorescence perfusion scintigraphy (FLUPS), had been developed that permits high-resolution measurement of the circulation time between the carotid artery and the retina. A bolus, consisting of 0.5 ml Na-fluorescein (20%) and 0.5 ml 99mTc-DTPA (20 mBq) is injected into the antecubital vein. The bolus is detected first by a transdermal gamma emission detector overlying the carotid artery with 5 measurements per second. The subsequent appearance of the bolus in the eye is simultaneously recorded with a scanning laser ophthalmoscope that permits high-resolution angiograms. A picture analysis system measures the increase in the intensity of the fluorescence over the optic disc. The temporal difference between the time concentration curves obtained with these techniques is the carotid-retina circulation time. The carotid-retina time of both eyes of 15 patients with unilateral central retinal vein and branch vein occlusion was measured in order to detect interocular changes in the circulation time. The carotid-retina time, as determined by FLUPS in normal eyes, ranged between 0.7 and 2.3 s. Patients with central retinal vein occlusion showed a carotid-retina time that was significantly (p less than 0.05) delayed by 3 to 150%. These data demonstrate that FLUPS is a valuable tool for monitoring defects in the ocular circulation.