[Ophthalmological rehabilitation of visually impaired children]. / Ophthalmologische Rehabilitation sehbehinderter Kinder.

BACKGROUND: There are very few studies on visually impaired children in Germany; therefore, the aim of this study was to investigate the current spectrum of diseases of visually impaired children and the care of these children in schools and kindergartens with aids and integrative support. PATIENTS AND METHODS: In a retrospective study all children (n =303) who attended the outpatient department for the visually impaired of the University Eye Hospital Tübingen in 2013 and 2014 were evaluated. The target values were ophthalmological diagnosis, best corrected visual acuity, needs for magnification, prescribed aids, measures for early support and integrative care and inclusion during schooltime. RESULTS: The most frequent diagnosis in this collective which led to visual impairment in children was optic atrophy (22.4%) followed by hereditary retinal dystrophy (18.5%), congenital nystagmus (9.9%), albinism (8.6%), retinopathy of prematurity (ROP, 7.9%), aniridia (4.6%), cerebral visual impairment (CVI, 4.3%) and severe myopia (3%). Of the children 21% suffered from multiple disabilities, 66% were visually impaired (visual acuity ≤0.3 and >0.05), 9% were severely visually impaired (visual acuity ≤0.05) and 6% were legally defined as blind (visual acuity ≤0.02). Of the schoolchildren 52% (n = 241) were able to visit a mainstream school within the framework of integrative care. For 77% of these schoolchildren integrative care was already provided by a special pedagogic institution at the time of presentation for school entry and 73% of all the schoolchildren needed magnifying aids at school: 20% used optical magnifying aids (e.g. reading stones) and 53% needed electronic magnifying aids, such as screen magnifiers or camera reading systems. CONCLUSION: Particularly for children, the use of magnifying aids for reading is essential for education in schools and 73% of the children used optical or electronic devices for reading. Of the children 52% attended a mainstream school and were additionally supported by special pedagogic counseling services.

[Requirements for low vision magnification aids in age-related macular degeneration: Data from the Tübingen low vision clinic (comparison of 2007-2011 with 1999-2005)]. / Bedarf an vergrößernden Sehhilfen bei altersbedingter Makuladegeneration: Daten der Tübinger Sehbehindertenambulanz (Vergleich der Jahre 2007 bis 2011 mit 1999 bis 2005).

BACKGROUND: The purpose of this study was to investigate if there has been a change in requirements for low vision magnification aids in recent years. PATIENTS AND METHODS: The collective data from age-related macular degeneration (AMD) patients from the Tübingen low vision clinic from the years 2007-2011 were compared with the patient collective from the years 1999-2005. Magnification needs and the prescribed magnifying aids for reading in the categories magnifying spectacles, hand-held magnifiers, monocular telescopes, electronic magnifiers and electronic reading devices were evaluated. In addition patients from 2010 and 2011 were divided into dry and neovascular AMD and the prescribed magnification aids were compared for these AMD forms. RESULTS: There was no significant change in in the prescribed magnification reading aids for AMD patients between the years 1999-2005 and 2007-2011. An electronic magnifier was prescribed most often (both collectives 43 %), followed by hand-held magnifiers (32 and 29.5 %, respectively) and magnifying spectacles (17 and 18.8 %, respectively). Also the magnifying needs and mean age of the AMD patients did not change significantly between the two periods (2007-2011 versus 1999-2005). The detailed analysis for dry and neovascular AMD for the years 2010 and 2011 showed no significant differences for the most commonly prescribed low vision aids. The prescription of low vision aids is not influenced by the AMD classification (dry or neovascular), only by the magnification needs. CONCLUSION: There is an unchanged and still high demand for rehabilitation aids of AMD patients, for dry as well as for neovascular AMD even after the introduction of anti-vascular endothelial growth factor (anti-VEGF) therapy.

[The influence of visual rehabilitation on secondary depressive disorders due to age-related macular degeneration. A randomized controlled pilot study]. / Einfluss visueller Rehabilitation auf sekundäre depressive Störungen bei altersabhängiger Makuladegeneration. Eine randomisierte kontrollierte Pilotstudie.

BACKGROUND: Age-related macular degeneration (AMD) often leads to visual impairment, loss of reading ability, reduced quality of life and secondary depression. The present study examined if visual rehabilitation has a preventive effect on secondary depression in these patients. MATERIAL AND METHODS: In a controlled pilot study 20 patients were randomized into 2 groups whereby 9 underwent visual rehabilitation at first examination and 11 received magnifying visual aids only after 3 months. Psychosocial status was assessed by the geriatric depression scale (GDS) and the German version of the Centre for Epidemiologic Studies depression (CES-D) scale (main outcome parameter), cognitive status by the dementia detection test (DemTecT), minimental status (MMS) and quality of life by the National Eye Institute visual function questionnaire (NEI-VFQ 25). Ophthalmological examination included reading speed measurement by standardized texts (International Reading Speed Texts; IReST). RESULTS: Parameters of the CES-D scale, DemTect and the subitem exercise of social roles of the NEI-VFQ 25 emerged in a divergent manner. Patients of the rehabilitation group became less depressive and improved in cognitive and social abilities and in the control group vice versa. The interactive effect of group and time was statistically significant for all three tests. CONCLUSIONS: Visual rehabilitation has a positive impact on depression as well as cognitive status and quality of life in patients with AMD. The effects have to be confirmed in future studies with more patients and a longer observation period.

Binding of platelet glycoprotein Ibbeta through the convex surface of leucine-rich repeats domain of glycoprotein IX.

BACKGROUND: The mechanism of assembly of the platelet glycoprotein (GP) Ib-IX complex from GPIbalpha, GPIbbeta and GPIX subunits is not entirely clear. In this complex, ectodomains of both GPIbbeta and GPIX subunits contain two leucine-rich repeats (LRR) and share high sequence similarity. However, they differ noticeably in stability, hampering further analysis of their interaction. OBJECTIVES AND METHODS: Guided by analysis of the LRR structure, we report a well-folded Ibbeta/IX chimera and its usage in dissecting GPIX function. RESULTS: In this chimera, three non-contiguous sequences that may constitute the putative convex surface of the GPIbbeta ectodomain are replaced by their GPIX counterparts. Like GPIbbeta but unlike GPIX ectodomain, it can secrete from transfected Chinese hamster ovary cells and fold into a stable conformation. Furthermore, replacing the ectodomain in GPIX with the Ibbeta/IX chimera, but not the GPIbbeta ectodomain, preserved its interaction with GPIbbeta as demonstrated by its native-like GPIbbeta-induced increase in surface expression and coimmunoprecipitation. CONCLUSIONS: The putative convex surface of the LRR domain in GPIX is sufficient, in the context of full-length subunit, to mediate its association with GPIbbeta.

[Spectrum of ophthalmologic and social rehabilitation at the Tübinger Low-Vision Clinic : a retrospective analysis for 1999-2005]. / Ophthalmologische und soziale Rehabilitation sehbehinderter Patienten : Eine retrospektive Analyse an der Tübinger Sehbehindertenambulanz von 1999-2005.

BACKGROUND: In addition to medical care, the visual and social rehabilitation of low-vision patients is of increasing importance. The aim of our study was to evaluate the actual spectrum of patients concerning diagnoses and appropriate low-vision aids at a low-vision clinic. METHODS: In a retrospective study, the medical records of 4,711 patients treated at our low-vision clinic from January 1999 to December 2005 were reviewed and analyzed. The main outcome measurements were age, ophthalmologic diagnoses, magnification requirement, and prescribed low-vision aids, as well as social and professional rehabilitation measures. To evaluate the efficiency of visual rehabilitation, reading speed was measured in a subgroup of 930 patients before and after administration of low-vision aids. RESULTS: Age-related macular degeneration was, at 40%, the most frequent diagnosis. Other main diagnoses were tapetoretinal dystrophies, optic atrophy, and diabetic retinopathy. The median magnification need was 4x. A highly significant correlation existed between the measured magnification power and the magnification factor of the prescribed low-vision aids. Visual rehabilitation was frequently sufficient with simple optical low-vision aids such as high-plus reading additions and magnifiers. Closed-circuit television systems were necessary in 26%; however, 85% of these patients had a high magnification need of more than 6 x. For distance vision, a monocular telescope was the low-vision aid prescribed most often. A high proportion of patients needed more than two low-vision aids for different application areas. Forty percent of patients needed special social and professional rehabilitation measures. In a subgroup of 930 patients, the mean reading speed was 35+/-50 words/min before the use of low-vision aids, which increased significantly to 81+/-46 words/min with the use of such aids. Therefore, the reading speed essentially doubled following the use of low-vision aids. CONCLUSION: Our results provide actual, quantitative data about the need for and success of rehabilitation for visually impaired patients. A large number of patients suffer from age-related macular degeneration. Independent from the causal ophthalmologic diagnoses, most patients benefited greatly from the rehabilitation measures provided by the low-vision service and were thus able to improve their quality of life. In the face of the increasing number of visually impaired elderly patients, rehabilitation should start as early as possible.

[Accommodation ability under the aspect of refractive, demographic, and biometric parameters]. / Akkommodationsfähigkeit unter Einbeziehung refraktiver, biometrischer und demographischer Parameter.

PURPOSE: The aim of this study was to evaluate the accommodation ability in healthy phakic eyes in relation to refraction and biometric parameters in order to get comparable results for patients with the accommodative 1 CU posterior chamber lens. METHODS: The study included 120 normal eyes of 120 patients (77 males, 43 females, mean age: 40+/-18, range: 11-70 years). The inclusion criteria were spherical equivalent for distance refraction <2 D, astigmatism <1.5 D, and a best-corrected visual acuity > or =0.8. Exclusion criteria were diabetes, glaucoma, cataract, traumas, or previous surgery. Subjects were divided into six age groups at increments of 10 years. Each group consisted of 20 subjects. Measurements included subjective and objective refraction (D), the accommodation ability (D) assessed with an accommodometer, and biometric parameters using the IOLMaster. In addition, the relation of anterior chamber depth and length of the eye was calculated for analyzing the relationship of anterior eye segment and accommodation. RESULTS: The spherical equivalent for distance refraction was 0.04+/-0.6 D with a range of -1.5 to 2.0 D. There was no sex-related significant difference of accommodation range. The accommodation range (D) decreased significantly with increasing age (p<0.0001, r=-0.895). The highest decrease could be found between the ages of 30 and 50 years. In subsequent years, the decline in accommodation ability was comparatively less. In association with the anterior chamber depth and the relation of anterior chamber depth and length of the eye, the accommodation ability fell with increasing age (p<0.001). The length of the eye did not correlate with the accommodation ability (p=0.8). CONCLUSION: There is a strong relationship between accommodation ability and age. Accommodation ability decreases strongly from the 3rd to the 5th decade; after that the loss of accommodation ability is relatively lower. The increase in lens thickness during the life span can implicate a correlation between the change of anterior chamber depth in relation to the length of the eye and a decrease of accommodation ability. Our results confirm Duane's hypothesis of accommodation and age.

[Functional outcomes after penetrating keratoplasty in pseudoexfoliation syndrome (PEX)-keratopathy]. / Funktionelle Ergebnisse der perforierenden Keratoplastik bei Pseudoexfoliationssyndrom (PEX)-Keratopathie.

PURPOSE: Keratopathy in pseudoexfoliation syndrome (PEX-keratopathy) is a particular form of corneal endothelial decompensation, which requires a penetrating keratoplasty (PK) for visual rehabilitation at advanced states. The aim of this study was to evaluate the functional outcome and the development of intraocular pressure (IOP) after PK in patients with PEX-keratopathy depending on the presence of pre-existing glaucoma. PATIENTS AND METHODS: This retrospective study included 21 eyes of 21 patients (age 78.6 +/- 7.5 years) with a mean postoperative follow-up of 1.8 +/- 2.2 (median 2) years. The diagnosis of PEX-keratopathy was confirmed clinically as well as by electron microscopy. The recipient and donor trephinations were performed from the epithelial side using an 193 nm excimer laser (n = 11) or mechanically (n = 10). An iridotomy was performed routinely during PK. The postoperative treatment with topical steroid was standardized. RESULTS: Preoperatively, a secondary open-angle glaucoma (SOAG) with optic nerve damage was diagnosed in 11 patients (52 %). Topical antiglaucomatous treatment was needed in 81 % of patients with SOAG. Six weeks postoperatively, patients with SOAG showed a higher prevalence of increased intraocular pressure (IOP) and/or antiglaucomatous treatment compared to patients without SOAG (45 % vs. 20 %). Most of the mild-early intraocular pressure elevations were controlled in both groups during the follow-up. From one year post-PK, there was an increased need for topical antiglaucomatous treatment in both patient groups. In all eyes the IOP was controlled by topical antiglaucomatous treatment. Preoperatively, visual acuity was comparable in patients with and without SOAG (0.06 +/- 0.09 vs. 0.08 +/- 0.1, p = 0.7), but increased significantly more in patients without SOAG (0.38 +/- 0.1, median 0.4) than in patients with SOAG (0.2 +/- 0.1, median 0.2; p = 0.01) after PK. Visual acuity remained stable in both groups throughout the follow-up period. During follow-up only one eye developed an episode of reversible endothelial graft rejection 18 months postoperatively. An irreversible graft failure was seen in none of the patients. CONCLUSION: The functional outcome after PK in PEX-keratopathy seems to be strongly associated with pre-existing SOAG. Patients without SOAG may expect good visual rehabilitation without persistent postoperative IOP increases. However, patients should be followed-up for a prolonged period of time, because from 1 year following PK the need for topical antiglaucomatous treatment increased significantly.

[Clinical aspects and treatment of immune reactions following penetrating normal-risk keratoplasty]. / Klinik und Therapie der Immunreaktionen nach perforierender Normalrisiko-Keratoplastik.

PURPOSE: Endothelial graft rejection is one of the most common causes of graft failure following penetrating keratoplasty (PK). The aim of this study was to evaluate the incidence, time course and outcome of treatment of graft rejection after normal-risk PK and to identify possible risk factors for the recurrence of immune reactions and irreversible graft failure. PATIENTS AND METHODS: The study included 500 eyes from the prospective Erlanger Normal-risk Keratoplasty Study with a mean follow-up of 42 +/- 18 (median 40) months. Indications for PK were keratoconus in 48 %, Fuchs' dystrophy in 30 %, secondary bullous keratopathy in 11 %, non-vascularized corneal scars in 7 % and stromal dystrophies in 4 %. Standardized complete ophthalmological examinations were performed on a regular basis before, during the acute graft rejection and then regularly in a defined examination raster in an cornea out-patient service. RESULTS: During follow-up 29 eyes (5.6 %) developed an episode of endothelial graft rejection (23 eyes with acute diffuse and 6 eyes with chronic focal rejection type). Episodes of endothelial graft rejection clustered between 11 and 25 months postoperatively (15 from 29, 51.7 %). Most grafts (25 of 29) regained clarity after topical and systemic steroid treatment. Only 4 patients showed an irreversible graft failure requiring a repeat PK, all of whom had secondary bullous keratopathy as the primary indication for PK. Risk factors for irreversible graft failure were pre-existing anterior synechiae in 3 patients and secondary open angle glaucoma in pseudoexfoliation syndrome in one patient. Recurrence of graft rejection was seen in 5 patients (all with keratoconus) after a time interval of 8 to 12 months. Under very low topical steroid treatment no further recurrence was observed in all 5 patients up to 2 years. CONCLUSION: Patients should be followed-up on a regular base for longer postoperative periods, since most episodes of graft rejection were observed between 1 and 2 years after PK. Development of irreversible graft failure was strongly associated with pre-existing anterior synechiae and pre-existing glaucoma. Low-dose topical steroid treatment after immunological rejection seems to prevent the recurrence of further graft rejection.

[Results of the first 1,000 consecutive elective nonmechanical keratoplasties using the excimer laser. A prospective study over more than 12 years]. / Ergebnisse der ersten 1.000 konsekutiven elektiven nichtmechanischen Keratoplastiken mit dem Excimerlaser. Eine prospektive Studie über mehr als 12 Jahre.

BACKGROUND AND PURPOSE: The purpose of this prospective clinical cross-sectional study was to analyse indications, intraoperative, perioperative and postoperative pecularities and complications as well as postoperative functional and morphologic results of the first 1000 consecutive elective round laser keratoplasties. PATIENTS AND METHODS: The age of the 480 females and 520 males (362 x keratoconus), who had been operated on between 07/1989 and 04/2002 ranged from 20 to 92 years (mean 55+/-19). A total of 6 microsurgeons performed 718 x PK only, 222 x a triple procedure and 60 x additional IOL manoeuvres. Recipient and donor trephinations were accomplished with an 193 nm excimer laser (Carl Zeiss Meditec, Jena, Germany) from the epithelial side. RESULTS: In 895 eyes with perioperative corneal erosion, epithelial healing took not more than 3 days in half of cases. During a follow-up period of 1.9+/-1.5 years, in 35 eyes episodes of acute diffuse (8 irreversible) and in 12 eyes episodes of chronic focal (5 irreversible) endothelial immunologic graft reactions (4.7%) occurred between 6 weeks and 4.7 years after PK. Before/after suture removal, median values of astigmatism were 1.5 diopters (D)/2.5 D refractive, 3.0 D/3.3 D keratometric, and 4.0 D/4.2 D topographic. Best-corrected visual acuity was 0.50/0.60, respectively. CONCLUSIONS: More than 12 years of experience with this new technique indicate that besides optical advantages, nonmechanical trephination does not cause intraoperative or postoperative disadvantages for the patient. Under standardised surgical conditions a massive increase of astigmatism after suture removal seems to be avoidable with laser trephination in most cases due to reduction of decentration,"vertical tilt" and especially "horizontal torsion".

[Digital planimetry for long-term follow-up of glaucomatous optic disk injuries in patients with normal pressure glaucoma]. / Digitale Planimetrie zur Langzeitverlaufskontrolle der glaukomatösen Papillenschäden bei Patienten mit Normaldruckglaukom.

BACKGROUND: Aim of the study was to evaluate the validity of quantitative planimetry of the optic disc with a new digital method and to assess the correlation of the measurements with morphological changes in eyes with low tension glaucoma. MATERIAL AND METHODS: The study included 40 eyes from 40 patients (age 61+/-12 years) with low tension glaucoma with a mean follow-up of 4.9+/-2.1 (range 3-9) years. All patients underwent annually complete ophthalmological examination including 15 degrees color optic disc photographs and automated white-white visual fields. RESULTS: Out of 40 eyes morphological examination showed signs of progression in 18 eyes and in 22 eyes no morphological changes of the optic disc were detected The digital planimetrically measured optic disc area did not vary between the first and the last photos. The mean differences between measured values for optic disc area between two examinations were 0.027+/-0.071 mm(2) and the reliability coefficient (Cronbachs alpha) was 0.99. Neuroretinal rim area decreased statistically highly significantly in eyes with morphological progression, and in eyes without morphological changes decreased only slightly. CONCLUSIONS: The variation of measurements of the optic disc area can be minimized by consideration and adjustment of the individual image magnification of the photos using digital planimetry. This method allows the quantitative assessment even of slight changes of the neuroretinal rim area and is a useful examination for follow-up of glaucoma patients.

[Two years experience with the new accommodative 1 CU intraocular lens]. / Zwei Jahre Erfahrung mit der akkommodativen Hinterkammerlinse 1 CU.

After marked improvement of optical rehabilitation of cataract patients during the last decades due to small incision surgery and foldable intraocular lenses (IOL), presbyopia is now one of the great unsolved questions in ophthalmology. During recent years a new accommodative IOL, the 1CU lens, has been developed based on the concepts of K.D. Hanna and on finite element computer simulation models. The 1CU IOL is designed to transform contracting forces of the ciliary muscle into anterior movement of the IOL optic (optic-shift concept). After the first implantation of a 1CU IOL in Erlangen in June 2000, we have now successfully implanted the 1CU IOL in over 90 patients. Our experiences and the results of several clinical studies indicate good and safe implantability, good centration, no IOL-specific complications, and good distance visual acuity. In comparison to control groups with conventional IOL, patients with the 1CU enjoyed significantly better distance-corrected near visual acuity, a larger accommodative range, and increased anterior and posterior axial movement of the lens optic after medical stimulation or inhibition of the ciliary muscle. We interpret our results as confirmation of the optic-shift concept of the 1CU IOL. Overall, the concept of accommodative IOL appears attractive and may have a great potential in the future. Additional studies including randomized blind multicenter evaluation of the 1CU IOL are necessary to further evaluate long-term and accommodative results.

Retinal nerve fiber layer measurements using laser scanning polarimetry in different stages of glaucomatous optic nerve damage.

PURPOSE: To evaluate the diagnostic value of polarimetric measurements of the retinal nerve fiber layer (RNFL) thickness in different stages of glaucomatous optic nerve damage. METHODS: The study included 92 eyes of 46 controls (age 41.0+/-13.7 years) and a heterogeneous group of 232 eyes of 135 patients with different stages of glaucomatous optic nerve damage (age 54.0+/-10.2 years; 68 patients with primary open-angle glaucoma, 56 with normal-pressure glaucoma and 11 patients with secondary glaucoma due to primary dispersion syndrome or pseudoexfoliation syndrome). All control subjects and patients underwent complete ophthalmological examinations including scanning laser polarimetry of the RNFL using the GDx (Laser Diagnostic Technologies, San Diego, Calif.) and 15 degrees color stereo optic disc photographs. Only subjects and patients with disc area less than 3.4 mm(2) were included in the study. The total glaucoma group were divided into four subgroups according to the morphological criteria of the neuroretinal rim. RESULTS: The stage of morphological glaucomatous optic nerve damage was classified as follows: stage 0: n=92, stage 1: n=103, stage 2: n=65, stage 3: n=40, and stage 4: n=19. Differences in mean polarimetric retardation between controls and eyes with glaucoma were significant for all parameters except the variable symmetry. The most significant differences between controls and eyes with glaucomatous optic nerve damage were found with the "number" variable assigned by the neural network analysis ( P<0.001). With increasing stage of glaucomatous optic nerve damage, separation of the variable "the number" increased significantly. At a predetermined specificity of 90% the sensitivity of the groups with different stages of morphological glaucomatous optic nerve damage increased from 32% for stage 1 to 90% for stage 4. CONCLUSION: Polarimetric measurement of the RNFL thickness is significantly associated with morphological glaucomatous optic nerve damage. The fast performance, easy handling, and low cost of RNFL polarimetry mean that it can be included in the routine examination of glaucoma patients. Further study and refinement of this technique are indicated to improve its usefulness in both clinical diagnosis and in population-based case identification.

Impact of increased intraocular pressure on long-term corneal endothelial cell density after penetrating keratoplasty.

PURPOSE: Besides immunological graft rejection, persistently increased intraocular pressure (IOP) is among the most important causes for graft failure after penetrating keratoplasty (PK). The purpose of this study was to assess the longitudinal development of IOP after PK and to investigate possible correlations with corneal endothelial cell density. METHODS: This longitudinal prospective study included 209 eyes after PK with a complete follow-up at 3 months, 6 months, before first suture removal (16 +/- 5 months) and after complete suture removal (21 +/- 5 months). At each examination, IOP was measured by Goldmann applanation tonometry. Endothelial cell density was assessed by specular microscopy (EM 1100, Tomey). The indications for PK were 48% keratoconus, 34% Fuchs' dystrophy, 5.4% stromal dystrophies, 8.6% secondary bullous keratopathy and 4% corneal scars. An iridotomy was performed routinely during PK. The postoperative treatment with topical steroids was standardized. RESULTS: Preoperatively, the mean IOP was 13.6 +/- 2.9 mm Hg with increased IOP (>21 mm Hg) in 2.0% of eyes. After 3 months, the incidence of increased IOP (24.5 +/- 4.6 mm Hg) was highest (6.7%) and decreased thereafter to 3.0% after complete suture removal. No patients showed IOP higher than 30 mm Hg. A persistently increased IOP for more than 3 months was seen in 2% of patients. At 3 months postoperatively, the mean endothelial cell density was 1,977 +/- 496/mm(2) and did not decrease significantly (p > 0.05) until 6 months (1,771 +/- 507 cells/mm(2)). At the end of the follow-up period, the mean endothelial cell density was significantly reduced (1,347 +/- 501 cells/mm(2)). There was no significant correlation between IOP and mean endothelial cell density at any postoperative examination stage (p > 0.24). Patients with persistently increased IOP for more than 3 months did not have significantly different endothelial cell densities in comparison with those without increased IOP. CONCLUSION: From 6 months after PK, the incidence of increased IOP was not higher than the preoperative level. Mild to moderate temporary IOP elevations after PK do not seem to affect the endothelial cell density of the graft until complete suture removal. Further long-term studies are necessary to assess the clinical relevance of these observations.

[Conventional versus digital planimetry of optic disc photograph: a clinical comparative study]. / Konventionelle Fundusfotografie versus digitale Bildverarbeitung zur Planimetrie der Papille: Eine klinische Vergleichsstudie.

BACKGROUND: The optic disc size is an important parameter for the diagnosis of glaucomatous and non-glaucomatous optic nerve damage. The aim of this study was to compare quantitative measurements of the optic disc with the established conventional planimetry and a new digital method using Soft imaging system analySIS(tm) for Ophthalmology and to determine the reproducibility of this new method. PATIENTS AND METHODS: Fifty color stereo optic disc photographs of 50 patients (mean age 41.7 +/- 13.4 y) were included in the retrospective, comparative study. Conventional and digital planimetry was taken from one skilled examiner in a masked fashion. According to patient's number measurement values obtained with both methods were matched. Digital planimetric measurements of 10 optic disc photographs were repeated on day 7 and day 14. Statistical analysis was done using linear regression analysis, reliability coefficient and U-test. RESULTS: The planimetric values did not vary significantly between the two methods for optic disc area (3.19 +/- 0.65 mm(2) vs. 3.03 +/- 0.64 mm(2), p=0.96), for cup area (1.36 +/- 0.62 mm(2) vs. 1.21 +/- 0.63 mm(2), p=0.96) or for neuroretinal rim area (1.83 +/- 0.39 vs. 1.82 +/- 0.41 mm(2), p=0.98). There was also no significant difference of horizontal and vertical diameter of optic disc and cup as well as the diameter of the superior temporal and inferior temporal retinal artery and vein at the optic disc border between both methods (p < 0.5). Differences between measured values for optic disc, optic cup area and neuroretinal rim area obtained with both methods were 0.16 +/- 0.10 mm(2) (range - 0.05 to 0.24), 0.15 +/- 0.10 mm(2) (range - 0.12 to 0.26) and 0.014 +/- 0.11 mm(2) (range - 0.26 to 0.26). A high correlation of all planimetric values was observed between both methods (r=0.9, p < 0.0001). Using digital planimetry differences between day 1, day 7 and day 14 were 0.05 +/- 0.03 (range 0.02 to 0.10 mm(2)) for optic disc, 0.05 +/- 0.04 (range 0.0 to 0.13 mm(2)) for optic cup area and 0.05 +/- 0.05 (range 0.01 to 0.14 mm(2)) for the neuroretinal rim area. The reliability coefficient of digital planimetry was 0.9 for optic disc parameters. CONCLUSIONS: The comparable results between both methods and a high reproducibility suggest that the digital planimetry could be used either for clinical routine or scientific evaluation of the optic nerve.

Effect of neodymium:YAG laser iridotomy on number of aqueous melanin granules in primary pigment dispersion syndrome.

PURPOSE: Increased numbers of aqueous melanin granules have been reproducibly demonstrated in eyes with pigment dispersion syndrome using the cell count mode of the laser flare-cell meter. It was the aim of this study to measure the exact number of aqueous melanin granules in eyes with pigment dispersion syndrome and pigmentary glaucoma before and after Nd:YAG laser iridotomy. METHODS: Nine eyes of seven patients with a clinical diagnosis of primary pigment dispersion syndrome and secondary open-angle glaucoma (mean age 41.1 +/- 10.8 years) were included in this study. Aqueous cells were quantified using the cell count mode of the laser flare-cell meter (Kowa FC-1000) before and 30 min after medical pupillary dilation. Measurements were performed before and 15 +/- 7 weeks after Nd:YAG laser iridotomy. The main outcome measure was the number of aqueous melanin granules before and after Nd:YAG laser iridotomy. RESULTS: The number (mean and quartiles) of aqueous melanin granules/0.075 microl aqueous humor (normal/dilated pupil) before antiglaucoma treatment was 4.5 (4.0, 7.25)/ 9.0 (5.0, 13.0) and was significantly reduced after iridotomy [1.5 (0.75, 3.25)/4.0 (1.6, 6.25), P=0.016]. CONCLUSION: Nd:YAG laser iridotomy results in significant (65%) decrease of aqueous melanin granules in eyes with primary pigment dispersion syndrome. This finding appears to confirm the concept of reverse pupillary block in primary pigment dispersion syndrome and may indicate that laser iridotomy is a useful treatment option in this condition.

[Visual rehabilitation and intraocular pressure elevation due to immunological graft rejection following penetrating keratoplasty]. / Entwicklung von Visus und intraokularem Druck bei endothelialer Immunreaktion nach perforierender Keratoplastik.

PURPOSE: Endothelial graft rejection and intraocular pressure elevation are the most common causes of graft failure following penetrating keratoplasty (PK). Aim of this study was to evaluate the visual rehabilitation and the development of intraocular pressure during and after graft rejection. PATIENTS AND METHODS: The study included 20 eyes of 20 patients (age 54.7 +/- 19.8 years) with endothelial graft rejection, that fulfilled the following inclusion criteria 1) graft rejection was diagnosed and treated in our department; 2) at least one year follow-up after graft rejection; 3) avascular corneal pathology. The mean follow-up was 23 +/- 14 months. According to the type of surgical procedure patients were classified in PK only (n = 15, one after cataract extraction), PK combined with extracapsular cataract extraction and intraocular lens (IOL) implantation (n = 1); PK combined with secondary IOL-implantation or IOL-exchange (n = 4). Standardized complete ophthalmological examinations were performed on a regular basis before, during the acute graft rejection und then regularly in a defined examination raster in an out-patient service with cornea specialization. RESULTS: The time interval between first symptom of 18 acute diffuse and 2 chronic focal graft rejection and start of treatment was 9 +/- 13 days. Best-corrected visual acuity (CVA) was 0.6 +/- 0.2 before graft rejection and decreased significantly at the time of diagnosis (0.2 +/- 0.2; p = 0.001). Six weeks after graft rejection CVA was 0.5 +/- 0.2 and remained almost stable until one year after rejection (0.6 +/- 0.3) in 16 patients with reversible graft rejection. Only 4 patients (20%) showed an irreversible graft failure requiring Re-PK. Intraocular pressure (IOP) was not elevated in 75% of the patients (n = 15) and did not need any antiglaucomatous treatment during and after the rejection phase. In 5 eyes (25%) (3 after PK combined with anterior chamber IOL-explantation and secondary posterior chamber IOL-implantation; 1 with secondary pseudoexfoliation glaucoma and 1 steroidal responder) IOP was elevated during graft rejection (26 +/- 7 mmHg), but was controlled by intensive topical antiglaucomatous treatment. CONCLUSION: Typically, the visual rehabilitation after graft rejection was good if the clinical signs were diagnosed just in time and treated adequately. There is no direct correlation between graft rejection and intraocular pressure elevation. However, the development of intraocular pressure elevation seems to be strongly associated with preexisting glaucoma, preexisting anterior synechiae and/or simultaneous anterior chamber lens implant removal. A careful patient management after PK plays an important role to prevent the development of irreversible graft failure due to graft rejection.

Impact of short-term versus long-term topical steroids on corneal neovascularization after non-high-risk keratoplasty.

PURPOSE: To analyze incidence and extent of corneal neovascularization (CN) after non-high-risk keratoplasty and to find out whether duration of postoperative topical steroid therapy (6 vs 12 months) affects CN, corneal endothelial cell count, pachymetry, aqueous flare values, and best-corrected visual acuity at 1 year after keratoplasty. METHODS: Patients of the prospective Erlangen non-high-risk keratoplasty study with available high-quality corneal photographs taken preoperatively and 1 year later were analyzed (n=136). Corneal photographs were evaluated by two independent observers in a standardized semiquantitative fashion. Slides were projected with 100x magnification and corneal vessels classified into five grades with regard to the limbus, sutures and host-graft junction in each of 12 corneal sectors. Incidence and extent of CN after keratoplasty and relation to short-term (0-6 months) versus long-term (0-12 months) postoperative topical steroid therapy were analyzed. The effect of duration of topical steroid therapy on corneal endothelial cell count, pachymetry, aqueous flare values, and best corrected visual acuity was also analyzed. Of the 136 patients, 69 (51%) were randomly assigned to short-term and 67 to long-term topical prednisolone acetate 1%. RESULTS: Fifty-eight percent of patients (n=79) developed a CN within 1 year after keratoplasty in at least one corneal sector (mean 3.1 +/- 2.2, range 1-10). At 1 year after keratoplasty, only in 12% of these patients did at least one vessel reach the host-graft junction or grow into the donor cornea, whereas in 51% vessels were seen beyond the outer suture ends of the double running suture without reaching the host-graft junction. In 37%, capillaries were located between limbus and outer suture ends. New vessels usually pointed directly or indirectly to the outer suture ends and usually were located around the 12 o'clock and 6 o'clock positions. There was no significant difference regarding incidence and extent of CN 1 year after keratoplasty between the long-term and the short-term group. Duration of topical steroid therapy had no significant effect on corneal endothelial cell count and thickness, aqueous flare values and best-corrected visual acuity at 6 and 12 months postoperatively (only at 12 months, corneas in the long-term treatment group were slightly thicker; P=0.03). Interobserver correlation of vessel assessment was 0.77 (Kendall's tau B). CONCLUSIONS: CN is a common phenomenon after non-high-risk keratoplasty. New vessels rarely reach the host-graft junction, most commonly develop from the 6 o'clock and 12 o'clock positions and are usually located between epithelium and Bowman's layer (i.e., at the level of the superficial suture). The direction of vessel growth from the limbus towards the outer suture ends suggests release of angiogenic factors in this area. Prolongation of topical steroid therapy after non-high-risk keratoplasty beyond 6 months in this study did not significantly influence incidence and extent of CN, corneal endothelial cell count, aqueous flare values and best-corrected visual acuity observed 1 year after keratoplasty.

Blood-aqueous barrier breakdown after penetrating keratoplasty with simultaneous extracapsular cataract extraction and posterior chamber lens implantation.

BACKGROUND: The purpose of this study was to quantify breakdown of the blood-aqueous barrier (BAB) following penetrating keratoplasty (PK) with simultaneous extracapsular cataract extraction and posterior chamber lens implantation (triple procedure) and compare it with the alterations following PK only. METHODS: This study included 72 eyes after triple procedure and 227 eyes after PK only. The diagnosis for PK was Fuchs dystrophy in 39%, keratokonus in 44%, stromal corneal dystrophy in 3% and avascular corneal scars in 6% of cases. The postoperative topical steroid treatment was standardized in both groups. Aqueous flare was quantified using the laser flare-cell meter (FC-1000, Kowa) at defined postoperative intervals (10 days, 6 weeks, then every 3 months until 1 year postoperatively). Patients with conditions associated with impairment of the BAB were excluded from the study. RESULTS: In the early postoperative course, aqueous flare values (photon counts/ms) were significantly higher in patients with triple procedure (21.9 +/- 11.0) than in patients with PK only (9.8 +/- 3.2; P = 0.001). At 6 weeks postoperatively, aqueous flare returned to normal levels in patients after PK only (5.2 +/- 2.3), whereas patients with triple procedure still showed significantly increased flare values (10.8 +/- 5.6; P = 0.01). At 6 months postoperatively, aqueous flare values of patients with triple had returned to normal levels (6.8 +/- 3.8) and did not differ significantly from those after PK only (5.2 +/- 1.9; P = 0.09). CONCLUSION: Our results indicate that triple procedure causes a more extensive and longer-lasting breakdown of the blood-aqueous barrier than PK only. Quantification of aqueous flare with the laser flare-cell meter is useful in the postoperative follow-up after triple procedure. Further studies are required to investigate the clinical relevance of BAB breakdown on endothelial cell count and the incidence of subsequent immunological graft rejection.

Graft endothelium and thickness after penetrating keratoplasty, comparing mechanical and excimer laser trephination: a prospective randomised study.

PURPOSE: To assess the impact of nonmechanical trephination on the graft endothelium and thickness after penetrating keratoplasty (PK). METHODS: Inclusion criteria for this prospective, randomised, cross-sectional, clinical study were: (1) Treatment between October 1992 and December 1997; (2) one surgeon (G.O.H.N.); (3) primary central PK; (4) Fuchs' dystrophy (diameter 7.5/7.6 mm) or keratoconus (diameter 8.0/8.1 mm); (5) graft oversize 0.1 mm; (6) no previous intraocular surgery; (7) 16-bite double-running diagonal suture. In 179 patients (mean age 51+/-18 years), PK was performed using either the 193-nm Meditec MEL60 excimer laser ("Excimer") along metal masks with eight "orientation teeth/notches" (53 keratoconus, 35 Fuchs' dystrophy) or motor trephination with the Mikrokeratron (Geuder) ("Control": 53 keratoconus, 38 Fuchs' dystrophy). For donor trephination from the epithelial side an artificial anterior chamber was used in both groups. In 27% of the excimer and 29% of the control group a triple procedure was performed. Specular microscopy (EM-1000, Tomey) and pachymetry (SP-2000, Tomey) were performed before removal of the first suture (0.4+/-0.2 years postoperatively), before (1.1+/-0.4 years) and after (1.7+/-0.6 years) removal of the second suture but before any additional surgical intervention. RESULTS: Endothelial cell count: Neither "two-sutures-in" (1953+/-426/1804+/-385 cells/mm2, p=0.13), "one-suture-in" (1629+/-439/1765+/-440 cells/mm2, p=0.27), nor "all-sutures-out" (1259+/-493/1294+/-532 cells/mm2, p=0.83) differed significantly between Excimer and Control. Graft thickness: Neither "two-sutures-in" (527+/-58/524+/-16 mucrom, p=0.89), "one-suture-in" (537+/-72/551+/-40 microm, p=0.86), nor "all-sutures-out" (576+/-53/565+/-62 microm, p=0.38) differed significantly between Excimer and Control. Cell count and corneal thickness were not significantly different comparing Fuchs' dystrophy and keratoconus or comparing PK only and triple procedures. Graft thickness and endothelial cell count correlated highly significantly inversely with "all sutures out" (P<0.0001). CONCLUSIONS: Excimer laser trephination from the epithelial side using an artificial anterior chamber in donors seems to have no disadvantages concerning the graft endothelium after PK. Endothelial cell loss was not increased in eyes with Fuchs' dystrophy compared with keratoconus or after triple procedures compared with PK only.

[Modeling corneal topography with a subdivision scheme in keratoconus]. / Modellierung der Hornhauttopographie mit einem Subdivisionsschema bei Keratokonus.

BACKGROUND: Videokeratoscopy is often unable to obtain complete data sets in cases of irregular or asymmetric corneal topography. Subdivision schemes are very common in computer graphics for completion and smoothing of surfaces. Based on a network of triangular facets a smooth and complete surface in a standard coordinate system can be derived from topographic raw data. PATIENTS AND METHODS: We examined 88 patients with keratoconus and 40 normal controls. Polygons and polyhedra were defined from videokeratoscopic height data, and a surface was modeled using a modified butterfly subdivision scheme for a nonuniform sampled grid. To assess the model quality topographic raw data were changed to missing values centrally (at the apex of the cone) and in four midperipheral quadrants. The target value was the root mean square error, comparing the remodeled value of the subdivision scheme to the raw data at the position of the missing values for each group. RESULTS: Due to the nonuniform mesh of our Placido-based topographer we used a dynamic adaptive model and the governing dynamic differential equation. With a single missing value, no difference was detected between normals and patients with keratoconus. For a missing area consisting of 13 raw data points, the remodeling error was significantly higher in patients with keratoconus than in normals. With the neighborhood of 13 missing data points, the apex of the cone was remodeled in both groups of patients with less precision than with the peripheral missing data. CONCLUSION: The locality of the equation systems to be solved and the easy calculation of explicit formulas for the normals may simplify ray-tracing techniques and make subdivision attractive for large datasets in corneal topography even with irregular patterns.