Predictability of success and open conjunctival revision rates in the subsequent eye after XEN45 Gel Stent implantation according to lens status.

PURPOSE: To determine the predictability of success and the risk of open conjunctival revision in the subsequent eye after XEN45 Gel Stent implantation according to lens status. METHODS: This was a retrospective single-centre study involving 132 eyes of 66 participants who had undergone intraocular pressure (IOP)-lowering XEN45 Gel Stent implantation, either as a standalone procedure in phakic and pseudophakic eyes or in combination with phacoemulsification. Successful surgery was defined by three scores: IOP at follow-up < 21 mmHg (score A) or < 18 mmHg (score B) and an IOP reduction > 20% or IOP ≤ 15 mmHg and an IOP reduction ≥ 40% (score C). In all scores, one open conjunctival revision was allowed, and additional repeat surgery was considered a failure. The predictability of success and revision rate depending on the outcome of the first eye were calculated using Bayes' theorem. RESULTS: IOP-lowering did not differ significantly between the first and second eyes. Success rates of standalone surgery in the second eye after successful surgery in the first eye significantly exceed rates after prior failure. For the combined procedure, the rates did not differ significantly. For score A, we determined a 76.6% chance of success following a prior success and a 57.9% chance, if prior surgery failed. The corresponding probabilities were 75% and 59.1% for score B, while 66.7% and 15.7% for score C, respectively. We calculated a 60% risk for revision surgery in the standalone phakic group. If the first eye was not revised, the risk of revision in the subsequent eye was 20%. The corresponding risks were 72.7% and 5% for the standalone procedure in pseudophakic patients and 38.4% and 41.7% for the combined procedure, respectively. CONCLUSION: The results of our study offer a tool to predict the outcome of subsequent eye surgeries based on either the outcome in the initial eye and the type of surgery performed, owing to the high predictive potential.

The effect of additional trabecular aspiration to phacoemulsification and trabectome as a triple procedure in pseudoexfoliation glaucoma: a case-matched study.

BACKGROUND: Trabectome surgery combined with phacoemulsification is effective in lowering (intraocular pressure) IOP in pseudoexfoliation glaucoma. Trabectome surgery usually aims to remove two to four clock hours of the trabecular meshwork. When adding trabecular aspiration, the remaining meshwork can be treated as well, and therefore 360 degrees of the meshwork can be reached. This study was conducted to investigate the additional benefits and risks of adding trabecular aspiration to the combination of phacoemulsification and trabectome as a triple procedure. METHODS: Two groups of patients from two centres were compared. The first group underwent phacoemulsification and trabectome (Freiburg), and the second group underwent additional trabecular aspiration (Düsseldorf). Using a case-matched retrospective study design, 50 patients were included into each group. The clinical endpoint was the intraocular pressure at follow up. RESULTS: The mean follow up was 22 months. Mean intraocular pressure decreased in all 100 patients from 25.0 (SD 4.3) to 14.9 mmHg (SD 4.0). Comparing the two groups, the IOP reduction was from 25.0 (SD 5.0) to 14.1 (SD 4.4) mmHg in the triple procedure group compared to a reduction from 25.0 (3.6) to 15.7 (SD 3.4) mmHg in the phaco/trabectome group. The difference was statistically significant (p = 0.03). The number of medication after surgery was reduced from 2.2 (SD 0.9) to 1.7 (SD 0.9) while in the phaco/trabectome group the medication score was reduced from 2.2 (SD 1.0) to 1.1 (SD 0.1) (p < 0.001). CONCLUSIONS: This study shows that the combination of trabectome surgery and phacoemulsification leads to a clinically significant reduction of IOP over several years in patients with pseudoexfoliation glaucoma. The addition of trabecular aspiration as a triple procedure results in further lowering of IOP without causing more side effects. This finding might be biased by the higher medication score in the triple procedure group.

[Surgical options before and after trabectome surgery : Impact of previous surgeries, possibilities of revision surgery and complication management]. / Chirurgische Optionen vor und nach Trabektomchirurgie : Einfluss von Voroperationen, Möglichkeiten der Revisionschirurgie und Komplikationsmanagement.

BACKGROUND: Trabectome surgery is a new method to lower intraocular pressure through ablation of the trabecular meshwork. Technically, it is an ab interno trabeculotomy. The goal of this review is to investigate the options after failed trabectome surgery and evaluate the possibilities of trabectome surgery after failed previous glaucoma surgery. OBJECTIVES: A literature review was performed to answer the following questions: (1) Is trabectome surgery an option after failed glaucoma surgery? (2) Is trabeculectomy an option after failed trabectome surgery? (3) Which postoperative constellations require early revision surgery after trabectome surgery? RESULTS: Trabectome surgery is an option after failed trabeculectomy or failed tube surgery. Performing a trabeculectomy after failed trabectome surgery did not show disadvantages. Hypotony or hyphema is rare and self-limiting and, therefore, does not require further surgery. CONCLUSIONS: Due to a lack of randomized studies, recommendations should be taken with caution.

[Combined cataract and glaucoma surgery. Current options]. / Kombinierte Katarakt-Glaukom-Chirurgie. Aktuelle Optionen.

Trabeculectomy is no longer the gold standard for combined cataract glaucoma surgery considering the successful results following cataract surgery combined with trabeculotomy, viscocanalostomy and canaloplasty. The main disadvantage of these mostly non-penetrating procedures is the induction of conjunctival scarring which jeopardizes subsequent filtering surgery. Ab interno glaucoma surgery, including trabecular surgery and endocyclophotocoagulation, does not interfere with the conjunctival situation. These surgical options have a relatively minor risk profile for combined cataract glaucoma surgery compared to traditional filtering surgery; however, the pressure reducing efficacy of these ab interno approaches is limited with respect to the absolute reduction of intraocular pressure (IOP) and the achievable level of IOP. This has to be kept in mind when planning surgery.

Improvement of macular function by membrane differential filtration in diabetic retinopathy.

BACKGROUND: Alterations of blood rheology are assumed to substantially contribute to the pathogenesis of diabetic retinopathy. Membrane differential filtration (MDF) is an extracorporeal treatment which is able to optimize rheological parameters by eliminating high molecular weight proteins and lipoproteins from the blood. The present study was designed to investigate the effects of repetitive MDF on visual function in diabetic retinopathy. METHODS: 11 patients (11 eyes) with nonproliferative or inactive proliferative diabetic retinopathy underwent three treatment cycles during a mean period of 18 weeks. The best corrected visual acuity served as the main parameter of the study. The measurement of visual acuity, visual field, biochemical and rheological parameters was carried out 24 hours pre and post each treatment cycle and at follow up. The mean follow up time was 9 weeks during the post treatment period. RESULTS: Compared to baseline examination the visual acuity improved stepwise by a mean value of 1.4 lines (p = 0.02) after the last treatment and remained stable at follow up (1.3 lines, p < 0.001). The mean defect of the visual field was reduced by 2.8 dB (p = 0.13) after the treatment period and by 2.5 dB (p = 0.016) at follow up, respectively. CONCLUSIONS: Repetitive treatment with membrane differential filtration is able to improve visual function in patients with diabetic retinopathy. The present study suggests that repetitive membrane differential filtration treatment could be a useful adjunct along with laser treatment to influence the clinical course of diabetic maculopathy.

Influence of membrane differential filtration on the natural course of age-related macular degeneration: a randomized trial.

PURPOSE: Membrane differential filtration is able to optimize rheologic parameters by eliminating high molecular weight proteins and lipoproteins from the blood. Following the hypothesis that these changes result in an improvement of the microcirculation, the authors tested the efficacy of membrane differential filtration in improving visual function in patients with age-related macular degeneration (ARMD). METHODS: Forty patients (40 eyes) were randomized into two groups. The treatment group was treated five times over a period of 21 weeks. In both groups, 9/20 of the eyes showed subfoveolar subretinal neovascularization. The main parameter of the study was visual acuity (VA). Electroretinogram (ERG), electrooculogram, and macular visual evoked potentials were also recorded. Plasma and whole blood viscosity and erythrocyte aggregation were measured. RESULTS: The 20 patients treated repeatedly over a period of 21 weeks showed a mean improvement of 0.63 lines (SD 1.8) of VA on Early Treatment Diabetic Retinopathy Study charts. The control group showed a deterioration of 0.94 lines (SD 1.7) compared to VA at baseline examination. The amplitude of the ERG photopic a-wave and the flicker ERG was significantly increased. The rheologic parameters were lowered in all treated patients. CONCLUSION: Repetitive treatment with membrane differential filtration is able to improve visual acuity of patients with ARMD and the natural course of this disease. Several questions arise from the results of this study. Further research will show if it is possible to optimize the selection of patients for subgroups with predictive responses through morphologic and functional tests and how to create an optimized and individual treatment strategy determined by the quality, intensity, and frequency of treatment sessions.

[Modification of vision by change in rheologic parameters in senile macular degeneration through membrane differential filtration--initial results of a randomized study]. / Beeinflussung des Visus durch Anderung rheologischer Parameter bei der altersabhängigen Makuladegeneration (AMD) durch die Membrandifferentialfiltration--Erste Ergebnisse einer randomisierten Studie.

BACKGROUND: Membrane differential filtration (MDF) is known to optimize rheological parameters by eliminating high molecular weight proteins und lipoproteins from the blood and was shown to influence ocular perfusion parameters. Following the hypothesis that these changes may influence the natural course of age-related macular degeneration (AMD) we tested their efficacy in improving visual function in these patients in a randomized trial. PATIENTS AND METHODS: 20 patients (36 eyes) were randomized into two groups. Ten patients (18 eyes) were treated with MDF and ten (18 eyes) served as controls. The first group was treated five times over a period of 21 weeks. In both groups 8/18 of the eyes showed subfoveolar subretinal neovascularisations. Main parameter of the study was visual acuity. Macular visual evoked potentials were also recorded. Plasmaviscosity, whole blood viscosity and erythrocyte aggregation were measured. RESULTS: The ten patients, treated repeatedly over a period of 21 weeks, showed a mean improvement 1.1 (SD 1.9) lines after 21 weeks, while the control group showed a deterioration of visual acuity (0.6 lines, SD 1.7). The macular visual evoked potentials showed an increase of 0.28 microV (SD 1.12) for the therapy group and a deterioration of 0.57 microV (SD 1.31) in the control group. The rheological parameters were lowered in all patients. CONCLUSIONS: We conclude that repetitive treatment with MDF is able to improve visual function in patients with AMD. Further research is necessary to show how to optimize the selection of patients and how to create an individual treatment strategy.

Improvement of visual acuity in patients suffering from diabetic retinopathy after membrane differential filtration: a pilot study.

BACKGROUND: Membrane differential filtration is an extracorporeal treatment procedure which eliminates high molecular weight proteins and lipids from the blood. This pilot study was initiated to investigate the short-term effects on blood rheology and visual function in patients suffering from diabetic retinopathy. METHODS: Six patients with non-proliferative diabetic retinopathy, clinically significant macular edema (five patients, nine eyes) and inactive proliferative diabetic retinopathy (one patient, one eye) underwent a single treatment with a hollow fiber secondary plasma filter. The main parameter measured was visual acuity prior to and after treatment. Biochemical and rheological parameters (whole blood and plasma viscosity, and erythrocyte aggregation) were also measured. The mean follow-up was 25 (range 4-90) days after treatment. RESULTS: The mean improvement of visual acuity was 1.4 lines (SD 0.8 lines, p = 0.002) 24 h after therapy. This remained stable during the follow-up period. The rheological measures were significantly lowered. A significant reduction of total protein, fibrinogen, IgG, IgM, IgA, alpha-2-macroglobulin, total cholesterol, LDL and HDL was found. CONCLUSION: This study demonstrates the rheological impact of membrane differential filtration. It was shown that rheological changes correlated with clinical improvement in patients suffering from diabetic retinopathy with clinically significant macular edema.

Electrophysiological abnormalities in age-related macular degeneration.

BACKGROUND: Results from psychophysical tests indicate that in age related macular degeneration (ARMD) retinal function is globally impaired. Observations in single ARMD cases showing abnormalities of the electrooculogram (EOG) and electroretinogram (ERG) encouraged us to systematically examine ARMD patients by means of electrophysiological tests to confirm a global retinal dysfunction in ARMD. METHODS: Sixty-six patients with ARMD were examined clinically and by means of EOG, ERG, triple scotopic ERG, and fluorescein angiography (FA). RESULTS: EOG data were considerably reduced in ARMD. Scotopic a- and b-waves of the ERG were mildly affected. The bright flash response showed reduced b-waves with normal implicit times. The amplitude of the oscillatory potential OP2 was significantly reduced and photopic responses were also pathologic compared with an age-matched control group. Geographic atrophy and pigment epithelium detachment showed specific abnormalities in the ERG, whereas in soft drusen EOG changes were more conspicuous. CONCLUSIONS: In addition to data from psychophysical tests the results from electrophysiological examinations indicated a global reduction of retinal function in ARMD which seemed to be present not only in the macula but also elsewhere in the retina.

[Multi-flash ERG in cone dystrophies and cone-rod dystrophies]. / Das Mehrfachblitz-ERG bei Zapfendystrophien und Zapfen-Stäbchendystrophien.

BACKGROUND: Scotopic electroretinograms elicited with a multiple flash procedure were reported to be helpful in diagnosis of macular diseases. To evaluate the contribution of rods and cones to the recovery of light responses as recorded with this technique we performed a triple flash ERG procedure in patients with cone dystrophies and cone-rod dystrophies. MATERIALS AND METHODS: In 8 patients with cone dystrophy and 8 patients with cone-rod dystrophy and also in 18 healthy controls we recorded a standard ERG and the scotopic triple flash ERG with intensities between 0.01 and 0.2 cds/m2. Interflash intervals were adjusted at 140, 280, and 560 ms. Responses of the standard ERG were analysed as well as b-wave amplitudes at the short dark interval (140 ms) and the longer dark interval (280 ms). These responses were compared to responses after a long interflash interval (560 ms). Using a theoretical model parameters of b-wave recovery were determined and compared between the groups. RESULTS: In cone dystrophies responses of the scotopic triple flash ERG and the b-wave recovery parameters were normal whereas in combined dystrophies the triple flash responses were abnormal and the recovery data were pathologic. CONCLUSIONS: Cones did neither contribute to responses obtained with the multiple flash technique nor did they affect b-wave recovery as tested with this technique. Pathologic responses as described earlier with this technique in macular diseases could only be attributed to pathomechanisms globally affecting the rod system, e.g. dysfunction of retinal energy metabolism.

Corneal injury after carbon dioxide laser skin resurfacing.

PURPOSE: To describe a corneal injury in both eyes of a patient who had undergone carbon dioxide laser skin resurfacing. METHOD: Case report. RESULTS: A 67-year-old woman had severe pain and decreased vision in both eyes after undergoing laser skin resurfacing treatment with a pulsed carbon dioxide laser. Clinical examination disclosed a corneal ulcer, a bullous keratopathy, and intrastromal bleeding. After perforating keratoplasty, the histologic examination of the cornea showed signs of thermal injury. CONCLUSIONS: The results of the histologic examination and the onset of symptoms within 24 hours after therapy suggest that the laser application caused the corneal damage. Safety guidelines for this procedure should be reviewed.

Changes of hemorheological and biochemical parameters after plasma perfusion using a tryptophan-polyvinyl alcohol adsorber leading to clinical improvement in patients suffering from maculopathy.

BACKGROUND: Selective adsorption is an extracorporeal treatment able to reduce high-molecular-weight proteins and lipids. We evaluated its efficacy in lowering hemorheological parameters to achieve a better microcirculation of the retina. PATIENTS AND METHODS: Ten patients suffering from maculopathies of various origin underwent a selective plasma adsorption procedure using the TR-350. Plasma and whole blood viscosity, erythrocyte aggregation and proteins and lipids were determined before and 24 h after therapy. RESULTS: Selective adsorption therapy reduced the high-molecular-weight proteins and lipids. Plasma viscosity, standardized whole blood viscosity and erythrocyte aggregation were significantly lowered to 87, 88 and 65%, respectively, of their values prior to treatment. An improvement of visual acuity was achieved in 6/10 patients. Minor side effects were noted in 2/10 patients. CONCLUSIONS: Selective adsorption using the TR-350 adsorber is a safe technique, showing a high impact on blood rheology. The changes of hemorheological parameters led to clinical improvement in 6/10 patients suffering from retinal disorders.

Episodic acute hypotonia after Nd:YAG laser capsulotomy--retinal function and choroidal swelling.

In a patient with uveitis who had been treated with Nd:YAG laser capsulotomy after cataract surgery, several episodes of acute hypotonia occurred which were associated with changes in clinical tests of the eye and of visual function. Immunosuppressive and immunomodulating treatment appeared to reverse the changes in intraocular pressure and normalise the test results. The significance of these observations is discussed.

Clinical efficacy of haemorheological treatment using plasma exchange, selective adsorption and membrane differential filtration in maculopathy, retinal vein occlusion and uveal effusion syndrome.

The aim of the study was to test the clinical efficacy of haemorheological treatment with extracorporeal techniques in ocular diseases. We treated patients suffering from maculopathies of different origin: age-related (AMD, n = 17), uveitis-associated (n = 14) and myopia-associated maculopathy (n = 5). We also treated patients with uveal effusion syndrome (n = 3) and central retinal vein occlusion (n = 4) resistant to haemodilution or steroid therapy. The treatment consisted of plasma exchange, selective adsorption with a tryptophan-polyvinylalcohol adsorber and membrane differential filtration. Maculopathy patients underwent two treatments while the other patients received between 1 and 7 treatments. Pulsatile ocular blood flow was measured in 10 patients before and after therapy. The main parameter for evaluating clinical outcome was the change in visual acuity. Severe side-effects did not occur. The rheological parameters including plasma viscosity, whole blood viscosity and erythrocyte aggregation were statistically significantly lowered. Of 36 patients suffering from maculopathy, 25 showed an improvement of at least 1 line of visual acuity after therapy, 7/17 patients in AMD, 6/14 in uveitis and 0/5 in myopia improved 3 lines or more. All patients suffering from retinal vein occlusion improved at least 1 line and two showed an improvement of 3 lines or more. In uveal effusion syndrome, an improvement of 3 lines or more was reached in all patients. Plasma exchange, selective adsorption and membrane differential filtration are effective rheological treatment approaches to improving visual acuity in patients suffering from maculopathy except myopia-associated maculopathy. Efficacy in patients suffering from central retinal vein occlusion and uveal effusion syndrome was proven, even when the patients were resistant to previous haemodilution or steroid therapy. We conclude that a rheological approach should be considered before invasive methods such as laser coagulation, radiation therapy or surgery are applied.

Changes of haemorheological parameters when using plasma exchange, selective adsorption and membrane differential separation.

At present, conventional haemorheotherapy consists of changes in life-style, drug therapy and haemodilution. Extracorporeal therapy has been considered only for the treatment of hyperviscosity syndromes. However, a wide range of viscosity-related syndromes may be amenable to rheological therapy if appropriate techniques were available. According to our data, plasma exchange, selective adsorption and membrane differential filtration may lead to an improvement of haemorheology and clinical conditions. For reasons of economy and feasability, membrane differential filtration is favoured over other techniques of differential separation therapy.

Change in hemorrheological and biochemical parameters following membrane differential filtration.

INTRODUCTION: The elimination of high molecular weight proteins may have a positive influence on disorders of the microcirculation due to an improvement in rheological parameters. We therefore attempted to evaluate the rheological efficacy of membrane differential filtration (MDF). PATIENTS AND METHODS: Ten patients suffering from macular disease underwent MDF. Rheological and biochemical parameters as well as visual acuity were determined one day before and after therapy: The study aimed at a reduction in plasma viscosity, standardized whole blood viscosity at hematocrit 0.45 and erythrocyte aggregation at hematocrit 0.3. RESULTS: Severe side-effects were not observed. The rheological parameters were significantly reduced. In detail the posttreatment values were reduced as compared to the pretreatment values as follows: plasma viscosity 85%, standardised whole blood viscosity 86% (hematocrit 0.45), erythrocyte aggregation 59% (hematocrit 0.3), total protein 81%, IgG 66%, IgA 59%, IgM 33%, alpha-2-macroglobulin 30%, triglycerides 102%, total cholesterol 47%, VLDL cholesterol 94%, LDL cholesterol 33%, HDL cholesterol 62%. Visual acuity was improved in 7/10 patients. CONCLUSIONS: MDF is a safe and highly effective method for lowering biochemical and improving rheological parameters which led to improvement in visual acuity. We have already replaced plasma exchange with MDF in our clinical practice of hemorrheological therapy.