[Therapy of malignant glaucoma]. / Therapie des malignen Glaukoms.

Malignant glaucoma is a rare and complex eye disease but the exact cause has not yet been clarified with certainty. Malignant glaucoma can be treated with medication or by means of laser surgery or open incisional surgery. In this article the possible procedures for the treatment of malignant glaucoma (medicinal and surgical) are presented together and justifications for the procedures described are given.

Minimally invasive surgery technique for re-enclavation of prepupillary iris-claw IOLs.

BACKGROUND: Disenclavation is a common complication of prepupillary iris-claw intraocular lenses (IOL). We present a new minimally invasive revision surgery technique for reenclavation of prepupillary iris-claw IOLs using standard 23 Gauge (G) vitrectomy instruments. HISTORY AND SIGNS: Three cases of revision surgery by unilaterally dislocated prepupillary iris-claw IOLs are presented. THERAPY AND OUTCOME: Two 20 G sideports 90 degrees apart were constructed. Healon 10® was injected to maintain the anterior chamber. A standard enclavation needle was introduced to rotate the optic into correct position and a 23 G endgrasping forceps was used to grasp and stabilize the IOL for enclavation. The reenclavation was successful in all three cases and the mean visual acuity improved from preoperatively 0.1 (range counting fingers [CF] to 0.25) to 0.6 (range 0.4 to 0.8) with no significant induction of astigmatism. CONCLUSIONS: This minimally invasive reenclavation technique for repositioning of the prepupillary iris claw IOL appears to lead to successful and rapid visual rehabilitation.

Bimanual anterior segment revision surgery for anterior capsule contraction syndrome associated with anterior flexion of intraocular lens haptics.

PURPOSE: To report the incidence of anterior capsule contraction syndrome (ACCS) and to present a novel minimally invasive bimanual technique for anterior segment revision surgery associated with ACCS with anterior flexion of the intraocular lens haptics. METHODS: A consecutive cohort of 268 eyes of 161 patients undergoing phacoemulsification and implantation of the same type of hydrophilic acrylic aspheric intraocular lens cohort were analysed and a novel technique of minimally invasive bimanual technique for anterior segment revision surgery is described. RESULTS: We identified four eyes (1.5%) of three patients with advanced ACCS. Successful restoration of a clear visual axis with minimal induction of astigmatism and rapid visual rehabilitation was achieved in all four cases. CONCLUSION: This technique is a safe and minimally invasive alternative to laser or vitrector-cut capsulotomy to restore a clear visual axis. In cases of advanced ACCS, it offers the option for haptic reposition or amputation.

Saccade testing to distinguish between non-organic and organic visual-field restriction.

AIM: The authors described and tested a simple bedside procedure to detect non-organic visual-field loss. METHODS: Prospective comparative observational case series of 16 patients with non-organic visual-field loss and 15 patients with organic visual-field loss were examined. Saccade patterns provoked by a stimulus outside the claimed visual field were assessed by a masked observer. RESULTS: Whereas, in organic visual-field defects, eye movements as noted by the observer were in small and erratic searching patterns towards the visual-field defect in all patients (15/15), most patients with non-organic visual-field loss (14/16) were able to jump directly to the presented red cap in one directional large saccade, although the stimulus was outside their stated visual field. The sensitivity of the saccade test in detection of non-organic visual-field loss by a masked observer was 87% (95% CI 60% to 97%) and the specificity was 100% (95% CI 75% to 100%). The positive predictive value for non-organic visual-field loss of the saccade test was 100%, and the negative predictive value was 90%. CONCLUSIONS: The saccade test is a quick and reproducible examination to use and is largely independent of the patient's willingness for cooperation. The authors believe that the test will be of value to clinicians on bedside evaluation when non-organic visual-field loss is suspected.

Non-invasive biometric assessment of ocular rigidity in glaucoma patients and controls.

PURPOSE: To determine in vivo whether a pharmacologically induced change in intraocular pressure (IOP) leads to measurable changes in axial eye length and whether there is a difference between glaucoma patients and control subjects. METHODS: 42 subjects (19 patients with primary open angle glaucoma and 23 control patients matched for age and gender) underwent axial eye length measurement using partial coherence laser interferometry and measurement of IOP using dynamic contour tonometry before and 2 h after oral intake of 500 mg acetazolamide. Student's t-test was used to compare differences in the means. RESULTS: An identical drop in IOP was induced in both the glaucoma (mean+/-SEM: 2.90+/-0.44 mmHg, n=19) and the control group (mean+/-SEM: 3.17+/-0.32 mmHg, n=23). The change in axial eye length was significantly smaller (P=0.026) in the glaucoma group (mean+/-SEM: -14.2+/-3.2 microm, n=19) compared with the control group (mean+/-SEM: -23.0+/-2.98 microm, n=23). CONCLUSIONS: Our results strongly suggest that the ocular rigidity is increased in patients with established glaucoma in comparison to control subjects. Ocular rigidity could play a role in the pathogenesis and pathophysiology of glaucoma. Determination of ocular rigidity could be helpful in detection of glaucoma.

Significance of Staphylococcus lugdunensis bacteremia: report of 28 cases and review of the literature.

BACKGROUND: Staphylococcus lugdunensis endocarditis has been associated with an aggressive course. The aim of this study was to determine factors associated with the development of endocarditis in patients with S. lugdunensis bacteremia. METHODS: A retrospective analysis of all patients with S. lugdunensis bacteremia in three tertiary care centers in Switzerland was performed. Data regarding medical history, symptoms, and susceptibility of S. lugdunensis isolates were collected. Our results were reviewed in the context of the current literature. RESULTS: A total of 28 patients with S. lugdunensis bacteremia were identified. Of the 13 patients with endocarditis, all were community acquired. Cardiac surgery was performed in 85% of these patients; mortality was 23%, reflecting the aggressive course of this disease. In contrast, in the 15 patients without endocarditis, no complications associated with S. lugdunensis bacteremia were observed. In 73%, a probable source was identified in the form of a venous catheter or other foreign device. Only three of these episodes were community acquired. No difference was observed in susceptibility of the S. lugdunensis isolates to penicillin, which was 77% in endocarditis isolates, and 87% in isolates of bacteremia without endocarditis, respectively. CONCLUSION: S. lugdunensis bacteremia is associated with endocarditis in up to 50% of patients. Every patient with community-acquired S. lugdunensis bacteremia should be carefully examined for signs of endocarditis. Once S. lugdunensis endocarditis is diagnosed, close monitoring is essential and surgical treatment should be considered early. In the nosocomial setting, endocarditis is far less frequent, and S. lugdunensis bacteremia is usually associated with a catheter or other foreign materials.

[Posterior chamber intraocular lens in the anterior chamber]. / Hinterkammerlinse in der Vorderkammer.

BACKGROUND: The choice of design for intraocular lenses (IOLs) mainly depends on the selected location for the implant. HISTORY AND SIGNS: We report the case of dislocation of a foldable open-loop posterior chamber IOL into the anterior chamber during retinal detachment surgery. After several vitreoretinal interventions visual acuity was hand movements. THERAPY AND OUTCOME: The IOL remained in the anterior chamber without complications such as IOP rise or endothelial decompensation for several years. CONCLUSIONS: Foldable open-loop posterior chamber IOLs can be left in suitable anterior chambers for years without complications such as rise of intraocular pressure or corneal endothelial damage. Repeated measurements of endothelial cell density can provide an informative basis for the operative removal of this lens.

[Iris granulomas of unknown aetiology]. / Irisgranulome ungeklärter Aetiologie.

BACKGROUND: Non-pigmented tumours of the iris are rare and their clinical classification can be difficult, especially in the absence of systemic manifestations. HISTORY AND SIGNS: We report the case of a unilateral vascular, non-pigmented iris tumour in a 47-year-old patient. Clinically, the iris lesion showed progressive growth and tumour vascularisation. THERAPY AND OUTCOME: A systemic work-up failed to reveal any underlying systemic disease. Biopsy showed a non-necrotising granuloma. The lesion responded well to systemic corticosteroid therapy. CONCLUSIONS: Isolated granulomas of the iris are rare and clinically often indistinguishable from malignant tumours like melanoma. Due to the clinical course and the regression under corticosteroid therapy we concluded that this iris granuloma may be an isolated ocular manifestation of sarcoidosis.

[Scarring alopecias]. / Vernarbende Alopezien.

The irreversibility and the possible important cosmetic consequences of scarring alopecia demand special diagnostic attention in order to promptly attain a precise diagnosis and specific treatment. Scarring alopecias are either due to permanent damage to essential parts of the hair follicle or destruction of the entire hair follicle. They are classified into the categories of primary scarring alopecias, where the hair follicle is the primary target of destruction, and secondary scarring alopecias, where the follicular damage results incidentally from events around impinging on the follicular unit. The differential diagnosis of the more common primary scarring alopecias, e.g. follicular lichen planus, chronic cutaneous lupus erythematosus and folliculitis decalvans, can be difficult when based only on anamnestic and clinical findings. The scalp biopsy is essential for appropriate nosologic classification and has prognostic relevance. The primary therapeutic goal is to halt progression of the irreversible process as early as possible by means of immunomodulatory, immunosuppressive or antiinfectious agents, respectively.

Fibrosing alopecia in a pattern distribution: patterned lichen planopilaris or androgenetic alopecia with a lichenoid tissue reaction pattern?

BACKGROUND: Androgenetic alopecia is characterized by a defined area of progressive nonscarring alopecia. The clinical and histological findings in 15 women and 4 men with progressive scarring alopecia in a pattern distribution were studied. The results were evaluated and compared with clinicopathologic entities that feature scarring of the central scalp area, specifically, lichen planopilaris, pseudopelade, and follicular degeneration syndrome. OBSERVATIONS: Patients developed progressive fibrosing alopecia of the central scalp, without the multifocal areas of involvement typical of lichen planopilaris and pseudopelade. Perifollicular erythema, follicular keratosis, and loss of follicular orifices were limited to a patterned area of involvement. Biopsy specimens of early lesions demonstrated hair follicle miniaturization and a lichenoid inflammatory infiltrate targeting the upper follicle region. Advanced lesions showed perifollicular lamellar fibrosis and completely fibrosed follicular tracts indistinguishable from end-stage lichen planopilaris, pseudopelade, or follicular degeneration syndrome. CONCLUSIONS: Some patients with androgenetic alopecia might have additional clinical and histological features of inflammation and fibrosis limited to the area of androgenetic hair loss. In these patients, the histological findings of early lesions are identical to those seen in lichen planopilaris. The lichenoid tissue reaction leading to follicular destruction in these patients might be pathogenetically related to the events underlying androgenetic alopecia.