Ultrastructural analysis of explanted CyPass microstents and correlation with clinical findings.

PURPOSE: The purpose of this study was to obtain insight into cellular processes after CyPass microstent implantation into the supraciliary space. With this knowledge, we expected to find some reason for surgical failure. METHODS: Nine CyPass microstents of 8 patients with primary open-angle glaucoma (n = 1), pseudoexfoliation glaucoma (n = 5), uveitic glaucoma (n = 1), and posttraumatic open-angle glaucoma (n = 1) were explanted due to recurrence of IOP elevation, corneal decompensation, or persistent hypotony. The explants were processed for light and transmission electron microscopy. RESULTS: Fibrotic material, consisting of collagen fibrils, microfibrils, pseudoexfoliation fibrils produced by activated fibroblasts, was detected in the stent lumen of 4/5 pseudoexfoliation glaucoma patients and also in posttraumatic open-angle glaucoma. Fibrotic material was also present on the outer surface and within fenestrations of the majority of stents. Complete absence of fibrotic reaction was noticed in 3 of 9 microstents. CONCLUSION: Although MIGS is known to be less invasive than conventional surgery, implants placed in the suprachoroidal space may be adversely affected by a fibrotic tissue reaction resulting in implant failure. Understanding mechanisms and risk factors leading to fibrotic scarring following antiglaucomatous surgery may help to develop novel strategies that improve surgical outcome.

[Clinical and sonographic examination findings in patients with carotid-cavernous sinus fistulas]. / Klinische und echographische Untersuchungsbefunde bei Patienten mit Carotis-Sinus-cavernosus-Fisteln.

BACKGROUND: Symptoms and clinical findings in patients with carotid-cavernous fistulas are specific. Nevertheless, they can be very mildly expressed. This study aims to point out the potential diagnostic value of ultrasound of the orbit. METHODS: A total of 25 patients with a reliable angiographic diagnosis of a fistula were reviewed retrospectively. We analyzed the symptoms, clinical findings and demonstrability in ultrasound of the orbit. RESULTS: The most common clinical findings were nerve palsy, dilation of episcleral vessels and exophthalmos. If an ultrasound had been part of the examination a dilation of the superior ophthalmic vein could be demonstrated in all cases. CONCLUSION: The expeditious ultrasound investigation provides valuable information for the diagnosis of red eyes which are resistant to treatment. The examiner has to consider a fistula and perform an ultrasound especially when diplopia has newly occurred. Finally, the expedient neuroimaging can be arranged.

[Bilateral posterior persistent hyperplastic primary vitreous]. / Bilateraler posteriorer persistierender hyperplastischer primärer Glaskörper.

Bilateral persistent hyperplastic primary vitreous (PHPV) represents a rare entity of a congential malformation. This casuistic presents for the first time in the German literature the case of a 4-month-old child with bilateral posterior PHPV.

[Cavernous sinus thrombosis as a rare cause of exophthalmos in childhood : A case report]. / Sinus-cavernosus-Thrombose als seltene Ursache eines Exophthalmus im Kindesalter : Ein Fallbericht.

Complications of acute bacterial sinusitis mostly occur in children and adolescents. In particular, intracranial spread of the infection can lead to severe even fatal courses of the disease. This article is a case report about a 13-year-old boy suffering from left-sided headache, meningismus and exophthalmos as presenting symptoms. Cranial magnetic resonance imaging (MRI) showed merely right-sided sphenoid sinusitis; however, the diffusion-weighted MRI sequence indicated a left-sided cavernous sinus thrombosis, which could be confirmed by computed tomography (CT) angiography. Cerebrospinal fluid diagnostics showed significant leukocytosis confirming secondary meningitis. Finally, exophthalmos was explained by parainfectious cavernous sinus thrombosis and periorbital edema. This case report highlights the importance of extended and specific diagnostic imaging in cases of clinically suspected complications in children and adolescents with sinusitis and the diagnostic significance of diffusion-weighted MRI.

[Principles of glaucoma diagnostics with optical coherence tomography]. / Grundlagen der optischen Kohärenztomographie-basierten Glaukomdiagnostik.

BACKGROUND: In recent years many applications of optical coherence tomography (OCT) have led to a better understanding of glaucoma morphology. The clinical routine in the treatment of glaucoma is strongly influenced by the modern diagnostic aspects. METHODS: A selective search of the literature was carried out and the important aspects are presented taking own experiences into account. The measurement principles, diagnostic ability and pitfalls of the three OCT measurement procedures are highlighted. RESULTS: Retinal nerve fiber layer, macula and ganglion cell layer thickness as well as the minimum neuroretinal rim width have facilitated in particular the objective early diagnosis and follow-up measurements. CONCLUSION: For glaucoma, OCT measurements cannot replace the medical expert diagnosis but they represent a valuable decision-making aid for diagnostics and follow-up examinations.

[Structural alterations during the course of glaucoma disease]. / Strukturelle Veränderungen im Verlauf der Glaukomerkrankung.

BACKGROUND: Structural changes in the course of glaucoma disease affect the trabecular meshwork and ciliary body in addition to the optic disc as the primary site of glaucoma damage. OBJECTIVES: Latest results from experimental studies, animal models and measurements in human eyes are presented and discussed. RESULTS: The presenting scenario is complex with age, biochemical and mechanical stress factors leading to subsequent, irreversible tissue change in the trabecular meshwork and cribriform plate of the optic nerve, resulting in neuronal tissue loss. CONCLUSION: Knowledge of these changes will be the key for future glaucoma therapies.

[Successful brachytherapy of a clinically unapparent ciliary body melanoma]. / Erfolgreiche Brachytherapie bei klinisch inapparentem Ziliarkörpermelanom.

We report on a typical case of a ciliary body melanoma in a 59-year-old female, which was only noticed due to nonspecific unilateral vision disorders and which could only be seen in maximal mydriasis via a gonioscopic three-mirror lens. We further discuss tumor monitoring via ultrasound biomicroscopy (UBM) and execution and prognosis of Ru-106 brachytherapy.

[Pigment dispersion syndrome and pigmentary glaucoma. Morphometric analysis of the anterior chamber segment with SL-OCT]. / Melanindispersionssyndrom und -glaukom. Morphometrische Analyse des vorderen Augenabschnittes mittels SL-OCT.

BACKGROUND: The purpose of this study was to analyze if anterior chamber parameters are risk factors for the development of pigment dispersion syndrome (PDS) and/or for the conversion to pigmentary glaucoma (PG). PATIENTS AND METHODS: This study included a total of 63 eyes from 35 patients with PDS and PG and 65 eyes from 49 unaffected volunteers as the control group. The following parameters were measured by slit lamp optical coherence tomography (SL-OCT): anterior chamber volume (ACV) and depth (ACD), angle opening distance (AOD) and the trabecular iris space area (TISA) at 500 µm and 750 µm from the scleral spur. Comparisons between the following groups were performed: between the PDS/PG and the control group, between PDS and PG and between male and female patients. RESULTS: The results of ACV, ACD, AOD and TISA were significantly higher in PDS/PG patients when compared to the control group. There were no significant differences between PDS and PG. The gender-specific comparison also showed no significant differences. CONCLUSIONS: Significantly higher anterior chamber parameters are a possible risk factor for development of PDS; however, a higher risk of conversion to PG does not seem to correlate with increased anterior chamber parameters. The parameters of the anterior chamber are apparently not associated with the male predominance of PDS and PG.

[Structural diagnostics of course observation for glaucoma]. / Strukturelle Diagnostik der Verlaufsbeobachtung der Glaukome.

BACKGROUND: Imaging of the structural progression of glaucoma enables measurement of the neuroretinal rim of the optic disc, retinal nerve fibre layer and thickness of the ganglion layer. METHODS: High resolution disc photography, laser scanning tomography, scanning laser polarimetry and optical coherence tomography (OCT) are the current methods of choice to document and measure progression of this chronic degenerative disease. RESULTS: Loss of the neuroretinal rim is only a few mm(2) or mm(3) per year and has to be differentiated from age-related loss which shows less change over the years. The most pronounced loss is temporal both superior and inferior. Thinning of the retinal nerve fibre layer follows the same pattern with significant annual changes of only 6-7 µm. Modern OCT devices deliver measurements of the macula ganglion cell complex which can be even more sensitive than the thickness of the retinal nerve fibre layer. Qualitative criteria for structural progression are papillary hemorrhage, rarification of papillary vessels and specific changes of the retinal pigment epithelium. CONCLUSIONS: Structural loss due to glaucoma can be imaged and measured with different methods in different tissues. The evaluation of significant changes is still the responsibility of the ophthalmologist by taking all findings into account.

[The most important signs of a glaucomatous disc]. / Die wichtigsten ophthalmologischen Papillenveränderungen bei den Glaukomen.

Glaucomatous optic atrophy is the result of both primary and secondary glaucomas leading to functional defects. Loss of axons and ganglion cells leads to a specific atrophy of the optic nerve head. Increased cup size and depth with loss of neuroretinal rim tissue are accompanied by changes of the retinal vessels and juxtapapillary retinal pigment epithelium. Changes of the retinal nerve fibre layer, caused by ganglion cell loss may be earliest signs of glaucomatous atrophy. The marked variability of optic disc size and form may influence the quality of ophthalmoscopic evaluation in extreme variants. Peripapillary haemorrhages and changes of pulsation properties of the retinal venules may give prognostic information for the course of the disease. These signs may be evaluated and even semiquantitatively measured with limited technical effort. They lay the basis for the evaluation of modern imaging and measuring techniques. This article summarises criteria described by Jonas and other authors in the light of modern imaging techniques and adds the latest scientific results.

[Papilledema and echographically detectable retro-orbital dilatation of the sub-arachnoidal space with open fontanelle - six case reports]. / Stauungspapille und echografisch nachweisbare retroorbitale Erweiterung des Subarachnoidalraums bei offener Fontanelle - Sechs Kasuistiken.

This paper analyses the case reports for three children in which a papilledema occurred before the age of one year. Furthermore, an analysis is also given of three further case reports for children aged less than one year in which, in spite of open fontanelle, no papilledema was found, however, a dilatation of the sub-arachnoidal space was demonstrated echographically. Even in children less than one year of age in which an open fontanelle still exists and in whom a neuro-paediatric clarification of internal hydrocepalus is made, in spite of opththalmoscopically inconspicuous findings for the papilla an echography is indispensable for the evaluation of the sub-arachnoidal space. Here, the early recognition of a dilatation of the retro-bulbar sub-arachnoidal space can possibly prevent the occurrence of a consecutive optic atrophy. At the present time, the data available do not allow the recommendation of an upper age limit for an echographic examination.

Influence of atypical retardation pattern on the peripapillary retinal nerve fibre distribution assessed by scanning laser polarimetry and optical coherence tomography.

AIM: To investigate the influence of atypical retardation pattern (ARP) on the distribution of peripapillary retinal nerve fibre layer (RNFL) thickness measured with scanning laser polarimetry in healthy individuals and to compare these results with RNFL thickness from spectral domain optical coherence tomography (OCT) in the same subjects. METHODS: 120 healthy subjects were investigated in this study. All volunteers received detailed ophthalmological examination, GDx variable corneal compensation (VCC) and Spectralis-OCT. The subjects were divided into four subgroups according to their typical scan score (TSS): very typical with TSS=100, typical with 99 ≥ TSS ≥ 91, less typical with 90 ≥ TSS ≥ 81 and atypical with TSS ≤ 80. Deviations from very typical normal values were calculated for 32 sectors for each group. RESULTS: There was a systematic variation of the RNFL thickness deviation around the optic nerve head in the atypical group for the GDxVCC results. The highest percentage deviation of about 96% appeared temporal with decreasing deviation towards the superior and inferior sectors, and nasal sectors exhibited a deviation of 30%. Percentage deviations from very typical RNFL values decreased with increasing TSS. No systematic variation could be found if the RNFL thickness deviation between different TSS-groups was compared with the OCT results. CONCLUSIONS: The ARP has a major impact on the peripapillary RNFL distribution assessed by GDx VCC; thus, the TSS should be included in the standard printout.

Frequency doubling technique perimetry and spectral domain optical coherence tomography in patients with early glaucoma.

PURPOSE: To assess the combined diagnostic power of frequency-doubling technique (FDT)-perimetry and retinal nerve fibre layer (RNFL) thickness measurements with spectral domain optical coherence tomography (SDOCT). METHODS: The study included 330 experienced participants in five age-related groups: 77 'preperimetric' open-angle glaucoma (OAG) patients, 52 'early' OAG, 50 'moderate' OAG, 54 ocular hypertensive patients, and 97 healthy subjects. For glaucoma assessment in all subjects conventional perimetry, evaluation of fundus photographs, FDT-perimetry and RNFL thickness measurement with SDOCT was done. Glaucomatous visual field defects were classified using the Glaucoma Staging System. FDT evaluation used a published method with casewise calculation of an 'FDT-score', including all missed localized probability levels. SDOCT evaluation used mean RNFL thickness and a new individual SDOCT-score considering normal confidence limits in 32 sectors of a peripapillary circular scan. To examine the joined value of both methods a combined score was introduced. Significance of the difference between Receiver-operating-characteristic (ROC) curves was calculated for a specificity of 96%. RESULTS: Sensitivity in the preperimetric glaucoma group was 44% for SDOCT-score, 25% for FDT-score, and 44% for combined score, in the early glaucoma group 83, 81, and 89%, respectively, and in the moderate glaucoma group 94, 94, and 98%, respectively, all at a specificity of 96%. ROC performance of the newly developed combined score is significantly above single ROC curves of FDT-score in preperimetric and early OAG and above RNFL thickness in moderate OAG. CONCLUSION: Combination of function and morphology by using the FDT-score and the SDOCT-score performs equal or even better than each single method alone.

[Acute visual loss with bilateral corneal edema]. / Akuter Visusverlust mit beidseitigem Hornhautödem.

An 84-year-old woman presented with bilateral visual loss that had appeared 3 days previously. Split lamp examination showed bilateral corneal edema with normal intraocular pressure. The patient complained of headache and vomiting, and finally collapsed. Elevated levels of inflammation markers led to the suspicion of an inflammatory disease. After investigation for internal or neurological diseases, a biopsy of the temporal artery was performed. Giant cell arteritis (Horton's disease) was found, and steroid therapy was begun. The patient's general condition then improved.

[Long-term follow-ups of patients with glaucoma with digital planimetry]. / Digitale Planimetrie zur Langzeitverlaufskontrolle bei stabilen und progredienten Glaukomen.

BACKGROUND: The purpose of this study was to investigate whether digital planimetry is appropriate for quantification of neuroretinal rim loss in patients with glaucoma, with and without progression. PATIENTS AND METHODS: The optic discs of 44 patients, whose illness had been well documented with photographs over a period of at least eight years were divided in a progression group and an unchanged group with regard to glaucoma. After this evaluation we measured each disc by digital planimetry and correlated the results. The researcher conducting the measurements was unaware of the patients' date of examination and the diagnosis. RESULTS: While the neuroretinal rim decreased by only 0.06 A+/- 0.15 mm(2) on average in the group of patients without glaucoma, the average decrease was 0.30 A+/- 0.27 mm(2) in the group with progression. This corresponds to a yearly decrease on average of merely 0.0043 A+/- 0.011 mm(2) (0.25%/a) in the group without progression and one of 0.0228 A+/- 0.025 mm(2) (1.9%/a) in the group with progression. Mean neuroretinal rim loss was 0.25% per year in the group without progression of glaucoma, and 1.9% per year in the group with progression. This annual difference is significant. (p = 0.003). The average observation time in the morphologically better group was on average significantly shorter (12.3 years compared to 14.5 years). CONCLUSION: Digital planimetry was able to determine if a morphological progression was found in a clinical examination or if a glaucoma showed no signs of worsening. So we can use this method of digital planimetry of optic discs to examine and re-examine older and more recent photographs to always get the best results of a possible progression of glaucoma.

3D vs 2D qualitative and semiquantitative evaluation of the glaucomatous optic disc atrophy using computer-assisted stereophotography.

BACKGROUND AND PURPOSE: Real colour documentation of the optic nerve head (ONH) is one of the most important methods to identify the early progression of glaucomatous optic nerve damage. This study compares the qualitative and semiquantitative evaluation of ONH photographs, using a 3D time-multiplexing system and conventional 2D photography, visualised on a computer monitor. PATIENTS AND METHODS: Stereophotographs of the ONH were converted by special software in a 3D file. The same images were shown in 2D and 3D to 22 subjects with different training grades (residents and ophthalmologists). The evaluation based on a standardised questionnaire, containing semiquantitative parameters of the ONH. A weighted score for quality of ONH assessment counted the correct answers of the observers to compare their evaluation in 2D to the one made in 3D. RESULTS: All of the observers achieved a significant better evaluation of the ONH with 3D than with 2D images. No significant differences were observed between both groups. Classification errors with respect to the 'gold standard' were lower for 3D measurements as compared with 2D measurements (P=0.007). No significant differences were observed between the gold standard and residents or ophthalmologists for the ONH size, but for the c/dratio the stereoscopic images lead to better results. CONCLUSION: This study showed a better evaluation of parameters associated with the glaucomatous ONH atrophy with 3D images compared with 2D, independent of the clinical training grade. The computer-based evaluation of the ONH atrophy by using a time-multiplexing system (shutter-glasses) may improve the diagnosis of glaucoma patients.