[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.

[Optic Nerve Head Diagnostics with Optical Coherence Tomography]. / Papillendiagnostik mithilfe der optischen Kohärenztomografie.

BACKGROUND: With a cooperative patient, examination of the optic nerve head using optical coherence tomography (OCT) is fast and easy to perform and facilitates identification and monitoring of different pathological changes in the optic nerve head. MATERIALS AND METHODS: Characteristic findings and scanning options are illustrated using case examples to simplify recognition of infrequent diseases of the optic nerve head and to facilitate treatment decisions using OCT results. RESULTS: Pathological changes and characteristic OCT findings are shown for glaucoma, for different anomalies of the optic nerve head, for non-glaucomatous optic atrophies and for optic disc swelling for different reasons. The most suitable OCT parameters and examination modes are listed to differentiate between specific pathological changes. CONCLUSION: Optic nerve head examination using the OCT facilitates rapid diagnosis of infrequent and hard to distinguish pathological changes, as well as exact monitoring of chronic progressive diseases of the optic nerve. Correct application and evaluation of results gathered using OCT examination of the optic nerve head facilitates accurate diagnosis and correct decisions.

[Gonioscopy - How, Why, What for?] / Gonioskopie ­ wozu, weshalb, warum?

Aim Gonioscopy is used to exam the anterior chamber angle and the neighbouring structures. Gonioscopy can be performed using a contact lens, with the patient sitting at the slit lamp or in a supine position. Due to the total inner reflection of the cornea, the anterior chamber angle would otherwise be invisible in a healthy eye. During normal daily clinical routine, gonioscopy is often omitted, due to lack of time, although additional information could be gained. Materials and Methods The aim is to give a summary of the diagnostic possibilities using gonioscopy and to emphasise the importance of this relatively easy clinical method. Results The development of gonioscopy, the appropriate tools, proper procedure at the slit lamp and the most popular grading systems are described. In addition, an overview of detectable pathological changes in the anterior chamber angle is given and future prospects about developments in gonioscopy. Conclusion Gonioscopy can provide additional information otherwise missed by slit lamp examination or ophthalmoscopy alone. Up to now, no (semi-)automatic devices have been developed which could completely replace gonioscopy. Therefore gonioscopy remains an important part of a complete ophthalmological examination and should be learned, mastered and performed regularly by every ophthalmologist.

[Role of the aging visual system in glaucoma]. / Rolle des alternden visuellen Systems bei Glaukomen.

BACKGROUND: Glaucoma is the second leading cause of blindness worldwide and is usually diagnosed in higher age groups. The goal was to survey how patient age influences the development of glaucoma. MATERIALS AND METHODS: A web-based search on aging of the visual system and its influence on glaucoma was performed and the most important results are summarized. RESULTS: The prevalence of glaucoma rises with age. Aging processes of the trabecular meshwork and the uveoscleral outflow pathway lead to a rise in the intraocular pressure. Chronically elevated intraocular pressure leads to remodelling of the lamina cribrosa and narrowing of its pores through which ganglion cell axons leave the eye. Age-dependent glia cell, mitochondria and immune system alterations are discussed to influence glaucoma. Patient age and further age-related nonophthalmological systemic diseases also influence adherence and persistence to the prescribed therapy. CONCLUSIONS: Aging is an important risk factor for developing glaucoma and is a main factor which influences therapy and course of the disease. At this point in time it remains unclear to which extent additional factors determine the development of glaucoma.

[Bilateral eye injuries by external transversal force]. / Bilaterale Augenverletzung durch transversale Gewalteinwirkung.

A 49-year-old female victim of violent crime with an acute bilateral loss of vision was referred to our hospital. The ophthalmological evaluation showed complete subconjunctival hemorrhage of both eyes, bilateral hemophthalmos and hypotonia of the left eye. These raised the suspicion of an occult scleral rupture. We immediately performed exploratory surgery and found a perforating scleral lesion of the left eye and a penetrating scleral lesion of the right eye. Furthermore, a small, cruciform wound was detected on the left temple. In cooperation with the department of radiology, the extraordinary injury pattern was reconstructed: a horizontal stab wound with perforation of the left eye and penetration of the right eye caused by a screwdriver. Visual rehabilitation necessitated further surgical interventions. Besides the intraoperative approach, immediate primary wound management within 100 h of trauma plays a pivotal role for long-term outcome.

[Differential diagnosis of juvenile normal pressure glaucoma]. / Differenzialdiagnose juveniles Normaldruckglaukom.

The case of a 50-year-old female patient with autosomal dominant optic atrophy is described, which was initially misinterpreted and treated as normal pressure glaucoma. Bilateral partial optic atrophy can be diagnosed by chance with mild manifestation of symptoms and can initially be misinterpreted as glaucoma. Taking a detailed medical history and performing a thorough optic nerve head examination can raise the suspicion of hereditary optic atrophy. The reliable detection of autosomal dominant optic atrophy by genetic investigations should be strived for in such cases.

Changes of anterior chamber architecture induced by laser peripheral iridotomy in acute angle closure crisis.

In acute angle closure crisis (AAC), a laser peripheral iridotomy (LPI) is performed to balance the pressure gradient between anterior and posterior chamber. The hereby induced changes in anterior chamber architecture were analyzed using Scheimpflug photography (SP). SP was performed in eyes with AAC and in fellow eyes (FE) before and after LPI. Intraocular pressure (IOP), anterior chamber volume (ACV), anterior chamber depth (ACD), anterior chamber angle width (ACA), and central corneal thickness (CCT) were analyzed. The group consisted of 18 patients (14♀, 4♂; 69 ± 11 years) with unilateral AAC. Mean IOP in AAC eyes decreased from 49.3 ± 2.8 mmHg at presentation to 13.7 ± 1.6 mmHg after LPI (p = 0.001). Mean ACV increased from 48.2 ± 3.6 to 60.6 ± 2.4 mm(3) in AAC eyes (p < 0.001) and from 60.4 ± 4.6 to 74.1 ± 3.7 mm(3) in the FE (p < 0.001). Mean ACD increased from 1.27 ± 0.08 to 1.44 ± 0.06 mm (p = 0.01) in AAC eyes and decreased in FE from 1.72 ± 0.08 to 1.59 ± 0.04 mm (p = 0.5). Mean ACA increased from 16.8 ± 1.6 to 20.5 ± 1.5° in AAC eyes (p = 0.01) and from 18.5 ± 1.4 to 22.6 ± 1.5° in the FE (p = 0.01). Mean CCT did not change significantly in both groups after LPI (AAC p = 0.09; FE p = 0.9) but a statistically significant difference between the two groups was detectable before LPI (p = 0.04) which disappeared thereafter (p = 0.14). Using Scheimpflug photography, a significant difference of ACV, ACD, and ACA can be detected after LPI in eyes suffering from acute angle closure crisis which demonstrates the effectiveness of LPI.

[Pattern laser trabeculoplasty and argon laser trabeculoplasty for treatment of glaucoma]. / Pattern-Laser-Trabekuloplastik und Argon-Laser-Trabekuloplastik zur Glaukombehandlung.

INTRODUCTION: Argon laser trabeculoplasty (ALT) and pattern laser trabeculoplasty (PLT) are two laser surgery methods for treatment of open angle glaucoma and the effect in reducing intraocular pressure (IOP) of these methods was compared in a retrospective study. METHODS: The IOP, the best corrected visual acuity (BCVA) and the eye drop glaucoma medication used by patients who were treated by ALT or PLT in this clinic between January 2011 and December 2012 were compiled and evaluated. RESULTS: An ALT was carried out on 22 eyes from 22 patients (13 right and 9 left eyes in patients with an average age of 71.1 ± 1.5 years, 7 men and 15 women) and a significant average reduction of IOP from 18.6 ± 0.9 to 15.3 ± 0.7 mmHg (p < 0.001) was observed an average of 8.2 ± 0.8 weeks after ALT. The number of dropped glaucoma medications per eye (p = 0.19) and the mean BCVA both remained constant (p = 0.15). A PLT was carried out on 20 eyes from 20 patients (12 right and 8 left eyes in patients with an average age of 69.9 ± 2.6 years, 10 men and 10 women) and a significant average reduction of IOP from 20.2 ± 1.1 to 15.6 ± 0.8 mmHg (p < 0.001) was observed an average of 8.3 ± 0.6 weeks after PLT. The number of dropped glaucoma medications per eye (p = 0.08) and the mean BCVA both remained constant (p = 0.59). The difference in the reduction of IOP between the ALT and PLT groups was not significant (p=0.26). CONCLUSION: Both PLT and ALT are effective methods for treatment of open angle glaucoma and lead to similar significant reductions in IOP.

[Firework-related eye trauma from 2005 to 2013]. / Bulbustraumata durch Feuerwerkskörper von 2005 bis 2013.

PURPOSE: Fireworks combusted during New Year's Eve festivities can cause different eye traumas which often need complex reconstructive surgery. It was our aim to systematically analyse these eye trauma cases which were treated at our clinic during the last eight years. MATERIALS AND METHODS: Age, gender, side, trauma mechanism, treatment methods and outcome were analysed for all eye trauma cases caused by fireworks during the New Year's Eve celebrations from 2006 to 2013. For statistical analysis all trauma cases were divided into two groups of major and non-major eye trauma. RESULTS: The total number of patients treated was 122 (28 women, 94 men, mean age 26.2±13.0 years) with 137 traumatised eyes (77 right, 60 left). 24.6% of patients were ≤18 years of age. 76.2% were bystanders. 50 eyes from 46 patients (37.7%) suffered from major eye trauma. 26 patients (21.3%) were hospitalised. 8 eyes (5.8%) suffered from a penetrating injury or globe rupture and underwent primary reconstructive surgery. Further 16 eyes (11.7%) suffered from major eye trauma without open globe injury. In the aftermath 11 eyes (8.0%) went blind (visual acuity<1/50). Gender, side and role of the patient were not significantly different between the two groups. Mean age was significantly higher in the major eye trauma group (p=0.01). CONCLUSION: Young male bystanders have a high risk for suffering from eye trauma caused by fireworks. However older patients suffer from major eye trauma more often. More education and prophylaxis of eye trauma caused by fireworks is desirable.

[Scheimpflug photography of acute angle closure]. / Scheimpflug-Fotografie bei akutem Winkelblock.

PURPOSE: In acute angle-closure glaucoma a laser iridotomy (IO) is performed to balance the intraocular pressure between the anterior and posterior chambers. The changes induced in the anterior chamber architecture were analyzed using Scheimpflug photography. MATERIAL AND METHODS: Scheimpflug photography was performed in eyes with acute angle closure and in the contralateral eyes before and after IO. RESULTS: In a group of 10 patients (8♀, 2♂, average age71.2 ± 5.3 years) 10 eyes with acute angle closure and 10 contralateral eyes were analyzed. The anterior chamber depth, central corneal thickness and anterior chamber angle did not change significantly after IO. The mean anterior chamber volume showed a statistically significant increase in the 10 eyes with acute angle closure and in the 10 contralateral eyes. CONCLUSION: Anterior chamber volume increases due to IO but not anterior chamber depth, central corneal thickness and anterior chamber angle in eyes with acute angle closure.

[1-year results after posterior lamellar keratoplasty with manually dissected donor tissue]. / 1-Jahres-Ergebnisse nach posteriorer lamellärer Keratoplastik mit manuell disseziertem Spendermaterial.

OBJECTIVE: Posterior lamellar keratoplasty (PLK) is a reasonable alternative to penetrating keratoplasty (PK) for pathological changes of the corneal endothelium. The lamellar preparation of the donor tissue can be done in an automated fashion with a microkeratome, Descemet Stripping Automated Keratoplasty (DSAEK) or manually, Descemet Stripping Endothelial Keratoplasty (DSEK). Here, we describe our clinical results with one year follow-up using manually dissected donor lamellae for PLK. METHODS: For 28 eyes (28 patients) best-corrected visual acuity, corneal topography, esthesiometry, pachymetry, as well as endothelial cell count were measured before, 1 day, 1 and 6 weeks, as well as 3, 6 and 12 months after surgery. RESULTS: 3 of 28 grafts showed primary graft failure. For 19 eyes (no other vision-limiting diseases), the best-corrected visual acuity rose on average from 1.0 +/- 0.53 to 0.4 +/- 0.20 (logMAR) 1 year after surgery. The surgically induced astigmatism changed from 3.8 +/- 2.8 dpt preoperatively to 1.4 +/- 1.0 dpt 12 months after DSEK. The pachymetry measured by slit lamp showed an averaged thickness of 649 +/- 54 mm pre- and 776 +/- 75 mm one week and 636 +/- 79 mm 1 year after surgery was performed. The endothelial cell count of the grafts was 2615 +/- 156 cells/mm (2), after one year postoperatively the mean endothelial cell count was 2084 +/- 536 cells/mm (2). The esthesiometry showed a slight rise from 0.96 +/- 0.34 g/mm (2) pre- to 0.96 +/- 0.03 g/mm (2) one year post-surgery. CONCLUSIONS: The postoperative course of our patients shows that improvement of visual acuity by PLK with manually dissected donor tissue is possible.

[Albumin eye drops for treatment of ocular surface diseases]. / Albumin-Augentropfen zur Behandlung von Augenoberflächenerkrankungen.

For more than 10 years eye drops made from autologous serum have become an established therapy to support corneal wound healing in ocular surface diseases, such as persistent epithelial defects and dry eye. Serum eye drops can only be dispensed by institutions which have obtained a specific license from the appropriate local authorities and this applies to only a few institutes in Germany. The main protein component of serum is albumin which is commercially available as a quality controlled medical product from the pharmaceutical industry and could thus be used as an alternative to autologous serum eye drops. The wound healing effect of albumin eye drops has already been demonstrated in vitro. Here we outline the therapeutic principles and present our first clinical experiences with eye drops made from albumin in the treatment of ocular surface disorders.

[Evaluation of dynamic contour tonometry in keratoconus]. / Evaluierung der dynamischen Konturtonometrie bei Keratokonus.

PURPOSE: The gold standard for measuring intraocular pressure (IOP) until now has been Goldmann applanation tonometry (GAT), which depends on the central corneal thickness (CCT) and curvature. In patients with keratoconus who have an abnormal corneal geometry and thickness, measurement of pressure with GAT is often difficult and not very reproducible. We compared the impact of the central corneal thickness (CCT) on the IOP measured with dynamic contour tonometry (DCT), a digital method which is adapted to the corneal geometry, and GAT in patients with keratoconus. METHODS: IOP was measured in 54 patients (38 men and 16 women, mean age of 36+/-9.9 years) with GAT and DCT in randomized order. All patients had a keratoconus which was assured by topography. In addition central corneal thickness (CCT) was measured with the Pentacam. For statistical analysis the Pearson correlation was calculated and a Bland-Altman diagram plotted. RESULTS: Mean corneal thickness was 486.2+/-45.5 microm. DCT measured the IOP at a mean value of 14.9+/-2.6 mmHg and GAT at 13.3+/-2.9 mmHg. With a mean difference of 1.6+/-2.4 mmHg DCT measured significantly higher than GAT (p0.05) nor those with DCT (r=0.08; p>0.05) showed a significant correlation to central corneal thickness. CONCLUSION: The example of keratoconus confirms that IOP measured by GAT is lower than if measured by DCT. Because both methods are independent of the CCT they are equally acceptable for IOP follow-up in eyes with keratoconus, which may result in progressive corneal thinning in the long term.

[Autologous serum and alternative blood products for the treatment of ocular surface disorders]. / Eigenserum und alternative Blutprodukte zur Behandlung von Augenoberflächenerkrankungen.

Eye drops made from autologous serum have been increasingly used in the past decade to treat ocular surface disorders such as persistent epithelial defects and dry eye. Due to biologically active ingredients such as growth factors, vitamins, and nutrients, they can be used to lubricate the ocular surface and support epithelial wound healing. According to current legal requirements, they can be dispensed only for outpatient treatment if the producer has obtained a license from the appropriate local authorities. Therefore, the production and dispensing of autologous serum eye drops in Germany is currently limited to a very few institutions and their patients. We review the current evidence on the use of serum eye drops, recommend a standard protocol for their production, and describe a number of recently emerging alternative blood products for the treatment of ocular surface diseases along with their potential advantages and limitations.

[On the use of autologous serum eyedrops in Germany : results of a survey among members of the Cornea Section of the German Ophthalmological Society (DOG)]. / Zum Stand der Anwendung von Eigenserum-Augentropfen in Deutschland : Ergebnisse einer Umfrage unter den Mitgliedern der Sektion Kornea in der DOG.

PURPOSE: The use of serum eye drops has become more common for treating ocular surface diseases such as persistent epithelial defect and dry eye. For the production and use of blood products, regulatory restrictions apply. We surveyed the practice of production and application of serum eyedrops among the members of the Cornea Section of the German Ophthalmological Society (DOG) in Germany. METHODS: A questionnaire concerning the application of topical blood-derived therapeutic agents for use in the eye was sent to 103 institutions in 2005 and 2007. The questionnaire included 14 groups of questions. RESULTS: The rate of response was 49% in 2005 and 55% in 2007. Sixty-five percent (2005: 48%) of the institutions used blood-derived products as therapeutic agents in the eye (in 96%, serum eye drops). In 2007, 17% of the centers stated that they had a license to produce serum eye drops according to the official regulations (2005: 10%). Three hospitals stopped using serum eyedrops for regulatory reasons. In 2007 1,237 patients were treated (2005: 1,389); 36% of the ophthalmic departments produced the serum eye drops themselves (2005: 55%) and 43% produced them in cooperation together with or exclusively in another institution. Quality controls (e.g., virus serology and sterility checks) were performed in 47% (2005: 24%). In 2005, one corneal fibrin deposit was described. In 2007, no complication was reported. CONCLUSION: Although fewer patients were treated in total in 2007, the number of centers using serum eye drops increased between 2005 and 2007. Serious complications were not described. Some hospitals stopped the production and use of serum eye drops because of regulatory reasons or had the drops produced by nonophthalmic institutions with a license to produce blood-derived products. In view of prospective randomized clinical trials showing that autologous serum support ocular surface wound healing, this therapy should be accepted as a standard of care.

[Early latency in pattern-reversal and flash mfVEP]. / Latenzunterschiede des kortikalen Aktivitätsbeginns bei Musterumkehr- und Blitzreizmuster im multifokalen VEP (mfVEP).

PURPOSE: The onset of cortical activity evoked by a visual stimulus, the early latency (fL), can be measured by the use of multifocal visual evoked potential (mfVEP). In this study we investigated differences in amplitude and fL between pattern-reversal and flash mfVEP. METHODS: The mfVEP was recorded from 20 subjects using flash and pattern-reversal stimuli. The recordings were done using a two-dimensional Laplacian derivation. After the signals from all 60 stimulus fields were squared and averaged, the sudden rise from baseline activity marked the beginning of evoked cortical activity, which defined the fL. RESULTS: The fL was 48.1+/-1.0 ms for pattern-reversal mfVEP and 52.2+/-1.3 ms for flash mfVEP. The maximum normalized amplitude was 22.5+/-2.8 for pattern-reversal mfVEP and 8.9+/-1.5 for flash mfVEP. Analysis of variance showed that the stimulus type had a significant effect on the fL (p< or =0.01) and on the maximum amplitude (p< or =0.01) of the evoked cortical potentials. CONCLUSIONS: The fL can be estimated more accurately with potentials of high amplitude. Because the maximum amplitude for pattern-reversal mfVEP was three times as high as for flash mfVEP, and because the fL was longer for flash mfVEP than for pattern-reversal mfVEP, the results of this study do not imply that flash mfVEP should be used for evaluating fL.