[Surgical treatment of diabetic macular oedema]

The therapy for diabetic macular oedema often remains unsatisfactory for both patient and treating physician. Therapeutic approaches comprise laser therapy as the evidence-based "basic therapy" and increasingly also intravitreal injections of drugs which, however, have only a limited effect. One argument for the use of vitrectomy in the treatment of diabetic macular oedema is its potentially permanent positive effect. On the one hand, removal of the adherent vitreous may facilitate the supply of the inner retina "per diffusionem" from the vitreous, on the other hand it may allow movement of harmful cytokines from the retina into the vitreous also by diffusion. Furthermore, from the pathophysiological standpoint, the vitreoretinal interface itself is modified by glycosylation processes and may thereby contribute to the occurrence of macular oedema. Pathological vitreofoveolar adhesions, which now can be visualised by use of ocular coherence tomography, may also add to the development of macular oedema in a mechanical-tractive manner. A critical analysis of the published clinical studies reveals that the macular retinal thickness is indeed reduced after vitrectomy, disappointingly however, this does not translate into better visual acuity in patients without detectable tractive components. But, in the case of eyes with tractive components of the diabetic macular oedema, there is good evidence for a surgical approach.

[Prioritisation in the German health care system--an issue in ophthalmology?]

At the 111th German Medical Assembly in May 2008 in Ulm, Germany, a public debate on rationing of health care performances was started. Since the money in the German health care system is not enough to provide every diagnostic or therapy for every patient as a coverage of the compulsory medical insurances, a lot of specific health care performances have been rationed during the last years not to be covered by the regular medical insurance any more, such as, e. g., PSA measurements in urology or IOP measurements in ophthalmology. In contrast to the health care system in Scandinavia, where rationing of health care performances is publicly documented by the government, no similar public statements exist in Germany. Due to this, it is left to physicians to explain to their patients the "hidden" rationing of public health care performances, which also leads to an increase in individual health care performances (IGeL in Germany) to be paid for privately by the patient. It is undoubtedly true that not all medically possible performances need to be paid for by the health insurance; however, an official determination of these "out of pocket" health care performances is necessary. Therefore, it was the aim herein to work out possible "stop" criteria--according to the Scandinavian system--for common eye diseases and consecutive therapies, which need not be paid for or only be paid after a delay by the health insurances.

Fibrotic racemose haemangioma of the retina

BACKGROUND

The racemose - or arteriovenous - haemangioma of the retina is a rare developmental anomaly. It can be associated with similar vascular anomalies in other regions of the central nervous system (Wyburn-Mason syndrome).

HISTORY AND SIGNS

We report a 24-year-old woman with a chronic headache from our outpatient clinic. Other than a white tortuous strand in the retina of the right eye, which resembled a filarium at first glance, no pathologies were found. Its ends were located at the optic disc forming a sling-shaped lesion extending to the anterior nasal periphery. Partial filling was shown by fluorescence angiography. An MRI of the neurocranium detected no additional vascular abnormalities.

THERAPY AND OUTCOME

So far our patient has not suffered from any visual complaints and she will be followed up yearly.

CONCLUSIONS

We show an unusual presentation of a retinal racemose haemangioma. Diagnosis of this entity should prompt further examinations to exclude any additional haemangiomas with respect to the Wyburn-Mason syndrome.

[Cost calculations for treating penetrating eye injuries within the DRG C01Z at a university eye hospital]

BACKGROUND

Since 2004, inpatient health care for penetrating eye injuries in Germany had been paid according to the calculated DRG C01Z. Because the extent of treatment mainly derives from the extent of eye damage, this DRG economically summarises very heterogeneous cases. It was the aim to check the cost recovery for the surgical treatment of penetrating eye injuries at a university eye hospital.

MATERIAL AND METHODS

Performance data for the DRG C01Z were collected for the years 2005 and 2006 using the E1 sheets according to section sign21 KHEntG. Costs for single operations were calculated from fixed and variable costs for the operating theatre and the ward, including costs for personnel and supplies.

RESULTS

In the 2-year period, out of 4,721 inpatient procedures, 180 perforating eye injuries were surgically treated. In 80 cases, a pure corneal/scleral suture (plus cataract surgery, n=10; mean operating time 67.81 min) was performed. In the other 100 cases, a pars plana vitrectomy (ppV) with adjuvant measures (mean operating time 124.69 min) was needed. Each operation had fixed surgical costs of EUR 130.60; variable costs, including personnel and supplies, varied between EUR 570 for corneal/scleral suture (+/-EUR 250 for combined cataract surgery (n=10) and EUR 1230 (mean) for a ppV. Cost-effective additional adjuncts such as cerclage, perfluorocarbon, gas, silicone oil, or cataract surgery led to extra costs of between EUR 51 and EUR 250 per adjunct (mean EUR 182). At least two of these adjuncts were used in 50% of ppVs, and at least one was used in 90% of ppVs. Hospitalisation costs were about EUR 2184 (EUR 273 per day), with a mean stay of 8 days. The overall costs of an operation for penetrating eye injuries differed significantly in terms of the procedure (corneal/scleral suture: EUR 2662, mean length of stay 7.06 days; ppV: EUR 3712, mean length of stay 8.62 days). Additional costs for multiple surgeries, as occurred in 11.1% of all cases, were not compensated by the DRG system.

CONCLUSION

In consideration of a relative DRG weight of 1,177 and a base rate of EUR 2723.79 in Bavaria for 2005 and 2006, perforating eye injuries were compensated within the C01Z DRG at EUR 3205,96. Thus, for ppVs no costs are recovered, whereas "pure suture" procedures are overweighted. Due to this inhomogeneity, a split in the C01Z DRG is necessary.

[Cost recovery for the treatment of retinal and vitreal diseases by pars plana vitrectomy under the German DRG system]

BACKGROUND

Since 2004 inpatient health care in Germany is paid according to calculated DRGs. Only a few university hospitals participated in distinct cost calculations of clinical treatment. It was the aim of this study to check the cost recovery at a University Eye Hospital for the surgical treatment of retinal and vitreal diseases by pars plana vitrectomy (ppV), which are included in DRGs C03Z and C17Z.

MATERIAL AND METHODS

The performance data for both DRGs were collected for the years 2005 and 2006 using the E1 sheets according to section 21 KHEntG. The mean duration of all procedures was collected by data from the internal controlling. Costs for single operations were calculated from fixed and variable costs for the operation theatre and the ward including costs for personnel and material.

RESULTS

In the 2-year period of 4,721 inpatient procedures 1,307 ppVs were performed. Each ppV had fixed surgical costs of 130.60 EUR; personnel costs varied between 575 EUR (C03Z; including cataract surgery; mean OP duration: 85 min) and 510 EUR (C17Z; no cataract surgery; mean OP duration: 73 min) at a proportion between general anaesthesia and local anaesthesia of 80/20. For a pure ppV material costs were 255 EUR. Additional adjuncts such as an encircling band, perfluorcarbon, ICG, tPA, gas and silicon oil or cataract surgery led to extra costs between 51 EUR and 250 EUR per adjunct und were used in 56% (C03Z) and 74.5% (C17Z) of all procedures. Costs for hospitalisation were about 1765 EUR at a mean residence time of 6.5 days. Thus, the overall costs of a pure basic ppV amounted to 2975 EUR (C03Z) and 2661 EUR (C17Z). In consideration of the current relative DRG weights of 1.08 and 0.957 and a current base rate of 2787.19 EUR in Bavaria, cost recovery is only given for basic ppV but not for complex ppVs having higher material and personnel costs. Additionally, the costs for multiple surgeries as occur in 5.9% of cases are not compensated by the DRG system.

CONCLUSION

The reimbursement for inpatient ppVs in a University environment is not covered for complex procedures requiring more cost-effective material and personnel time. To consider an adequate cost recovery for these procedures a DRG split for both DRGs (C03Z and C17Z) in basic ppVs and complex ppVs is required. We recommend this proposal for the InEK.

Retinal detachment in patients with acute retinal necrosis: a case series

BACKGROUND

Acute retinal necrosis is a rare and severe infectious ocular disease frequently complicated by retinal detachment.

PATIENTS AND METHODS

Records of six consecutive eyes from five patients with acute retinal necrosis were reviewed.

RESULTS

PCR analysis of intraocular fluids was positive for Varizella zoster virus, Herpes virus 1 or 2. Treatment consisted of systemic acyclovir, systemic and local corticosteroids as well as aspirin. Progression of the necrosis could be effectively controlled, however all eyes developed retinal detachment within 55 +/- 24 days. Retinal surgery including pars plana vitrectomy, encircling scleral buckling, liquid silicone or gas filling led to retinal reattachment in all patients during the follow-up time (590 +/- 242 days). The mean visual acuity at the end of the follow-up time was 0.4 +/- 0.3.

CONCLUSIONS

The diagnosis of acute retinal necrosis is reliably confirmed using PCR analysis of intraocular fluids. Currently available treatments are effective in stopping progression of the necrosis. There is, however, a high risk of retinal detachment, which can be successfully treated with vitreoretinal surgery.

Comparison of performance and patient satisfaction of two types of ERG electrodes

BACKGROUND

An age-controlled comparison concerning patient satisfaction and electrical performance of microfibres (DTL) and rigid contact lens (Henkes) corneal ERG electrodes was carried out.

METHODS

36 test persons underwent complete ophthalmological examination and were equally distributed into 3 age groups. Electroretinograms were recorded according to ISCEV standards. Randomly, in one eye a Henkes electrode was used and in the other eye a DTL electrode. Amplitudes of a- and b-waves and implicit times were measured and compared for the two electrode types.

RESULTS

34 of 36 test persons preferred DTL electrodes. Electrical performance concerning b-wave amplitudes was comparable. Statistically significant differences were detected only for scotopic combined cone-rod stimulation in the age groups 20 - 40 and 41 - 60 years between the different electrodes. Other recordings did not show differences. A statistically significant reduction of signal amplitudes with age was detected for scotopic isolated rod signals and combined cone-rod signals. Significance level was p < 0.05. No conjunctival or corneal erosions were found after ERG recordings for either electrode.

CONCLUSIONS

Electrical performance is comparable between electrodes. For scotopic stimulations age was a significant influencing factor for signal amplitude and should be respected for normative values. DTL electrodes were preferred by the vast majority of patients. No adverse clinical effects were observed for either electrode. DTL electrodes should be preferred due to hygienic reasons (single use) and patient comfort.

Comparison of tendency-oriented perimetry and dynamic strategy in octopus perimetry as a screening tool in a clinical setting: a prospective study

OBJECTIVE

The aim of this study was to compare the results of tendency-oriented perimetry (TOP) and a dynamic strategy in octopus perimetry as screening methods in clinical practice.

DESIGN

A prospective single centre observational case series was performed.

PARTICIPANTS AND METHODS

In a newly opened general ophthalmologic practice 89 consecutive patients (171 eyes) with a clinical indication for octopus static perimetry testing (ocular hypertension or suspicious optic nerve cupping) were examined prospectively with TOP and a dynamic strategy. The visual fields were graded by 3 masked observers as normal, borderline or abnormal without any further clinical information.

RESULTS

83% eyes showed the same result for both strategies. In 14% there was a small difference (with one visual field being abnormal or normal, the other being borderline). In only 2.9% of the eyes (5 cases) was there a contradictory result. In 4 out of 5 cases the dynamic visual field was abnormal and TOP was normal. 4 of these cases came back for a second examination. In all 4 the follow-up examination showed a normal second dynamic visual field.

CONCLUSIONS

Octopus static perimetry using a TOP strategy is a fast, patient-friendly and very reliable screening tool for the general ophthalmological practice. We found no false-negative results in our series.

Uveal effusion syndrome

BACKGROUND

The idiopathic uveal effusion syndrome is characterized by a spontaneous serous detachment of the choroid and ciliary body. Pathophysiology is related to a relative scleral impermeability to protein. A possible complication is the development of a serous retinal detachment.

HISTORY AND SIGNS

We present a 65-year-old male, mild hyperopic patient with a peripheral circular choroidal tumour OD, and macular retinal folds OU. Visual acuity was OD 0.5 due to an additional cataract and OS 1.0. Ocular inflammation was not present. Extensive medical, serological and immunological investigations were normal. On MRI a thicker sclera compatible with the diagnosis was measured.

THERAPY AND OUTCOME

Twelve months after the first presentation the patient has no complaints and the ocular findings are stable so that a therapy was not necessary up to now.

CONCLUSIONS

Uveal effusion syndrome is a rare disease which belongs to the differential diagnosis of choroidal tumour with serous retinal detachment. The correct diagnosis is important as sclerectomy or sclerotomy may be an effective treatment.

Besteht ein Zusammenhang zwischen einer Kataraktoperation und nachfolgender exsudativer altersbedingter Makuladegeneration? Eine große retrospektive Fallkontrollstudie

BACKGROUND

Many epidemiological studies indicate a positive correlation between cataract surgery and the subsequent progression of age-related macular degeneration (AMD). Such a correlation would have far-reaching consequences. However, in epidemiological studies it is difficult to determine the significance of a single risk factor, such as cataract surgery.

PATIENTS AND METHODS

We performed a retrospective case-control study of patients with new onset exudative age-related macular degeneration to determine if cataract surgery was a predisposing factor. A total of 1496 eyes were included in the study: 984 cases with new onset of exudative AMD and 512 control eyes with early signs of age-related maculopathy. Lens status (phakic or pseudophakic) was determined for each eye.

RESULTS

There was no significant difference in lens status between study and control group (227/984 [23.1 %] vs. 112/512 [21.8 %] pseudophakic, p = 0.6487; OR = 1.071; 95 % CI = 0.8284-1.384). In cases with bilateral pseudophakia (n = 64) no statistically significant difference of the interval between cataract surgery in either eye and the onset of exudative AMD in the study eye was found (225.9 +/- 170.4 vs. 209.9 +/- 158.2 weeks, p = 0.27).

CONCLUSIONS

Our results provide evidence that cataract surgery is not a major risk factor for the development of exudative AMD.

Intravitreal Triamcinolone Acetonide for Serous Retinal Pigment Epithelial Detachments in Exudative Age-Related Macular Degeneration

BACKGROUND

Due to the high risk of RPE tears PDT is usually not performed in eyes with serous RPE detachments (sRPED). For this reason this subform of exudative AMD was so far untreatable.

PATIENTS AND METHODS

We report on a prospective uncontrolled observational case series. 20 eyes of 20 patients with subfoveal sRPED demonstrated by OCT were treated between June 2005 and April 2006 with intravitreal triamcinolone acetonide (IVTA). In 15 cases there was a primary sRPED, in 5 cases it had developed after one or more sessions of photodynamic therapy with Visudyne.

RESULTS

There was a trend for better average visual acuity in the group with primary sRPED from 0.73 logMAR (0.19 Snellen equivalent) at baseline (n = 15) to 0.68 logMAR (0.21 Snellen) after one month (n = 15) (p = 0.19) and to 0.60 logMAR (0.25 Snellen) after three months (n = 14) (p = 0.41). The maximal height of sRPED decreased to an average of 35.3 % after one month (n = 15) and increased again to 56.9 % after 3 months (n = 14). One patient was lost to follow-up. In the group of eyes with sRPED after PDT, one eye developed an RPE tear with severe vision loss two weeks after IVTA. In the remaining four eyes average visual acuity improved from 0.90 logMAR (0.13 Snellen) at baseline to 0.73 logMAR (0.19 Snellen) after one month and to 0.80 logMAR (0.16 Snellen) after 3 months. Complete resolution of sRPED was observed in 8/20 eyes (4/5 eyes with sRPED after PDT and 4/15 eyes with primary sRPED).

CONCLUSIONS

IVTA seems to be a therapeutic option in otherwise untreatable eyes with sRPED.

First Clinical Experience with Anecortave Acetate (Retaane®)

BACKGROUND

Anecortave acetate is an angiostatic cortisene which is injected as a posterior juxtascleral depot and has been shown to be effective in the treatment of exudative age-related macular degeneration (AMD). The compound is not yet approved in Switzerland but can be used as "compassionate use" in individual cases.

PATIENTS AND METHODS

An uncontrolled case series with standardised documentation of ETDRS visual acuity, near acuity, need for magnification and fluorescein angiography was performed.

RESULTS

22 eyes of 19 patients (8 male, 11 female, average age 78.8 years) were treated with a posterior juxtascleral depot injection (PJD) of 15 mg anecortave acetate. The mean change in visual acuity after 3 months in eyes treated with anecortave acetate was -2.6 ETDRS letters corresponding to 0.52 Snellen lines. 3/20 eyes gained more than 1 line. 11/20 eyes showed stable visual acuity (+/- 1 Snellen line, +/- 5 ETDRS letters). 5/20 eyes developed moderate vision loss (one to two Snellen lines, 6-10 ETDRS letters). 1/20 lost 18 ETDRS letters (> 3 Snellen lines). There were no moderate or severe adverse events.

CONCLUSIONS

A PJD of 15 mg anecortave acetate is safe and well tolerated. In eyes with occult CNV without recent progression or with residual neovascular activity after photodynamic therapy anecortave acetate may be an alternative therapeutic option before considering intravitreal anti-VEGF agents due to the much less invasive character and lower risk profile.

Vasoproliferative retinale Tumore

BACKGROUND

Vasoproliferative Tumors of the retina (VPTR) are benign tumors of unknown origin, occurring mostly in otherwise systemically healthy patients. These highly vascularised tumors are characterised by a pink to yellow colour on funduscopy and are usually situated in the inferior part of the retina. They are associated with intraretinal hemorrhages, intra- or subretinal exudates and hyperpigmentation of the retinal pigment epithelium.

MATERIALS AND METHODS

We performed a retrospective case review of seven cases which have been diagnosed with VPTR between 2004 and 2006 in the Department of Ophthalmology, University Hospital Zurich.

RESULTS

The median follow up was 8 months (range: 1-24 months). We found a presumed underlying cause for the VPTR in 6 out of 7 patients. 3 patients showed a long standing retinal detachment; in the other 3 there was an untreated chronic uveitis. In one case the tumour was surgically excised and histology was performed.

CONCLUSIONS

VPTR of the ocular fundus are a distinct entity in the differential diagnosis of intraocular tumors. These benign lesions represent reactive gliovascular proliferations, with varying degrees of both gliosis and of vascular proliferation. VPTR can be idiopathic, or they develop after inflammatory, vascular, traumatic, dystrophic or degenerative ocular diseases, in particular, uveitis. The major differential diagnosis includes other vascular lesions or tumors of the ocular fundus like capillary retinal hemangiomas, Coat' Disease or malignancies. The natural course of VPTR appears to be variable. The therapy is based on tumor size, localisation and complications.

[Photodynamic therapy of AMD for the first (better sight) and the second (worse sight) eyes]

BACKGROUND

Photodynamic therapy (PDT) is the standard treatment procedure for many forms of exudative and/or neovascular AMD. Despite therapy, visual acuity often drops to low vision levels. The cost efficiency of treating the eye in which vision is worse is therefore the subject of some controversy.

PATIENTS AND METHODS

A retrospective case-control study was conducted in all patients who were treated with PDT at the Universitätsspital Zürich between September 1999 and November 2004. Each patient's first (with worse vision) and second (with better vision) eyes were compared for situation on presentation and course during treatment.

RESULTS

In 117/228 cases (51.3%) visual acuity of the treated eye was better than (or identical to) that of the fellow eye at presentation. Visual acuity before therapy was an average of 0.58+/-0.27 logMAR [Snellen: 0.26 (0.14-0.49)] in the eyes with better visual acuity and 0.69+/-0.4 logMAR [Snellen 0.20 (0.08-0.51)] in the fellow eyes (p=0.015). After therapy there was no significant difference between the patient groups in visual acuity or in the magnitude of any change in visual acuity, or in lesion size or change in lesion size.

CONCLUSION

The outcome of PDT of a second eye (with better visual acuity) is not significantly better than the result obtained in the first eye (the one with worse visual acuity initially).

Vitreous haemorrhage in children

BACKGROUND

Vitreous haemorrhage in early childhood is rare and may cause few symptoms.

HISTORY AND SIGNS

Three children (aged 1, 2 and 6 years) with no history of trauma, presented with squint or unreactive pupil. Unilateral dense vitreous haemorrhage was found in all three children.

THERAPY AND OUTCOME

Rapid clearing of the vitreous opacities within a few weeks made surgical intervention unnecessary in two children. A 6-year-old boy underwent a vitrectomy. Thorough investigations revealed angle recession, retinal pigment epithelium (RPE) scars and an orbital floor bone fracture, respectively, suggesting ocular trauma as the cause for the haemorrhage in all three cases. With early amblyopia treatment, the visual outcome was good.

CONCLUSION

Trauma appears to be a likely cause for vitreous haemorrhage in small children. Even if there is a risk for the development of amblyopia, observation may be a reasonable approach in some cases, since even dense vitreous haemorrhage may resorb rapidly in young children.

Presumed Macular Toxicity of Intravitreal Antibiotics

BACKGROUND

Intravitreal injection is the most effective route for administration of antibiotics in intraocular infections.

PATIENTS AND METHODS

Two patients presented with a metal foreign body in the central vitreous without damage to the retina.

RESULTS

Foreign bodies were removed with an intraocular magnet and limited vitrectomy was performed. Because of leukocytic infiltration of the vitreous, 1 mg vancomycin and 0.4 mg amikacin were injected in the vitreous at the end of the surgery. Postoperative visual acuity did not reach preoperative values in both patients. ERG examination revealed reduced photoreceptor activity. We speculate that amikacin may have reached the macula in a high and toxic concentration in an incompletely vitrectomized eye.

CONCLUSION

The currently accepted intravitreal use of amikacin may cause retinal toxicity.

Macular Atrophy after Combined Intravitreal Triamcinolone Acetonide (IVTA) and Photodynamic Therapy (PDT) for Retinal Angiomatous Proliferation (RAP)

BACKGROUND

Retinal angiomatous proliferation (RAP) is a variant of exudative AMD that appears to respond poorly to standard PDT. This pilot study explores the potential efficacy and safety of combined intravitreal triamcinolone acetonide (IVTA).

PATIENTS AND METHODS

In a prospective interventional case series 10 eyes of 8 patients with RAP were treated with combined IVTA/PDT.

RESULTS

After 3 months there was no evidence of significant exudative activity in 7/10 eyes treated with IVTA/PDT, three eyes required re-treatment. After 6 months 4/10 eyes were "dry" on fluorescein angiography, visual acuity was stable (loss of less than 3 Snellen lines) or had improved in 5/10 eyes. 5/10 eyes had lost 3 or more lines, due to central macular atrophy in 4/5 eyes and secondary to a progressive exudative lesion in 1/5 eyes.

CONCLUSIONS

Intravitreal steroids combined with PDT appear to be a step ahead in the treatment of RAP. Our results, however, raise the question whether combined treatment may create more atrophy leading to vision loss in some cases.

Simultaneous Fluorescein and Indocyanine Green Angiography for Exudative Macular Degeneration

BACKGROUND

The present study investigates how often a simultaneous fluorescein and indocyanine green (ICG) angiography had therapeutic consequences and if it is useful as a clinical routine diagnostic tool.

PATIENTS AND METHODS

502 consecutive simultaneous angiographies in eyes with exudative macular degeneration were retrospectively studied.

RESULTS

A classic extra- or juxtafoveolar choroidal neovascularisation (CNV) was found in 3.5 % of the eyes. A subfoveal predominantly classic CNV was present in 19 % of the angiographies. ICG angiography showed a vascular network in 3 % of the eyes with occult CNV in fluorescein angiography. A neovascularisation supplied by retinal vessels (retinal angiomatous proliferation) was found in 9 % and a polypoidal choroidal vasculopathy (PCV) in 6 %. Other plaques or hot spots were visible in 4 %. In 11 eyes with progressive exudation from PCV and threatening of the fovea, laser treatment was successfully performed.

CONCLUSIONS

Combined angiography identifies treatable PCV. Advantages of a combined procedure (easier logistics, no missing of treatable cases) and arguments for a two step procedure with ICG angiography only in selected cases (lower costs, lower rate of adverse reactions) must be weighed against each other.

Can Eyelashes Migrate?

BACKGROUND

Intraocular cilia after penetrating injuries or surgery causing acute or subclinical inflammation are a well-known problem. In a healthy young patient with acute intraocular inflammation but no history of trauma the diagnosis may be missed initially.

HISTORY AND SIGNS

A young farmer presented with severe eye pain, scleritis and a circumscribed chorioretinal and vitreous infiltrate. There was no history or evidence of eye trauma or systemic disease.

THERAPY AND OUTCOME

Staphylococci were identified from vitreous material. During vitreous surgery an intraretinal cilium was found and removed. After intravitreal antibiotic treatment, the vision completely recovered.

CONCLUSION

Acute intraocular inflammation should alert the ophthalmologist to consider an intraocular foreign body as a possible cause even if there is no history of trauma.

Clinical and Electrophysiological Course of Acute Syphilitic Posterior Placoid Chorioretinitis

BACKGROUND

Syphilis can affect the anterior as well as the posterior segment of the eye at any stage.

HISTORY AND SIGNS

A 52-year-old man was referred to our clinic because of acute loss of his vision and hearing. Best corrected visual acuity (BCVA) was counting fingers (CF) right and 0.05 left eye, respectively. Fundoscopy revealed bilateral intraretinal macular haemorrhages and a large yellowish edematous lesion involving macula and midperipheral retina. Fluorescein angiography showed diffuse late edema. The visual field showed a defect corresponding to the edematous lesion. The "Ganzfeld" electroretinogram (ERG) was markedly reduced and the multifocal ERG in the affected area was not recordable.

THERAPY AND OUTCOME

VDRL, FTA-Abs and TPHA tests in serum and cerebrospinal fluid were positive. Intravenous penicillin therapy was initiated. BCVA, visual field and ERG eventually recovered completely.

CONCLUSIONS

Syphilis should be considered as a differential diagnosis in any unclear inflammatory ocular condition. Awareness of syphilitic posterior placoid chorioretinitis allows rapid diagnosis and therapy.

Blackening of a Choroidal Hemangioma after Photodynamic Therapy

BACKGROUND

Photodynamic therapy has recently advanced to a first line treatment of symptomatic circumscribed choroidal hemangiomas.

HISTORY AND SIGNS

A sixty-year-old male patient was referred with progressive visual loss in his left eye. Visual acuity measured 20/80 and fundus examination revealed a prominent red subretinal lesion superior to the fovea with adjacent pigment epithelial irregularities. Thickening of the central retina was seen on OCT imaging. Sonography revealed a dome-shaped lesion with a maximal thickness of 3.3 mm and high internal reflectivity. Combined fundus indocyanine green and fluorescein angiography showed early filling of large vessels within the tumor.

THERAPY AND OUTCOME

The hemangioma was treated with verteporphin photodynamic therapy. Two days after treatment, with vision unchanged, fundus examination revealed blackening of the tumor. Two months later vision increased to 20/40 and the tumor area was atrophic and bright red with a slight hyperpigmented rim. Angiography revealed the disappearance of tumor vessels and choroidal hypoperfusion in the area of treatment.

CONCLUSIONS

Choroidal hemangiomas may darken initially after photodynamic therapy. This is most probably caused by large coaguli within the voluminous lacuna-like blood-filled vessel system of the hemangioma that are induced by photothrombosis.

[Intravitreal chemotherapy for intraocular lymphoma]

Primary CNS and intraocular non-Hodgkin's lymphoma is currently mostly treated with systemic chemotherapy. After initially successful tumor regression, recurrence is common and usually treated with radiotherapy. However, after good primary therapeutic response, new tumor growth is frequently observed. Because of actinic complications, radiotherapy can be applied only once. For an intraocular recurrence of primary CNS and intraocular lymphoma, intravitreal chemotherapy (0.4 mg methotrexate and 0.4 mg dexamethasone weekly for 4 weeks and once a month thereafter) can be performed. A few weeks after initiation, regression of intraocular tumors and eventually improvement of vision can be achieved. Eyes remained free of recurrence up to 2 years after initiation of intravitreal injections. Intravitreal chemotherapy is an effective treatment for ocular recurrence of primary CNS and intraocular lymphoma after systemic chemotherapy and radiotherapy.

Traumatic rupture of the globe caused by cow horns

PURPOSE

We investigated the epidemiology, clinical findings and functional outcome of open-globe injuries caused by cow horns over a 50-year period in eastern Switzerland.

METHODS

We retrospectively evaluated the files of cases with ruptures of the globe caused by cow horns between 1950 and 1999.

RESULTS

We found 59 cases with ruptures of the globe by cow horns, accounting for 5% of all open-globe injuries. The incidence of these accidents did not change during the observation period. Twenty-two eyes (37%) were enucleated. Only 7 eyes (12%) retained a vision of > or = 0.1. Between 1950 and 1989 only 2/43 eyes (5%) reached a vision of > or = 0.1. In the 1990's, with the introduction of vitreous surgery 5/16 eyes (31%) had a vision of > or = 0.1. Four patients (7%) had blinding eye disease in the partner eye, and three (5%) had a second open-globe trauma.

CONCLUSIONS

In rural regions, with cattle breeding, open-globe injuries by cow horns are relatively common and the frequency is still the same as 50 years ago. The visual prognosis of these eyes is still guarded, but functional results have improved with the introduction of vitreous surgery. Patients who have had a rupture of the globe appear to have an increased risk for partner eye trauma. Therefore, all efforts are justified to preserve even limited vision in severely injured eyes.

[Acute zonal occult outer retinopathy (AZOOR)]

BACKGROUND

The "white dot syndromes" are a clinically heterogeneous group of inflammatory chorioretinopathies with an inconsistent classification. It is not yet clear if they represent distinct entities or if they are only different forms of the same basic disease.

CASE REPORT

A 53-year-old female patient presented with unilateral photopsia and reduced vision in the left eye. Funduscopy of the left eye showed peripapillary confluent whitish infiltrates in the deep retinal layers with corresponding enlargement of the blind spot. Slow progression of the lesions was observed followed by the development of subretinal fibrosis in the macula. The ERG was reduced in the left eye. In both eyes there were small round, partly confluent areas of RPE atrophy in the lower fundus periphery without inflammatory reaction in the vitreous body or anterior chamber.

CONCLUSION

The presented case shows overlapping features of acute zonal occult outer retinopathy (AZOOR), multifocal choroiditis and diffuse subretinal fibrosis and uveitis. This case and other previously described cases with overlaps between different clinical entities support the theory that clinically different inflammatory chorioretinal diseases may represent parts of a spectrum of one common disease.

Phacoemulsification following treatment of choroidal melanoma

BACKGROUND

Little is known about the risks, effects and results of phacoemulsification following treatment with different modalities of choroidal melanoma.

METHODS

In a retrospective study, records were evaluated of 72 patients who underwent cataract surgery after treatment of choroidal melanoma (35 were treated with iodine-125 plaques, 27 with ruthenium-106 plaques, eight by tumor excision, and two with proton beam irradiation). The data were analyzed with respect to complications, effects on postoperative tumor care and visual outcome.

RESULTS

Phacoemulsification was performed at a mean interval of 21.5 months after primary tumor therapy. An intraocular lens (IOL) was implanted in 93% of the cases. The mean postoperative follow-up time was 16.2 months. Preoperative problems were rubeosis iridis (30.5%), secondary glaucoma (34.7%) and posterior synechiae (41.6%). Intraoperatively, defects of the posterior capsule occurred in 12.5%. Visual acuity equal to or better than preoperative vision was found in 95.8% of the patients as the best postoperative measurement and in 72.2% at the last follow-up measurement. A deterioration of more than two lines in visual acuity was observed in 4.2% as the best postoperative vision and in 27.8% at the last documented examination. Phacoemulsification was not the cause of deterioration in any of the cases. After cataract surgery, tumor retreatment was necessary in 19.4%. Treatment of radiation retinopathy was performed for the first time in 13.8%. Metastases developed in six patients (8.3%).

CONCLUSION

Phacoemulsification following treatment for choroidal melanoma is both possible and advisable. The majority of patients have enhanced visual acuity. No decrease of vision occurred as a result of cataract extraction. The postoperative care of intraocular tumors and the treatment of radiation retinopathy is improved by timely cataract surgery.

[Double vision caused by double intraocular lenses]

An 80-year-old man had intraoperative loss of an intraocular lens (IOL) in the vitreous and simultaneous implantation of an anterior chamber lens. For the first 3 years his course was uncomplicated, but after this time he noted monocular double vision. The IOL in the vitreous had moved into the optic axis of the eye. The case presented here underlines the possibility of complications occurring even years after surgery due to an IOL left behind in the vitreous. The double IOL implant technique should be reserved for very few selected indications.

[Simultaneous ICG- and fluorescein-angiography for fundus examination]

BACKGROUND

An indocyanine-green (ICG) angiography is rarely used as the only diagnostic procedure. Almost always it is performed additionally to a fluorescein angiography. The use of simultaneous ICG and fluorescein (SIF) angiography therefore makes sense. Several examples for the application of SIF-angiography are presented.

MATERIALS AND METHODS

SIF-angiography was performed using a 2-wavelength scanning laser ophthalmoscope (SLO). Images were digitally recorded in real time with a graphics workstation. The following cases will be presented: choroidal neovascularization in age-related macular degeneration, choroidal hemangioma, inflammatory fundus disease (APMPPE) and idiopathic polypoidal choroidal vasculopathy.

RESULTS

ICG and fluorescein angiography can be simultaneously recorded with the 2-wavelenghth SLO. The quality of the combined pictures is comparable to single-channel recordings of separate ICG and fluorescein images. We show results of the above mentioned cases.

CONCLUSIONS

SIF angiography is time efficient and allows precise comparison and analysis of the transit of both dyes through retinal and choroidal circulation. The topographic relation of pathologic findings in ICG angiograms with the critical retinal vascular landmarks is facilitated.

Rubeosis iridis after vitrectomy for diabetic retinopathy

BACKGROUND

Iris rubeosis and neovascular glaucoma (NVG) are serious complications of vitrectomy for proliferative diabetic retinopathy. The present study analyzes incidence and risk factors of these complications.

METHODS

Preoperative and postoperative iris rubeosis were compared in 389 diabetic eyes after vitrectomy. Minimum follow-up was 6 months (median 26 months). Risk factors were studied using multivariate logistic regression analysis.

RESULTS

Following vitrectomy, in 8.5% of the eyes stromal iris rubeosis developed de novo; NVG occurred in 5%. Significant risk factors for postoperative rubeosis were preexisting iris neovascularizations and postoperative retinal detachment. Six months after surgery, regression of preexisting iris rubeosis was observed in 57% of the eyes. In eyes without preoperative iris rubeosis, progression was found in 13% of cases 6 months postoperatively.

CONCLUSION

With current surgical techniques iris rubeosis is more commonly regressive than progressive after vitreous surgery in diabetic eyes.

Electrophysiological evaluation of visual loss in Müller cell sheen dystrophy

AIMS

To describe the clinical picture and electrophysiological findings in Müller cell sheen dystrophy, a recently reported retinal dystrophy.

METHOD

A basic ophthalmological evaluation as well as recording of standard electro-oculography and electroretinography were performed in one patient at the onset of visual loss and after 1 year of follow up.

RESULTS

A 61 year old woman presented with visual loss in the right eye. Multiple folds at the level of the internal limiting membrane were seen at the posterior pole in both eyes. Macular oedema was present in the right eye. The visual acuity of the right eye was 6/30 and of the left 6/9. A paracentral scotoma was found in the right eye. Electro-oculographic examination of both eyes gave normal results. Electroretinography (ERG) revealed reduced b-wave and flicker amplitudes in the right eye; these potentials were normal for the left eye. The ON response in the right eye was reduced and delayed; it was normal in the left eye. A further loss of visual function was noted 1 year later in the right eye, but the ophthalmoscopic findings were unchanged. The ERG of the right eye had a negative waveform when dark adapted. Light adapted responses showed an unusual delayed b-wave, broad and delayed ON and OFF responses and a missing flicker response, suggesting a Müller cell dysfunction. Light adapted responses were slightly reduced in the left eye.

CONCLUSIONS

Electrophysiological data indicate Müller cell dysfunction as a background of functional loss in Müller cell sheen dystrophy. This is in agreement with previously reported histological findings in this disorder.

[Vitrectomy in diabetic retinopathy: outcome, risk factors, complications]

BACKGROUND

Functional results, risk factors and complications of vitrectomy for diabetic retinopathy were studied to improve our estimation for benefits and risks of vitreous surgery with current techniques.

MATERIALS AND METHODS

The course of 389 consecutive eyes, who had undergone vitreous surgery for complications of diabetic retinopathy within a four year period, was retrospectively reviewed. The minimum follow-up was 6 months, the median 26 months. Risk factors were studied using multivariate logistic regression analysis.

RESULTS

Six months postoperatively 25% of the eyes had a visual acuity of 20/60 or better, a vision of less than 5/200 was found in 25% of the eyes. The most important risk factors were detachment of the macula and iris rubeosis. Only 16% of the eyes with tractional detachment of the macula had a postoperative vision of 20/200 or better, although in 86% the macula was anatomically successfully reattached. Postoperative retinal detachment was observed in 18% of all eyes. The incidence of this serious complication was only 5% after surgery for vitreous hemorrhage, but 54% after vitrectomy for tractional detachment of the macula.

CONCLUSIONS

In eyes with advanced stages of long-standing tractional detachment of the macula, the functional prognosis is very poor due to the underlying microvascular disease. In less advanced stages with vitreous hemorrhage and flat retina the risk of vitreous surgery is low.

[Long-term vision follow-up after vitrectomy in diabetic retinopathy]

BACKGROUND

We investigated whether visual acuity remained stable in the long run after vitrectomy for complications of diabetic retinopathy and which risk factors for a decrease in vision could be identified.

MATERIALS AND METHODS

The charts of 389 patients who had undergone vitreous surgery for complications of diabetic retinopathy between 1990 and 1994 were retrospectively reviewed. The median follow-up was 26 months with a minimum of 6 months.

RESULTS

Seventy-two percent of the eyes with a vision of 20/200 or better within 6 months after surgery retained this vision after 2 years. The percentage of eyes with vision of less than 5/200 was 25% after 6 months and increased to 41% after 4 years. After 2 years 24% of the eyes had lost two or more lines compared to the best vision within the first 6 months after surgery. The main cause for a decrease of vision in type-I diabetics was retinal detachment, in type-II diabetics a progression of maculopathy and opticopathy. Risk factors for a detachment were pre-existing retinal detachment before surgery and reduced postoperative vision. The risk factor for a progression of maculopathy and opticopathy was a silicone tamponade.

CONCLUSIONS

Eyes with good vision soon after surgery remain stable in the long run. Eyes with advanced stages of diabetic retinopathy and only ambulatory vision after surgery have an increased risk for new loss of visual function in the long run.

[Limits and possibilities of vitreous body surgery in diabetic retinopathy]

BACKGROUND

Several indications for vitreous surgery for complications of diabetic retinopathy have been established, but there is little well-founded information concerning situations in which visual prognosis is poor and vitreous surgery should not be performed.

MATERIALS AND METHODS

The charts of 389 patients who had undergone vitreous surgery for complications of diabetic retinopathy between 1990 and 1994 were retrospectively reviewed. The minimum follow-up was 6 months with a median of 26 months. Using multivariate logistic regression analysis we studied factors which were correlated with a postoperative visual acuity of less than 5/200. A model was developed predicting the probability of an unfavorable visual outcome in various situations.

RESULTS

Forty-five eyes (12%) had a best postoperative visual acuity of less than 5/200. Risk factors were detachment of the macula, extent of the detachment, iris neovascularisations and the duration of visual loss. For reoperations similar risk factors were found. The chance that an eye with total tractional retinal detachment of more than 6 months duration and with rubeosis of the iris will achieve a postoperative visual acuity of 5/200 or better is only 2%.

CONCLUSIONS

Eyes with total tractional retinal detachment, especially with longer duration of the detachment and rubeosis, have a very poor chance of achieving useful vision and should not be operated.

[Phenocopies of hereditary retinal degenerations]

BACKGROUND

Phenocopies of retinal degenerations mimic the clinical signs of inherited retinal dystrophies. The purpose of this study is to discuss the difficulties of differential diagnosis.

METHODS

Four patients were examined ophthalmologically and by standard electroretinography (ERG).

RESULTS

(a) A 19-year-old woman presented with progressive visual loss, bone spicules, concentric narrowing of visual fields and extinguished ERG responses. At 3 years of age, she had developed a retinopathy induced by an infection with measles. (b) A 27-year-old man had bilateral visual loss, night blindness, pigmentary retinal changes, marked attenuation of visual fields and a reduced ERG. All signs of syphilitic retinopathy were regressive under antibiotic therapy. (c) A 59-year-old man showed a visual loss in the left eye, bilateral photophobia, color vision disturbances and a ring scotoma. Cone responses were nonrecordable in the ERG. A birdshot chorioretinopathy was suggested by ophthalmoscopic appearance and HLA typing. (d) A 40-year-old woman presented with paravenous pigmented retinochoroidal atrophy associated with Behcet disease.

CONCLUSION

Systemic viral or bacterial inflammation as well as autoimmune disorders may present as phenocopies of hereditary retinal degenerations. A faulty diagnosis may have serious consequences, because necessary therapy may be withheld. Moreover, the misdiagnosis of a hereditary retinal degeneration may have severe effects on the psychic and social status of the patient.

Cataract surgery and YAG-laser capsulotomy following vitrectomy for diabetic retinopathy

The present study was initiated to assess time-course and risk factors for the development of cataract and posterior-capsule opacification as well as complications of cataract surgery and YAG-laser capsulotomy following vitrectomy for diabetic retinopathy. The charts of all patients undergoing vitrectomy for diabetic retinopathy during a 5-year period in a university eye hospital were retrospectively reviewed. The course of 306 consecutive eyes in which the lens was retained during vitrectomy was analyzed for subsequent cataract surgery and YAG-laser capsulotomy. The first 6 months after cataract or YAG-laser surgery were examined for the occurrence of complications. Data were analyzed with regard to the time course using Kaplan-Meier life-table analysis. The proportion of eyes that underwent cataract surgery after vitrectomy increased nearly linearly with time, approaching 75% after 5 years. Silicone tamponade (relative risk 1.9; P = 0.0005) and transscleral retinal cryotherapy (relative risk 1.4; P = 0.003) were risk factors for subsequent cataract surgery. No significant cataractogenous effect of intravitreal gas as compared with balanced salt solution was found. YAG-laser capsulotomy was performed in 60% of vitrectomized diabetic eyes within 2 years but in only 10% of nondiabetic controls (P < 0.0001). Within 6 months of extracapsular cataract surgery with implantation of an intraocular lens (IOL) in 54 eyes, no serious complication was observed. After YAG-laser capsulotomy, vitreous hemorrhage occurred within 6 months in 6 of 21 eyes. In conclusion, cataract surgery was performed in 75% of the phakic eyes within 5 years of vitrectomy for diabetic retinopathy. Posterior capsular opacification is particularly common in this subset of eyes. No serious complication was observed after extracapsular cataract surgery with IOL implantation, but YAG-laser capsulotomy was associated with an increased risk for vitreous hemorrhage.

Primary vitrectomy without scleral buckling for rhegmatogenous retinal detachment

BACKGROUND

Pars planta vitrectomy has evolved as an alternative method in the treatment of more complicated rhegmatogenous retinal detachments. We report a series of patients who underwent primary vitrectomy with gas tamponade without the use of additional scleral buckling.

METHODS

A retrospective study of 53 patients with a follow-up of 6-45 months (mean 17.8 months) was carried out. Preoperative findings included unusual, multiple or large breaks, vitreous haemorrhage, proliferative vitreoretinopathy and bullous retinal detachment. Preoperative visual acuity was between light perception and 1.0, with 30% (16/53) of patients with 0.4 or better.

RESULTS

Retinal reattachment was achieved in 64% of cases (34/53) with one and in 92% (49/53) with one or more operations. Final visual acuity was between light perception and 1.0, with 41% (22/53) of patients with 0.4 or better. Cataract formation occurred in 86% (37/43) of all patients with a clear lens preoperatively. Macular pucker was noted in 11% (6/53) and postoperative proliferative vitreoretinopathy causing redetachment in 6% (3/53).

CONCLUSION

With primary vitrectomy, a high final anatomical success rate with few intraoperative complications can be achieved in more complicated forms of rhegmatogenous retinal detachment. The major drawback of the procedure is the high incidence of post-operative cataract formation.