[Enlarged blind spot and reduced visual evoked potentials due to melanocytoma of the optic disc]

A 59-year-old male patient presented with clinical characteristics of a melanocytoma of the optic disc in the right eye. Using functional tests, such as visual acuity, visual fields, visual evoked potentials (VEP) and imaging procedures (e.g., fundus photography and spectral domain optical coherence tomography) the findings were documented. Best corrected visual acuity was 25/20 in both eyes. Ophthalmoscopy showed a slightly prominent and pigmented tumor in the upper third of the optic disc. Comparing both eyes, an enlarged blind spot and a reduction of VEP were detectable.

[External Dacryocystorhinostomy--Analysis of Patient Material of the University Hospital Halle from 2000 to 2011]

BACKGROUND

The aim of this retrospective study was to collect additional data on the long-term success (LTS) of external dacryocystorhinostomy (ext-DCR) and the impact of pre-, intra- and postoperative factors on the surgical outcome. This was intended to increase the precision of the indication for DCR.

METHOD

A retrospective, non-comparative study was conducted on 637 ext-DCR due to dacryocystitis performed at the Department of Ophthalmology, University Hospital Halle. This included all surgical interventions on patients of at least 11 years of age. Using standardised questionnaires and patient records, 60.75 % (n = 387) of patients were surveyed. Follow-up was 1.0 to 12.0 years (mean, 4.0 years).

RESULTS

Analysis of patient satisfaction showed satisfactory (20.2 %) and very satisfactory (74.2 %) results. LTS was 94.4 % (n = 365). Factors negatively influencing postoperative outcome were prior surgical interventions of nose and/or sinus, previous ext-DCR and transcanalicular lacrimal surgery. Surgical outcome was positively influenced by lacrimal sac size and lacrimal stenting. Large saccus lacrimales and use of monocanalicular intubates improved LTS.

CONCLUSIONS

LTS of ext-DCR shows very good results, thus underlining its superiority to other surgical approaches. Special attention should be paid to diseases and previous surgical interventions on the nose and/or sinus that effect the lacrimal duct system. Therefore, a special committee of ENT physicians and ophthalmologists has been established at the Department of Ophthalmology, University Hospital Halle. From the surgical point of view, it is important to create an adequate mucosal anastomosis using lacrimal and nasal mucosa. Restoration is possible with lacrimal stent materials. The indication for ext-DCR was restricted by competition with transcanalicular endoscopic interventions to preserve physiological lacrimal drainage.

Nd:YAG Laser Hyaloidotomy for the Treatment of Acute Subhyaloid Hemorrhage: A Comparison of Two Cases

INTRODUCTION

Subhyaloid hemorrhage, whether spontaneous or in the context of a Valsalva maneuver, can lead to an acute decrease in vision when located in the premacular region. Nd:YAG laser hyaloidotomy (NYLH) is a minimally invasive treatment option.

METHODS

We examined two different clinical courses based on two case reports of NYLH. One case report described a 52-year-old female patient who presented with a painless decrease of vision to 20/200. The fundoscopy verified a subhyaloid premacular hemorrhage. The precipitating event for the hemorrhage could not be determined, and a NYLH was performed 5 days after the event. The other patient was a 48-year-old man who suffered an acute visual decrease (hand motion) after developing a migraine with vomiting. Fundoscopy showed a dense subhyaloid premacular hemorrhage. NYLH was performed 1 day after the hemorrhage. These clinical courses were documented based on fundus photographs, ultrasounds, and spectral-domain optical coherence tomography (SD-OCT).

RESULTS

In both cases, there was an effect with approximately 2.2 mJ of laser energy. In the female patient, we observed a gradual but constant increase in vision. After 4 weeks, her vision improved to 20/20. In the male patient, the vision increased to 25/20 1 day after treatment. However, his vision returned to hand motion as he developed a diffuse vitreous opacification. Because of delayed reabsorption, vitrectomy was considered. Since the optical axis was clear with good vision, we decided against this surgery. Complete reabsorption took more than 3 months.

CONCLUSION

After NYLH for subhyaloid hemorrhage, pronounced vitreous body opacification could develop despite a rapid increase in vision, and requires close monitoring by the surgeon. Fundus photography and SD-OCT are suitable means for clinical course evaluations.

Pressure-Lowering Effect of Fistula Occlusion in a Patient with Secondary Glaucoma Due to an Intracranial Arteriovenous Fistula

Introduction

This case report presents the pressure-lowering effect of transluminal fistula occlusion in a patient suffering from secondary glaucoma due to carotid cavernous fistula (CCF).

Case Report

A 76-year-old Caucasian woman presented with dilated epibulbar vessels with elevated intraocular pressure (IOP, >30 mmHg) as well as glaucomatous excavations of the optic disc in both eyes. Cerebral digital subtraction angiography revealed a CCF with bilateral orbital communication. Preoperative diurnal pressure profiling showed an average IOP of 25.8 mmHg (right eye) and 26.6 mmHg (left eye). Transluminal intervention and fistula occlusion led to a decrease in IOP of about 9 mmHg. A post-operative oculomotor nerve palsy regressed spontaneously.

Conclusion

Secondary glaucoma due to CCF might be affected by fistula occlusion. Therefore, it should be considered before any surgical glaucoma interventions are performed. Diurnal pressure profiling is an effective tool for monitoring therapeutic success.

Electronic supplementary material

The online version of this article (doi:10.1007/s40123-015-0036-0) contains supplementary material, which is available to authorized users.

[Treatment of congenital lacrimal duct obstruction: A prospective clinical cohort study]

BACKGROUND

Pressurized probing and irrigation is the method of choice for congenital lacrimal duct obstruction after conservative therapeutic strategies have failed. The aim of this study was to evaluate age dependence and success rates of different therapeutic options.

MATERIAL AND METHODS

A prospective cohort study of children with congenital lacrimal duct obstruction was performed. All children treated during the period between May 2009 and June 2010 were included. Surgical success was defined as the absence of epiphora and mucous discharge for a postoperative follow-up of 3 months. Odds ratios (OR) and 95 % confidence intervals (CI) of different variables were estimated using logistic regression.

RESULTS

A total of 111 children (137 eyes) underwent treatment for congenital lacrimal duct obstruction. The mean age of the children was 7.7 months (range 1-30 months). The success rate of probing under local anesthesia was 85.5 % (n = 100). Probing under general anesthesia without intubation of the lacrimal pathway was successful in 28.6 % (n = 2). Treatment under general anesthesia with intubation of the lacrimal pathway had a success rate of 94.2 %. If the primary treatment was complicated the OR was 1.9 (95 % CI: 0.7-5.1), for males the OR was 1.7 (95 % CI: 0.8-3.5) and in cases of a positive family history the OR was 1.5 (95 % CI: 0.7-3.3). With every increasing month of age the risk not to be treated successfully increased (OR: 1.3, 95 % CI: 1.2-1.5).

CONCLUSION

Syringing under local anesthesia is an effective therapy. The highest success rates were found at the ages of 1-6 months. Therapy with additional silicone tube intubation was highly successful.

[Manifestation of bilateral choroidal osteoma in childhood. Progressive myopia due to staphyloma posticum]

BACKGROUND

Case report of a 6-year-old boy with bilateral choroidal osteoma.

CASE REPORT

The patient was followed up for the next 6 years and during this period bilateral tumor progression was observed. In one eye a staphyloma posticum developed in the area of the osteoma which led to secondary anisometric myopia.

CONCLUSION

If undetected, this rare complication can lead to anisometric amblyopia; therefore, repeated cycloplegic refractometry is advisable in children with choroidal osteoma.

[Endoscopy of the Lacrimal Duct System in Children]

BACKGROUND

Pathologies of the lacrimal duct system show a frequent occurrence in paediatric ophthalmology. Mostly, the connection between the nasolacrimal duct and the nose fails to open but also combined diseases or congenital anomalies may be the reason. Because of complications, the chance for healing after a conservative therapeutic approach decreases and surgical intervention is necessary.

PATIENTS AND METHODS

The opportunity for transcanalicular endoscopy of the lacrimal duct system in children is shown by the presentation of three different case reports. Typical clinical findings are given and the use of dacryoendoscopy for diagnostic and therapeutic benefit is pointed out. Therefore, we present an 8-week-old child, suffering recurrent purulent inflammation due to an amniotocele (1), a 5-year-old child having a congenital lacrimal fistula (2) and another 5-year-old child with a severe chronic dacryocystitis of both eyes after several lacrimal duct surgeries showing remaining intrasaccal silicone tubes (3).

RESULTS

In all these cases transcanalicular endoscopy could be used successfully for reconstruction of the lacrimal duct systems. A bullous Hasner's membrane could be localized and opened (1). The lacrimal fistula was identified to communicate with the common canaliculus and combined stenosis of the canaliculus and saccus were treated (2). In the third case fragments of intrasaccal silicone tubes could be localised and the foreign bodies could be evacuated by transcanalicular surgery (3). The children with lacrimal fistula and the intrasaccal foreign bodies were treated with self-threading silicone tubing which was removed three months later. In the follow-up period (16 months in case 2, 22 months in case 3 and 38 months in case 1) recurrences of the lacrimal pathologies or clinical complaints were absent.

CONCLUSION

Transcanalicular endoscopy of the lacrimal duct system should not be regarded as the means of choice but it does offer additional diagnostic and therapeutic options for special indications. A main advantage of this kind of surgery is its minimally invasive character. Under visual control, topographic anatomy can be preserved. Dacryoendoscopy in children should be done only by experienced surgeons.

[Morphological analysis of corneal refractive lenticules--is there a correlation with refractive results?]

BACKGROUND

ReLEx®flex is a corneal refractive procedure performed by removing corneal lenticules with a femtosecond (fs) laser system. Using electron microscopy, tissue parameters of extracted lenticules were analysed for potential correlations to the refractive results. Furthermore, the effect of previous contact lens (CL) wear on refractive stability (regression) was tested.

PATIENTS AND METHODS

19 lenticules from 11 patients (age 24-56 years, 8 f, 3 m) were prepared for EM. The central areas of the samples were photographed and the distance between the collagen fibres and their diameters were digitally measured. ANOVA analysis was used to correlate postoperative refractional stability with time of preoperative CL use, fibre diameter and the coefficient of variation (CV) of fibre distance.

RESULTS

14 of 19 lenticules were from patients who had worn CL preoperatively. The cumulative duration of CL wear averaged around 31.2 ± 35.5 thousand hours. Preoperative CL use significantly influenced the postoperative regression: the longer time patients had worn CL, the greater was the regression towards myopia (p = 0.01). Additionally, the morphological parameters collagen fibre diameter (p = 0.09) and CV of fibre distance (p = 0.07) had an impact on regression.

CONCLUSIONS

Prolonged CL use and alterations in ultrastructural patterns affected the refractive stability after ReLExflex. Although the pathophysiological relationships between CL use, corneal morphological parameters, and refractive stability are still poorly understood, these findings could potentially be used as prognostic markers for postoperative refraction after ReLExflex.

Influence of microkeratome parameters on the stromal bed and flap edge quality in laser in situ keratomileusis

Purpose

Femtosecond lasers have become the standard for laser-assisted in situ keratomileusis (LASIK) flap creation, but advanced mechanical microkeratomes are still an alternative, more cost-effective way to create the flap. The SCHWIND Carriazo-Pendular microkeratome is one of the most commonly used microkeratomes. The influence of different cutting parameters (head-advance speeds, cutting heads) on morphology of LASIK cuts was investigated.

Setting

Experimental study performed at the University Eye Hospital of the Martin Luther University Halle/Wittenberg, Halle (Saale), Germany.

Methods

The Carriazo-Pendular microkeratome was used on freshly enucleated porcine eyes for lamellar keratotomy. After flap removal, the cutting edge and stromal bed were evaluated from scanning electron micrographs using an individualized scoring system. Four different settings of microkeratome parameters were compared. For each setting, eight cuts were evaluated (n=32).

Results

Different oscillation frequencies and head-advance speeds did not influence the cutting qualities. A higher oscillation/feed rate ratio seemed to be advantageous for a smoother interface. Concerning different cuttings heads, a deeper keratotomy led to sharper cutting edges. The thinner the flap, the more irregularities in the stromal bed appeared. Complications did not occur.

Conclusion

The Carriazo-Pendular microkeratome is a safe tool with which to create a LASIK flap and is a good alternative to a costly femtosecond laser. Deeper keratotomies, as well as the use of a higher oscillation/feed rate quotient, improve the cutting quality.