Beidseitiges kongenitales Glaukom bei einem Kind mit Cutis marmorata telangiectatica congenita: Ein Fallbericht

BACKGROUND

Cutis marmorata telangiectatica congenita is a rare, cutaneous and vascular anomaly characterised by congenital cutis marmorata, telangiectasis, and phlebectasia. Systemic abnormalities are frequently associated with this condition, although they may be highly variable. Ocular abnormalities are quite rare and include retinal detachment and congenital glaucoma. If glaucoma is present it is unilateral in most cases.

CASE REPORT

A case of bilateral congenital glaucoma associated with cutis marmorata telangiectatica congenita in a 4-month-old girl is presented. Follow-up and treatment over a four-year period are reported.

CONCLUSION

Congenital glaucoma is a rare ophthalmic condition encountered in patients with cutis marmorata telangiectatica congenita. If glaucoma is present it is most likely unilateral, although cases of bilateral glaucoma in these patients occur. Regular ophthalmological examinations are recommended for children with cutis marmorata telangiectatica congenita--especially if characteristic skin changes are present in the face.

[The different opacity patterns of Lisch corneal dystrophy]

BACKGROUND

Lisch corneal dystrophy is an epithelial corneal dystrophy where diffuse gray corneal opacifications are seen in direct illumination that appear in different patterns. Examination in retroillumination shows that these gray changes do consist of multiple densely crowded clear microcysts according to the opacity units. We wanted to investigate if one single case of Lisch corneal dystrophy can be differentiated easily from the other epithelial corneal dystrophies by exact analysis of the opacity units.

PATIENTS AND METHODS

We examined three non-related patients with Lisch corneal dystrophy at the slit-lamp. The epithelial corneal opacities were documented photographically with direct slit-lamp illumination and retroillumination.

RESULTS

All three patients showed the characteristic intraepithelial densely crowded clear microcysts in retroillumination. Diffuse gray radial opacities were noted in both corneas of a 15-year-old female patient. A club-shaped opacity was noted in one cornea of a 35-year-old female patient and a feathery gray opacity pattern was found in one cornea of a 49-year-old male patient. All three patients showed the characteristic densely crowded clear microcysts of Lisch corneal dystrophy in retroillumination.

CONCLUSION

Taking the previous literature into account, five different opacity patterns can be summarised: radial, band, flame/feathery, whorled and club-shaped gray epithelial corneal opacities. A single case of Lisch corneal dystrophy can be differentiated from other epithelial corneal dystrophies by means of an exact analysis of the opacity pattern and units by slit-lamp examination.

[The German Ophthalmological Society (DOG) during the Period of National Socialism]

Sixty-one years after the end of the Hitler dictatorship, the history of the German Ophthalmological Society (DOG) has still hardly been investigated. According to different sources, especially the reports of the DOG congresses 1934, 1936, 1938, and 1940, the following picture can be drawn: 1. The seizure of power ("Machtergreifung") of Adolf Hitler was appreciated by most of the DOG members. 2. After a change of the constitution the DOG came under the control of the "Reichsinnenministerium". However, it escaped the egalitarianism ("Gleichschaltung") and remained relatively independent. 3. Approximately 40 % of the heads of the German university eye clinics who were the most influential DOG representatives were members of the national socialistic German working party (NSDAP). Almost all of these joined the party in 1933 or later. 4. Up to the last congress in Dresden, 1940, the DOG activities were quite extensive. After that time the activities strongly declined. 5. The "Law for the prevention of genetically disabled offspring" ("Gesetz zur Verhütung erbkranken Nachwuchses") from January 1st 1934 was intensely discussed by the DOG. Some prominent ophthalmologists and DOG members were at least in part responsible for the sterilisations because of "congenital blindness". However, as far as it is known, the DOG itself did not intervene directly concerning the practice of sterilisation. 6. Between 1932 and 1940, the DOG lost approximately 12 % of its members. Many of these stemmed from foreign countries, and many were German Jews. The latter left the DOG, as Walther Löhlein stated after the end of the war, "voluntarily". However, a main reason for leaving the DOG was very likely the feeling of being unwanted. The national socialism had several disastrous effects on ophthalmology. Although single DOG members participated in the excesses, the DOG as an organization was not directly involved. However, taking into consideration that more than 10 % of the members of the pre-Hitler era left their scientific society it is a matter of interpretation whether the DOG remained completely innocent between 1933 and 1945.

Zur Häufigkeit der exzessiven Verdickung der epithelialen Basalmembran beim Keratokonus

BACKGROUND

In spite of a huge amount of morphological and biochemical findings the aetiology of keratoconus (KC) is still unclear. While the primary changes are seen and found mainly within the anterior corneal stroma, some authors believe that the corneal epithelium plays the major role in KC formation. Consequently, the epithelial basement membrane (BM) has become a matter of interest in KC research.

MATERIAL AND METHODS

The study included 55 consecutive patients who had a perforating keratoplasty performed because of KC. The corneal explants were processed for light microscopy in the usual manner. Slides were stained with PAS. The whole explant was investigated although the focus of interest was put on the epithelial BM. 10 normal corneas of eyes which had to be enucleated because of a choroidal melanoma served as a control.

RESULTS

In 3 patients (5.5 %) there was a significant linear thickening of the BM (thickness of the BM more than 5 % but less than 30 % of the thickness of Bowman's layer). Only in one patient (1.8 %) there was an excessive BM thickening (thickness of the BM more than 30 % of that of Bowman's layer) with focal (central) BM warts directed against the epithelium ("inverse cornea guttata"). In general, thickening of the BM was most pronounced paracentrally. None of the control corneas had a significantly thickened BM.

CONCLUSIONS

A massively thickened epithelial BM can be occasionally observed in KC but is rare on the whole. It is most likely an unspecific secondary phenomenon and not a prerequisite for KC development. The "inverse cornea guttata" was a unique finding.

Zur sozioökonomischen Bedeutung des Glaukoms

About 800,000 people in Germany suffer from glaucoma. As the population ages, the prevalence of glaucoma will rise and the socio-economic impact of the disease increase. The costs of glaucoma include those of diagnosis, medical, laser and surgical treatment, and costs of blindness as a result of glaucoma. So far the costs of diagnosis and screening programs are not well known but there is substantial knowledge of the therapeutic costs. Daily therapy costs are about 0.50 to 1.00 euro per patient. Every year the German statutory health insurance system pays about 1,000 euro per glaucoma patient. In addition, blindness due to glaucoma costs the German government over euro 150 million annually in Social Security benefits, lost income tax revenues, and health care expenditures. Demographic changes and scientific progress will even aggravate the socio-economic burden of this disease.

Sutureless Amniotic Membrane Fixation Using Fibrin Glue for Ocular Surface Reconstruction in a Rabbit Model

PURPOSE

Amniotic membrane transplantation has become an important treatment option for corneal surface reconstruction. However, suture fixation of the transplant has various disadvantages like corneal irritation, scarring, graft loss due to membrane shrinkage, and the need for subsequent suture removal. Replacement of sutures by bioadhesives might be an advantageous alternative. This controlled study was designed to evaluate a new sutureless technique for amniotic membrane fixation onto the corneal surface by using fibrin glue.

METHODS

Standardized disks of cryopreserved amniotic membranes were transplanted onto the deepithelialized cornea of 12 rabbits using either conventional suture fixation or a new fibrin glue technique. The rabbits were followed-up with slit-lamp examination and fluorescein staining until epithelialization was completed. Consecutively, the rabbits were killed and the eyes processed for histology and immunohistochemistry for cytokeratin-3.

RESULTS

All membranes of both groups stayed in place throughout the follow-up time and showed a progressive graft epithelialization that was completed after 12 days. Whereas suture-fixated membranes showed progressive tissue shrinkage, fibrin-glued sheets remained unaltered. In the bioadhesive group, histology revealed a smooth fibrin layer in the graft-host interface and a continuous, stratified layer of cytokeratin-3 expressing corneal epithelial cells on the membrane surface. In contrast, suture-fixated membranes showed contracted and prominent membrane edges with epithelial ingrowth into the submembrane interface.

CONCLUSION

Our results demonstrate the general feasibility of reproducible and reliable sutureless amniotic membrane fixation onto the corneal surface in rabbits. Stable adherence is maintained until epithelialization is completed. The sutureless technique gives sufficient manipulation time for the sheet before the final cross-linking process is completed. Furthermore, several advantageous characteristics could be demonstrated as increased biocompatibility, better epithelialization pattern and the lack of membrane shrinkage.

Hornhautstaphylom-Vorderkammeragenesie-Mikrophakie-Syndrom (kongenitales anteriores Staphylom)

CASE REPORT

Shortly after birth, a massive enlargement of the right eye was observed in an otherwise healthy male child. The cornea of the affected eye was vascularized and completely cloudy without a sharp border between cornea and sclera. The diagnosis of a congenital glaucoma was made but an operation was not undertaken because of the difficult anatomical situation and the lost function. When the child was almost 3 years old enucleation was performed to prevent complications due to corneal exposure, and to improve the cosmetic aspect.

RESULTS

The morphological investigations of the enucleated eye disclosed findings typical of what is called in the literature "congenital anterior staphyloma" or "congenital corneal staphyloma", namely a massively staphylomatous cornea with superficial neovascularization, destruction of Bowman's layer, and absence of Descemet's layer as well as corneal endothelium. Angle structures were completely absent, and the corneal back-side was lined by a pigment epithelial layer and focally by an additional inner layer of non-pigmented epithelium. There was no anterior chamber. The lens was markedly diminished in size (microphakia) and partly embedded in the corneal stroma. Pars muscularis and pars ciliaris of the ciliary body were separated. Elongated, thin ciliary processes were extended towards the small lens while the pars muscularis was fully covered by the retina.

CONCLUSIONS

This rare, complex malformation syndrome which can be easily distinguished from primary congenital glaucoma should not be reduced conceptually to the corneal staphyloma because this staphyloma constitutes only a part of the whole. Taking the leading morphological aberrations into consideration we would rather propose the new term " corneal staphyloma- anterior chamber agenesia- microphakia syndrome (CSAMS). We hypothesize that CSAMS may be due to a pathological fusion of the early anterior optic cup. As the posterior eye segment is often normal in CSAMS, a staphyloma excision along with a sclero-keratoplasty might be an alternative therapeutic option to avoid enucleation and restore ambulatory vision.

[Neoplastic secondary glaucomas]

With few exceptions all intraocular tumours can principally induce elevation of intraocular pressure (IOP). The frequency of IOP-elevation is mainly dependent on the biologic behaviour of the neoplasm (benign / malignant), its dimensions, localization, and its ability to provoke secondary changes like retinal detachment, hemorrhages, inflammation, and necroses. There are many and diverse pathomechanisms which may cause a "neoplastic glaucoma". The leading mechanisms are direct invasion of the chamber angle by tumour cells, rubeosis iridis, and forward displacement of the iris-lens-diaphragm with (lens induced) pupillary block. As intraocular tumours may have pressure-lowering effects too, eyes bearing a tumour may also be hypotonic or normotonic inspite of a "glaucomatous chamber angle morphology". The therapy of the tumour-induced glaucomas is hardly validated and generally follows the treatment of the other secondary glaucomas. However, filtration procedures are contraindicated when a malignant tumour is diagnosed or suspected. Because of the progress of tumour therapy with salvation of eyes which had to be enucleated in former times and prolongation of survival in some tumour entities (like Non Hodgkin's lymphoma and metastases) the significance of tumour-induced glaucomas will probably further increase in the future.

Karunkeltumor unklarer Dignität

CASE REPORT

A sixty year old woman presented with a tumor of the caruncle that had persisted for one year. Ophthalmologic history was unremarkable. Physical examination disclosed an indolent, tight elastic, highly vascularizated tumor. The lesion measured five millimeter in diameter. Histopathology revealed tall columnar cells with small round nuclei. The cytoplasm stained positive with hematoxylin and eosin. The typical histopathologic features were consistent with an oncocytoma.

CONCLUSION

Tumors of the caruncle are very heterogenous because the caruncle contains tissues of the conjunctiva and the epidermis. Therefore to exclude a malignant process an excisional biopsy should always be performed even so in general tumors of the caruncle are benign. The most frequent tumors of the caruncle are papilloma, nevi, pyogenic granuloma, epithelial inclusion cyst and chronic inflammation. In only 4 % of the cases oncocytomas are found even the oncocytoma is considered to be a typical tumor of the caruncle.

Experimental Implantation and Long-term Testing of an Intraocular Vision Aid in Rabbits

OBJECTIVE

To develop an intraocular vision aid to provide artificial vision in severely traumatized eyes, where neuroretinal function could be preserved but irreversible anterior segment opacification resulted in blindness.

METHODS

The basis of an intraocular vision aid is in principle a telemetric circuit to bridge the opaque cornea and to allow for artificial light stimulation of the retina. The visual prosthesis comprises an external high-dynamic range complementary metal oxide semiconductor camera and digital signal processing unit and an intraocular miniaturized light-emitting diode array to project the image onto the retina. For in vivo testing of long-term function and biocompatibility, silicone-encapsulated active photodiodes were implanted in 13 pigmented rabbits and were followed up for up to 21 months.

RESULTS

Lens extraction and stable fixation of the device in the ciliary sulcus were successful in all cases. For up to 21 months inductive energy transmission and wireless stimulation of the implants could be maintained. Electrophysiologic data and histology demonstrated a good tissue biocompatibility in the long-term follow-up.

CONCLUSION

The results demonstrate the general feasibility and biocompatibility to implant and fixate an intraocular light-emitting diode prosthesis. Inductive energy transmission to the intraocular device and wireless light stimulation are assured in the long term but depend on meticulous water-impermeable encapsulation of the delicate microelectronic components. Clinical Relevance An intraocular vision aid compound system with a high-resolution light-emitting diode matrix might be a future treatment option to restore vision in blind eyes with severe anterior segment disorders.

Subcutaneous tumor of the lower eyelid: a potential manifestation of a Dirofilaria repens infection

PURPOSE

To report a case of Dirofilaria repens presenting as a subcutaneous tumor of the lower eyelid.

METHODS

Interventional case report.

RESULTS

A 29-year-old man of Greek origin without systemic symptoms presented with a 3-week history of a small painless mass localized in the medial part of the lower eyelid. There was no history of a preceding trauma, injury, or visual impairment; however, the patient had recently been on a holiday in Italy. The lesion persisted after systemic antibiotic treatment. Routine blood tests were normal and the efferent tear ducts were patent. Upon surgical intervention a yellowish, pea-sized cyst-like structure was found beneath the orbicularis muscle and removed in toto. Histologic examination revealed the presence of a wormlike structure with the characteristic features of a single adult Dirofilaria repens nematode.

CONCLUSIONS

Infection with the nematode Dirofilaria repens has to be considered in the differential diagnosis of malignant and benign tumors of subcutaneous periocular tissues in patients who traveled to endemic areas.

Augenverletzungen im Kindes- und Jugendalter

Childhood trauma of the eye and its adnexa represents approx. 4 - 20 % of all eye injuries. Due to ambiguous patient history and limited cooperation a comprehensive diagnosis of pediatric eye trauma is often difficult. The weakness of the infantile cornea, the thin and elastic anterior lens capsule, and the firm vitreous with its strong adherence to the retina bear particular intra- or postoperative problems. Moreover, the quick development of secondary cataract and the high risk of PVR may complicate the posttraumatic and postoperative course. Small infants represent a special subgroup in various regards mainly because of the risk of amblyopia which often causes functional loss in spite of a good anatomical reconstruction. The relative frequency of certain injuries differs between children and adults. The ocular manifestation of child abuse as well as bite and fireworks injuries are characteristic for childhood and will be discussed more in detail.

Das intraokulare Non-Hodgkin-Lymphom und seine Therapie - eine Fallserie mit 10 Patienten

BACKGROUND

The timely and correct diagnosis of intraocular non-Hodgkin's lymphoma represents a huge challenge to clinicians. Two thirds of intraocular lymphomas are a manifestation of a primary CNS lymphoma (PCNSL) arising outside the lymphatic system and are localized in the brain, the meninges or the spinal chord. Ten to twenty percent commence as vitreous or retinal infiltrates mimicking uveitis. Ninety five percent of PCNSL are B cell lymphomas.

PATIENTS

Three exemplary cases from a group of ten patients treated between 1998 and 2002 are presented. A table provides a summary of the relevant details of all ten patients.

RESULTS

The mean age at presentation was 63.5 years with a female to male ratio of 6 to 4. Nine patients were diagnosed as having intermediate or posterior uveitis, in one patient choroidal metastases were suspected. Six patients had a concomitant CNS lesion while four patients showed isolated intraocular lymphoma only. The presence of a highly malignant B cell lymphoma was proven by vitreous biopsy in nine cases and by stereotactic biopsy of a CNS lesion in one patient. All patients were treated by intravenous chemotherapy, however, no binding recommendations with regard to treatment exist to date.

CONCLUSIONS

We give an overview of all current treatment regimens and their pitfalls. At present it is recommended that all patients with proven PCNSL be entered in a multicenter randomized study under the auspices of the Department of Internal Medicine III of the Benjamin-Franklin-University-Hospital, Berlin and the Department of Neurology of the University Hospital of Tuebingen.

Ocular manifestation of primary nervous system lymphoma: what can be expected from imaging?

Primary ocular lymphoma, which affects the posterior parts of the eye, is an ocular manifestation of primary central nervous system lymphoma (PCNSL). It used to be the ocular disease with the shortest time of survival, even worse than ocular melanoma. Death ensues by CNS dissemination. Unfortunately, ocular lymphoma may be the initial manifestation of PCNSL and diagnosis is frequently difficult, even if vitreal biopsy is performed. Therefore, it should be determined whether cross sectional imaging may be helpful in detection and differential diagnosis of ocular lymphoma. MRI of seven patients (female = 6, male = 1, median age 62 years) with biopsy proven ocular lymphoma were retrieved from the files of our hospital and of a multicenter PCNSL study. In four patients, ocular lymphoma was the first manifestation of PCNSL, in three a cerebral lesion had occurred in the first place. Progression to cerebral lymphoma was seen in three of the four patients with initial eye manifestation. Imaging was performed using a dedicated thin section protocol in four patients. An intraocular abnormality was found in four cases, always in T1-weighted images after contrast injection. Differential diagnosis from uveitis or ocular melanoma was not possible by imaging alone. The examination was falsely negative in the remaining three patients.Hence, imaging has a low sensitivity for ocular lymphoma and does not facilitate differential diagnosis against uveitis or ocular melanoma.

[Massive intraocular invasion of conjunctiva by squamous cell carcinoma--a case report]

BACKGROUND

Squamous cell carcinoma of the conjunctiva is a mostly solitary growing tumor located at the limbus region, which seldom invades the eye. We present an unusual case of conjunctival carcinoma with marked intraocular involvement, which appeared primarily as a chronic inflammation with corneal ulcer.

CASE REPORT

A 89-year-old female patient was referred to our institution with a suspected ulcus rodens of the cornea. Since one year a refractory conjunctivitis persisted despite of different local treatment. At first presentation, a marked bacterial keratoconjunctivitis with circular necrosis of the conjunctiva, corneal infiltration and perforation was seen. Visual acuity of the right eye was light perception. The left eye was unremarkable. Enucleation of the right eye was performed. Histopathologic examination revealed the diagnosis of squamous cell carcinoma of the conjunctiva with intraocular involvement. There was a marked infiltration of the choroid even behind the equator. No metastases were found.

CONCLUSION

Advanced squamous cell carcinoma associated with superinfection may present as a primary inflammatory process. There may be extensive involvement of the choroid. Metastases are probably rare even in advanced cases of this type of carcinoma.

[Conjunctival neuromas and prominent corneal nerve fibers as diagnostic indication of multiple endocrine disease]

BACKGROUND

Multiple endocrine neoplasias (MEN-syndromes) represent diverse, mostly autosomal-dominant inherited, seldom sporadic diseases. MEN 2B-syndrome comprises medullary thyroid carcinoma, pheochromocytoma and mucosal neuromas.

PATIENT

A 30 year old male patient presented with bilateral chronic irritation of the ocular surface. The biomicroscopy revealed intraconjunctival worm-like alterations, prominent corneal nerves and nodules on the upper lid margins.

HISTOLOGY

The performed conjunctival biopsy showed nearly no goblet cells, but prominent intrastromal, immunohistochemical S100-positive neuromas.

RESULTS

The initiated investigations revealed bilateral multifocal medullary thyroid carcinoma and a left sited pheochromocytoma.

CONCLUSION

Conjunctival neuromas and prominent corneal nerves can be diagnostic for the MEN 2B-syndrom. Early diagnosis and prophylactic thyroidectomy are expected to improve the life expectancy even in asymptomatic gene-carriers.

[Corneal ring opacity (Ascher ring)--a case report]

PATIENT

A 63-year-old man without complaints presented with a bilateral symmetric opacity of the cornea between the mid and the outer periphery which was classified as Ascher's ring.

CONCLUSIONS

Ascher's ring is a very rare entity. Characteristic slit lamp features allow its differentiation from other anular corneal opacities. Corneal or systemic alterations of the lipid metabolism can be discussed. Heredity can be suspected but could not be proved as yet. The visual prognosis is excellent. Therapy is not necessary.

Alteration of the vascular supply in the rabbit ciliary body by transscleral diode laser cyclophotocoagulation

BACKGROUND

Besides the direct destruction of the non-pigmented ciliary epithelium by cyclodestructive procedures, further mechanisms are responsible for the decrease of intraocular pressure. This study evaluates the alteration of the ciliary body vascularization by contact transscleral diode laser cyclophotocoagulation in rabbit eyes.

METHODS

Pigmented chinchilla bastard rabbits were used. Preliminary experiments were conducted to determine the parameters for diode laser cyclophotocoagulation of the pars plana or pars plicata. Then, treatment of the pars plicata (three rabbits) or pars plana (three rabbits) was performed in the right eye of six rabbits. After 2, 6 and 12 weeks histologic and transmission electron microscopic studies were performed. Furthermore, three rabbits received pars plicata cyclophotocoagulation of the right and pars plana cyclophotocoagulation of the left eye. After 2, 6 and 12 weeks, vascular casts of the ciliary body were investigated by scanning electron microscopy.

RESULTS

Histologic and transmission electron microscopic studies showed a marked coagulation necrosis with subsequent ciliary body atrophy, destruction of the ciliary epithelium, pigment dispersion in the ciliary body stroma and peripheral anterior synechiae. Examination of vascular casts of the ciliary body revealed a marked rarefication of the capillary network within the treated areas of the ciliary body in all eyes and at every time of investigation. Anterior to the laser burns the capillary network was not markedly affected in the eyes with cyclophotocoagulation of the pars plana. After 3 months short vessel sprouts were seen, but regeneration was mostly incomplete.

CONCLUSIONS

The vascular casting technique is an excellent method for the investigation of changes in ciliary body vascularization after cyclodestruction. This study is the first to demonstrate a marked rarefication of the ciliary body vascularization after diode laser cyclophotocoagulation using vascular casts. The results suggest that alteration of vascularization probably acts as a strong synergistic mechanism in the decrease of intraocular pressure after cyclophotocoagulation of the pars plicata.

Immunology and growth characteristics of ocular basal cell carcinoma

BACKGROUND

Knowledge about immunological features and growth characteristics of palpebral (ocular) basal cell carcinomas (BCCs) is limited. In particular, it is unclear whether ocular BCC represents in this regard a special BCC entity or not.

METHODS

Twenty BCCs of the lid area (ocular BCCs) were investigated immunohistologically using monoclonal antibodies against CD4, CD8, CD45Ro, CD50, CD68, HECA-452, Ki67 (MIB1), and the p53 epitope. For comparison, nine BCCs excised distant from the eye (non-ocular BCCs) were evaluated.

RESULTS

In BCCs the distribution of the immunocompetent cells investigated is markedly irregular. These cells are localized mainly around BCC islands. Only a few of them invade tumour cell aggregates. The CD4:CD8 ratio as detected by immunohistochemistry is >1 in 82% of ocular BCCs and in 88% of nonocular BCCs. Often there are dense infiltrations of CD68+ cells (macrophages) and HECA-452+ cells adjacent to tumour cell aggregates. The growth fraction [percentage of proliferating (Ki67+/MIB 1+) cells] varies from 0% to more than 30%. Proliferative activity is enhanced at the invasion front. Additionally, the amount of p53+ cells differs considerably among the BCCs.

CONCLUSIONS

CD4+ T cells seem to be the most important cell population for BCC immunosurveillance, offering the chance for conservative interferon therapy. The role of CD68+ and HECA-452+ cells has to be further elucidated. In many tumours the large amount of proliferating cells contrasts to the usually slow growth of BCCs, indicating strong apoptotic processes. The results can be regarded only as semiquantitative. So far, ocular and nonocular BCCs exhibit no essential differences regarding immunocompetent cell infiltration and growth characteristics. According to this, palpebral BCCs are "normal" BCCs and not a special BCC variant. Therefore, results from dermatological research concerning BCC can be extended without limitations to their counterparts in the lid area.

[Cyanoacrylate injuries of the eye]

BACKGROUND

Cyanoacrylates are contained in nail glues, instant glues, and tissue adhesives such as Histoacryl. Cyanoacrylates may inadvertently contaminate the conjunctival sac and cause massive loss of visual function and serious discomfort to the patient.

PATIENTS

Over a 10-year period five patients with a cyanoacrylate lesion of the ocular surface have been observed. Four were injured by instant glue and one by Histoacryl. Therapy included moderate rinsing. In the most severely affected patient parts of the glue were removed mechanically; spontaneous rejection of the glue was awaited in the other four. After the glue had been rejected, four patients showed corneal erosion which healed without problems. Visual function returned to normal in all patients, and there was no persistent tissue damage.

CONCLUSIONS

Cyanoacrylates exert no substantial thermal, chemical, or toxic effects on the ocular surface when inadvertently entering the conjunctival sac. Cyanoacrylate trauma therefore has a very favorable prognosis. The conservative approach of awaiting spontaneous glue rejection is appropriate.

[Transient blindness after subconjunctival anesthesia for diode laser cyclophotocoagulation]

BACKGROUND

Retro- and parabulbar anaesthesia can be associated with severe sight-threatening and life-threatening complications and may compromise optic nerve function, especially in eyes with advanced optic neuropathy. Subconjunctival anaesthesia usually does not influence optic nerve function. We report on two patients who developed transient amaurosis after subconjunctival anaesthesia.

PATIENTS

In two patients (75 and 77 years old) with advanced refractory glaucoma a diode laser cyclophotocoagulation was performed to lower the increased IOP. For local anaesthesia, 2 ml of 2% mepivacaine was placed beneath the conjunctiva. The needle was placed at least 6 mm from the limbus to avoid bleeding at the injection site near the limbus. After 10 minutes, both patients observed a decrease of their vision of the treated eyes. A few minutes later, an amaurosis of the treated eyes was found in both patients, which was fully reversible after 2 to 3 hours. At fundus examination, no vessel occlusion was seen.

CONCLUSIONS

Subconjunctival anaesthesia may cause transient blindness in patients with advanced optic neuropathy. The incidence of this side effect seems very low.

[Telomerase activity in uveal melanomas]

BACKGROUND

The maximum number of cell divisions of a certain cell population is genetically fixed so that aging cells become non-dividing (senescent) at least. This replicative life span, also known as "Hayflick limit", is probably defined by a "critical" length of the telomeres. Telomeres are special DNA-sequences located at the four ends of the chromosomes which are shortened with each cell cycle. Cells of most, but not all malignant tumours have been shown to reactivate the enzyme telomerase so that telomeres can be reconstructed, "Hayflick limit" can be overcome, and unlimited cell division can be established. This study was undertaken to elucidate whether telomerase reactivation is used by uveal melanoma cells.

MATERIALS AND METHODS

Fresh tumour tissue was removed from 10 untreated uveal melanomas after enucleation. Telomerase activity was determined using a PCR ELISA according to the Telomeric Repeat Amplification Protocol (TRAP). Normal tissue of the skin and the conjunctiva served as control.

RESULT

Telomerase activity was detectable in 90% of the investigated uveal melanomas. All control specimens were telomerase negative.

CONCLUSIONS

Uveal melanoma growth seems to depend on telomerase reactivation. Thus, telomerase inhibition could offer a new principle for uveal melanoma therapy in the future.

[Walker-Warburg syndrome in adulthood?]

BACKGROUND

Walker-Warburg-Syndrome (WWS) comprises malformations of the brain and the eyes with muscle dystrophy. Its course is usually lethal within the first 60 weeks of life. As far as we know there are no reports in the literature dealing with WWS in adults.

CASE REPORT

A 70-year old female died because of cardio-pulmonary failure while she had an infection of the respiratory tract. The patient had been mentally deficient and had suffered from recurrent single convulsions. 17 years before death funduscopy had revealed an optic atrophy. Diabetes mellitus was known for ca. 15 years. The neuropathologists found a lissencephaly with a typical histology and a cerebellar malformation. Histologically, the eyes showed diabetic changes like vacuolization of the iris pigment epithelium and a thickening of basement membranes. There were marked deposits in the Pars plicata of the ciliary body and drusen formation in Bruch's membrane. The nerve fiber layer of the retina seemed to be thinned, and there was a considerable rarefication of optic ganglion cells.

CONCLUSIONS

Taking the clinical and especially the morphological data into account, a Walker-Warburg-Syndrome was assumed. Within the eyes developmental and diabetic changes were combined. Because the cerebral and ocular malformations were comparably mild, the patient became unusually old, and visual function allowed at least good orientation. References were searched by medline and by the indices of known papers.

[Tübingen 1895-1899. Incidence, diagnosis and therapy of selected optic nerve, uveal and retinal diseases 100 years ago]

BACKGROUND

The records of the University Eye Clinic are almost completely preserved at the historical archive of the University of Tübingen since 1865 and shell now be reduced.

MATERIALS AND METHODS

150 records from the historical archive of the University of Tübingen were selected. We were interested in those patients treated for the first time at the University Eye Clinic between 1895 and 1899. Only diseases of the optic nerve, the uveal tract and the retina were considered. The records were distributed into groups following historical classification and statistics of the same period. These statistics were also used to compare our selection with all patients treated. For information about frequency, diagnostics and therapy a questionnaire was developed.

RESULTS

Glaucoma: The data of the subgroup "Glaucoma simplex" showed high correspondence with the historical data regarding the frequency (24.3 vs. 25.5%). The data of the subgroup "Glaucoma secundaria" differed (34.5 vs. 25.5%). Testing the visual acuity was the first step of examination here and in all groups (100%). Measurement of intraocular pressure with digital palpation followed (86.3%). First of all Eserin eye drops were applicated (76.5%). Iritis: The frequency of acute iritis was 16.8 vs. 25.0%, and of chronic iritis 59.6 vs. 52.2%. As typical symptoms ciliar injections, fixed anisocore pupil and exudation were often seen (80.0%). Chronic iritis showed as typical symptom posterior synechia (80.9%). Atropin eye drops were firstly applied in acute iritis (100%), chronical iritis was treated by iridectomy (57.1%). Myopia: In all subgroups our data differed from the historical data. Staphyloma posticum was the characteristic diagnosis (65.8%). Myopia was treated by decision of the lens. Retinal detachment: The frequency 37.2 vs. 28.0%. In nearly all cases retinal detachment was described after ophthalmoscopic examination (92.8%). The first therapeutical step was to keep the patients staying in bed (53.8%).

CONCLUSIONS

As expected, diagnostic and therapeutical options were strongly limited in Tübingen 100 years ago. Nevertheless, therapeutic successes were achieved in certain cases.

[Hallermann-Streiff syndrome: should spontaneous resorption of the lens opacity be awaited?]

BACKGROUND

As the lens may become absorbed spontaneously extraction of the congenital cataract in the Hallermann-Streiff syndrome is controversial.

PATIENT

A male newborn with Hallermann-Streiff syndrome was referred to the eye clinic because of a bilateral mature cataract. The risks of an operation seemed too serious because the eyes were extremely microphthalmic (a-p diameter approx. 10.5 mm). Instead, it was decided to await spontaneous lens absorption which then occurred slowly and completely between the beginning of the 2nd and the end of the 3rd year of life without considerable inflammatory responses. In the meantime, the child has a good orientation and is able to paint and to discriminate colours without optic correction.

CONCLUSIONS

The critical investigation of the literature reveals that the frequency of spontaneous lens absorption in the Hallermann-Streiff syndrome is probably (widely) underestimated. It can be estimated with up to 50% (or even more) if patients which were operated on are excluded and if untreated patients are followed up till the end of the 5th year of life. Functional results seem to be quite similar for treated and untreated eyes. Therefore we would recommend to await the spontaneous lens absorption in the Hallermann-Steiff syndrome especially when the cataract is combined with considerable microphthalmia.

[Eye injury caused by superglue]

BACKGROUND

Eye lesions caused by superglue (instant glue) are relatively rare, and hence therapeutical experiences are limited.

PATIENT

A female intended to treat a mild conjunctivitis by herself with anti-inflammatory eye drops. Inadvertently she took a tube of instant glue which then filled most of the conjunctival sac. After intensive rinsing the hardened glue was mechanically removed as far as possible. Remaining glue was spontaneously rejected within a few hours. After four days the resulting subtotal corneal erosion had healed, and visual function had returned almost to normal.

CONCLUSIONS

Inspite of the dramatic, acute aspect the clinical course after superglue lesions is usually benign. Therapeutically, vigorous manipulations seem to be more harmful than useful. Spontaneous rejection of the glue should be awaited instead.

[Cyclocryocoagulation in treatment of therapy refractory glaucoma: a retrospective analysis of 185 cryocoagulation procedures]

BACKGROUND

For several years it has been discussed whether cyclocryotherapy is still an up-to-date treatment of resistant inadequately controlled glaucoma. This retrospective study investigates the clinical aspects of 185 cyclocryotherapies between 1988 and 1997.

PATIENTS AND METHODS

At the University Eye Clinic of Tübingen, 114 patients received in 119 eyes (64.3%) one cyclocryotherapy, and in 66 eyes (35.7%) multiple cyclocryotherapies. The standard surgical techniques for cyclocryotherapy can be summarized as followed: probe placements per eye, 4 to 6; location of probe placement, inferior circumference (63.9%); distance of the applicator from limbus, 3 mm (50.7%); temperature of the probe tip, -70 degrees C (34.2%); and time of the treatment, 60 seconds (89.9%).

RESULTS

Intraocular pressure was on average 33.8 mm Hg before treatment. In all analysed glaucoma types intraocular pressure was lowered to 10.2 mm Hg (30%). The most frequent type of glaucoma was the neovascular glaucoma (55%). One year after treatment, this type showed on average, relative to all other types of glaucoma, the highest intraocular pressure (28.1 mm Hg) and a lowering of intraocular pressure by 8.3 mm Hg (22.7%). Half a year after cyclocryotherapy, a highly significant (p < 0.002) reduction of antiglaucomatous medication was achieved in comparison to the preoperative medication.

CONCLUSION

Despite the fact that cyclocryotherapy is not always effective, it is an ambulant surgical technique easy to apply, non-invasive, cost-effective and can be repeated to lower intraocular pressure in resistant chronic glaucoma. We conclude that cyclocryotherapy will remain useful until new techniques, like the diode laser cyclophototherapy (especially ultrasonic controlled), are developed as alternative therapies.

[Hyperplasia of sebaceous glands (Fordyce's disease) in an oral mucocutaneous graft: 45-year follow-up]

BACKGROUND

Diffuse sebaceous gland hyperplasia in transplanted buccal mucosa is a very rare condition. We report on a further patient with this entity.

PATIENT

In 1953, a now 68-year-old man suffered a severe alkali burn. Transplantation of oral mucosa was performed that same day in order to prevent perforation of the eye. Over the following 45 years, the patient developed multiple yellowish nodules within the grafts. Histologically, these nodules proved to be normally differentiated sebaceous glands.

CONCLUSIONS

Diffuse sebaceous gland hyperplasia originating from within oral mucosa and developing over an extended period of time is a clinical entity known as Fordyce's disease. It is this a late complication of mucocutaneous transplantation, and although it constitutes mainly a problem of cosmesis, functionally it can lead to aberrant secretion of sebum.

Complete occlusion of the anterior capsular opening after intact capsulorhexis: clinicopathologic correlation

PURPOSE

To report histopathologic findings of capsule contraction syndrome with complete occlusion of the capsulorhexis opening.

METHODS

Case report. In an 81-year-old woman, a complete occlusion of the anterior capsulorhexis opening developed 2 months after phacoemulsification and intraocular lens implantation. We surgically removed the contracted anterior capsule and analyzed the membrane by standard light microscopy and actin immunohistology.

RESULTS

Light microscopic analysis of the membrane showed fibrous tissue subcapsularly with metaplastic lens epithelial cells. The contracted capsulorhexis opening was filled completely with proliferated actin-positive lens epithelial cells.

CONCLUSIONS

Complete occlusion of the capsulorhexis opening can be attributed to excessive shrinkage of the capsule, probably caused by actin filaments found in the residual lens epithelial cells together with weak zonular support, and to the occlusion of the remaining central defect by massive proliferation of metaplastic lens epithelial cells.

[Allogenic heterotopic cartilage transplantation for primary corneal replacement in a rabbit model]

BACKGROUND

Aim of the present study was to investigate woundhealing after allogen heterotopic cartilage transplantation in a rabbit model.

MATERIAL AND METHODS

Cartilage discs were transplanted by central lamellar keratoplasty (diameter 5.0 mm) in eleven New Zealand White Rabbits. Cartilage was harvested of the ears of rabbits at the day of transplantation. The cartilage discs 0.5-0.6 mm thick were prepared with 5.2 mm diameter and transplanted within 12 hours. Fixation was performed by eight 10-0 nylon sutures. Postoperatively, dexamethasone ointment containing gentamicin was applied three times a day for three weeks. Clinical course was documented by photographs. For histological examinations the transplanted eyes were enucleated after one day or three days, and after 3, 6 or 12 months.

RESULTS

Allogen cartilage healed firmly in the cornea within two months. During the course of observation the cartilage grafts thinned and were replaced by normal appearing collagen fibrills. In one case neovascularisation of the cornea occurred and reached the cartilage graft, but did not invate. Histologically, in all cases no leukocytes could be seen in the cartilage or its neighbourhood. The cartilage grafts did not proliferate and remained avascular. The intraocular structures showed no inflammatory reaction.

CONCLUSIONS

Allogen cartilage grafts to a clear corneal pounch do not induce an inflammatory reaction. Therefore, autologous cartilage prepared of ears seems to be useful biological material in ophthalmologic surgical procedures, for example to fill up corneal defects. To investigate if cartilage grafts will be helpful to stop neovascularisation in keratoplasty further studies with vascularisized corneas are necessary.

[Primary pigment epithelial cysts of the iris]

PURPOSE

We want to present a case of bilateral, unusually large pigment epithelial cysts of the iris.

PATIENT

A four-year old girl presented with multiple, un-usually large, bilateral pigment epithelial iris cysts and tags at the pupillary margin. The right eye additionally presented with two adhesions of the cysts at the corneal endothelium. Otherwise, the anterior and posterior segment as well as the intraocular pressure were normal. The visual acuity was at least 0.8 without glasses, and there was no evidence of strabism or other functional impairments. At normal daylight and with non influenced pupils, the visual axis was not covered by the cysts. Since the lesions anamnesti cally appeared to be congenital and the clinical course had been benign, no therapy was initiated. The patient has been checked on at regular intervalls without any functional or morphological change.

CONCLUSION

Pigment epithelial cysts of the iris usually do not cause any complications due to their small size and stationary clinical course. In rare cases, the lesions can be so large, that they get into contact with the corneal endothelium and sometimes nearly cause visual impairment by covering the visual axis.

[Synophthalmia in an early human fetus]

BACKGROUND

The great majority of reports dealing with human cyclopia and synophthalmia are derived from fetuses at the end of pregnancy. Thus, data concerning early organization of the ocular anlage in this impressive ocular developmental anomaly are almost completely lacking. We therefore present a 12 week-old synophthalmic fetus.

CASE REPORT

After uneventful pregnancy spontaneous abortion occurred. Within the face of the hypotrophic fetus there was a central pigmented ocular anlage with an inferior fissure. A nose (proboscis) was not discernible. Histologically, there were two vesicles caudally which fused to one vesicle cranially. Differentiation was more advanced in the anterior and temporal parts of the anlagen. A coherent inner layer (of the optic cup) was not developed. Trisomy 13 was suspected but could not be proved by FISH-technique.

CONCLUSIONS

The fetus demonstrates that fusion of the ocular anlagen is finished at the end of the third gestational month and that synophthalmia/cyclopia is very likely to be associated with maldevelopment of the optic cup. As far as we know there is evidence for the first time that organization of the anlagen improves not only in the posterior to anterior and in the medial to lateral but also in the cranial to caudal direction.

[Focal mucinosis of the eyelid]

PURPOSE

To present a case of focal mucinosis of the eyelid.

PATIENT

A male patient of Turkish origin born in 1982 desired therapy in 1995 for an asymptomatic tumour of the left medial upper lid which had been present probably since birth. The tumour was reduced with argon laser photocoagulation. Fourteen months later, in 1997, the tumour had enlarged so that a surgical excision was performed which histologically was interpreted as an unspecific inflammation. In 1998, the tumour had grown again at the original site, and there were additional three pedunculated tumours nearby at the lid margin. All tumours were surgically excised. Histology showed empty spaces in the upper dermis which contained some connective fibers, benign appearing fibroblasts and some leukocytes. The PAS-reaction and S100-immunohistology were negative while the lesion stained positive for alcianblue. The epidermis was intact. A diagnosis of a focal mucinosis of the eyelid was established.

CONCLUSIONS

Focal mucinosis of the eyelid seems to be exceedingly rare. It is probably caused by a local overproduction of hyaluronic acid of unknown etiology. Our patient demonstrates that focal mucinosis might perhaps be congenital. Moreover it may recur if excision is not complete. Focal mucinosis should be included in the differential diagnosis of long-lasting, asymptomatic lid tumours.

[Acute tumor of the lower eyelid caused by spontaneous hemorrhage of an occult vascular anomaly]

PURPOSE

To present an unusual acute tumour of the lid.

PATIENT

A 37-year-old female physician presented with a swelling and a slight hematoma of the right lower lid. Palpation revealed two firm painless nodules under an intact epidermis. The patient confirmed that the lesion had developed within only one day without a preceding trauma. Both eyes were morphologically and functionally normal. Motility was free, and there was no exophthalmus. After three weeks the palpable nodules had not changed substantially. Magnetic resonance imaging disclosed a space-occupying lesion resembling an old hemorrhage or an inflammation. Excision was performed which revealed a thrombus-like structure. Histology showed multiple endothelium-lined vessels that were densely filled with erythrocytes, hemorrhages within the connective tissue, and old hemosiderin deposits. However, no thrombus could be found.

CONCLUSION

Although thrombosis was the preferred diagnosis on clinical findings, histology led to the diagnosis of a spontaneous hemorrhage most likely caused by an occult vascular malformation.

[Conjunctival cysts of the orbits: clinical aspects and histology in 4 patients]

BACKGROUND

Only a few reports concerning congenital conjunctival cysts of the orbit (primary nonkeratinized epithelial cysts) have been published.

PATIENTS

We describe four further cases of conjunctival cysts of the orbit, which were observed between 1995 and 1997 in Tübingen and Vienna. Histologically, all cysts were lined by nonkeratinizing epithelium with goblet cells. Epidermal appendages were found in the wall of one cyst. The patients' age was between 1 and 32 years. Clinically, the prominent symptom was swelling of the upper eyelid, persisting in three patients for more than several years. In one patients diplopia and restriction of eye movements developed within several weeks.

CONCLUSIONS

The cases we described are in accordance with the cases reported in the literature. Often a swelling of the upper eyelid persisted for several years, before the cyst has become symptomatic predominantly in an adult patient. In contrast to dermoid or epidermoid cysts, there is no bony erosion and the cysts are located in the superior to nasal orbit. These cysts are probably more common as it is represented in the literature.

[Wolfgang Stock, his ophthalmopathologic collection and progress in glaucoma treatment in the 2nd half of the 20th century]

BACKGROUND

As long as Wolfgang Stock was head of the University Eye Clinic Tübingen (1921-1952), he founded a voluminous collection of ophthalmopathological slides, which reflect the knowledge about and possible therapies for various eye diseases at that time.

MATERIAL

The "Collection Stock" contains ca. 450 glaucoma specimens. Of these, 50 were chosen at random and investigated macroscopically and microscopically. Each specimen was supplied with a (main) diagnosis. For comparison, 50 eyes with glaucoma enucleated between 1992 and 1997 were examined.

RESULTS

Nowadays, "glaucoma enucleation" is performed nearly exclusively because of secondary angle closure glaucoma. In contrast, the "Collection Stock" contains various eyes with 1. primary glaucoma without previous operation, 2. congenital glaucoma, 3. lens induced glaucoma, 4. aphakic glaucoma, and 5. complications after glaucoma surgery. No case of diabetic neovascular glaucoma or PEX-glaucoma was found.

CONCLUSIONS

Due to improvement in ophthalmological care, development of various pressure-lowering and anti-inflammatory drugs, new surgical techniques and, probably most important, introduction of the operation microscope, major advances concerning glaucoma therapy and avoidance of complications have been achieved in the last 50 years. Thus, the spectrum of "glaucoma enucleations" has changed dramatically, and certain types of (open angle) glaucoma Wolfgang Stock was very familiar with have in modern ophthalmopathological practice almost fallen into oblivion.

Argon laser therapy of benign tumors of the eyelid

PURPOSE

To report the therapy of benign eyelid tumors with an argon laser as an alternative to surgery.

METHODS

Forty-one patients with 47 benign tumors of the eyelid were included in this study. In all patients, the eyelid tumor was eliminated by argon laser. In 24 cases the lower eyelid and in 23 cases the upper eyelid was involved, including the lid margin in 17 cases. Laser spot size ranged from 150 to 500 microm. Argon laser power density varied between 4.1 and 61.1 W/mm2. Spots were counted between 40 and 1204. Twenty-seven of 41 patients treated were followed up; the mean follow-up period was 5.8 months (range, 3 to 24 months). Postoperatively, histologic confirmation was obtained in 42 cases of the 47 treated tumors.

RESULTS

All patients were satisfied regarding the laser therapy and the cosmetic result. Remarkably, the wounds were dry after argon laser therapy. No infections of the wounds occurred; wounds were epithelialized after 2 to 3 weeks by a normal-appearing epithelium. The area of argon laser treatment was less pigmented than the surrounding skin and showed no obvious remarkable notches. As a complication, one patient developed a viral conjunctivitis. No relapses occurred during follow-up.

CONCLUSIONS

Argon laser therapy of benign eyelid tumors may result in very satisfactory wound healing. Taking the short follow-up and the limited number of cases into account, it seems to be a useful alternative to traditional surgery, especially for tumors positioned close to the lacrimal papillae.

[Subepidermal calcified nodule (calculus) of the eyelid]

A 9-year-old boy presented with a painless hard tumor in the right lower lid. It had grown slowly since 12 months. Three months before presentation cryotherapy was administered by a dermatologist because of a presumed wart. Both eyes were normal. Clinical differential diagnosis included a keratoakanthoma and a wart. Excisional biopsy was performed. Histology revealed granular deposits which stained positive with hematoxylin-eosin and von Kossa stain. Though a secondary (dystrophic) calcinosis of the lid following cryotherapy could not be ruled out a diagnosis of an idiopathic subepidermal calcified nodule (calculus) of the lid was established.

[Atypical non-Hodgkin's lymphoma of the conjunctiva as an incidental finding in lower lid entropion]

PURPOSE

We want to demonstrate an unusual conjunctival Non-Hodgkin-Lymphoma with bleedings.

PATIENT

A 77-year-old female patient presented with an entropion of the left lower eye-lid. Bilaterally reddish, soft tumors showed in the lower fornices with circumscript bleedings. On account of an absolute arrhythmia of the heart the patient has been on a medication of cumarine-derivates since 9 years. Histologically we found underneath the epithelium densely packed lymphocytic cells with small uniform nuclei intermingled with many erythrocytes. The immunohistological investigations revealed a Non-Hodgkin-Lymphoma of B-cell origin.

CONCLUSIONS

Bleedings in a conjunctival Non-Hodgkin-Lymphoma can alter the clinical aspect of the tumor. It is necessary to inspect each entropion thoroughly in order to rule out any other pathological lesions.

[Lymphangioma of the conjunctiva]

A 23-year-old female presented with a yellow-brownish, asymptomatic tumour of the bulbar conjunctiva in her left eye. The lesion had been detected 5 years previously and had grown since then. Prior to presentation there were 2 episodes of intratumoral hemorrhage. Funduscopy revealed tortuous vessels on the left. Complete tumour excision was performed. Histology showed numerous channels lined by a flat endothelium, and inflammatory cells in the fibrous septae. A diagnosis of a conjunctival lymphangioma was established. The tortuosity of the retinal vessels was probably associated by chance or caused by an undetected orbital lymphangioma.

Cataract surgery at the end of the 19th century at Tübingen

Cataract extraction with a Graefe knife incision was the most important development in cataract surgery during the 19th century. To determine the indications, visual outcome, complications, and problems of cataract surgery performed a century ago, we reviewed patient records from the year 1895. With use of Graefe's technique of cataract extraction, the early postoperative visual acuity was 20/200 or better in 63% and 20/40 or better in 5%. A secondary cataract developed in about 30% of eyes. A flat anterior chamber persisted for more than two days in about 20% of eyes. Astigmatism was not regularly measured, but was markedly increased after surgery. Surgery for secondary cataract was performed in only 20 eyes. There was a complication rate of nearly 50% in secondary cataracts. These results demonstrate some of the major problems of cataract surgery 100 years ago: secondary cataract, insufficient wound closure, high astigmatism, and aphakia as a refractive problem.