[Successful treatment of Fusarium-associated keratitis with multiresistant pathogen and multimorbid patient]

A 75-year-old man (not a contact lens wearer) presented with Fusarium-associated hypopyon keratitis. After several weeks of empirical and subsequently targeted antimycotic treatment, no considerable improvement was observed. However, after sclerokeratoplasty (11.2 × 11.2 mm) combined with prolonged antimycotic therapy a good local result with relapse-free long-term follow-up was achieved.

[Therapy for congenital dacryostenosis]

The congenital dacryostenosis occurs frequently in about 5 % of all newborns. It may occur both as a unilateral and as a bilateral form with a family disposition for dacryostenosis. In a large number of cases we see a stenosis of the ductus nasolacrimalis due to a persistant membrane of Hasner or due to a mucosa plaque. The conservative treatment starts with lacrimal sac massage, detumescent eyes and nose drops. With further permanent complaints, probing of the lacrimal passages in a so-called "bundle wrap anaesthesia" may be performed depending on the age and physical appearance of the child. Further probing and silastic tube intubation under general anaesthesia should be performed in the case of persistence. Apart from the congenital stenosis we rarely find other alterations of the lacrimal system like aplasia of the canaliculi, saccus or ductus nasolacrimalis as well as tear duct diverticles or even fistula of the canaliculi or saccus which may lead to permanent epiphora. Facial disorders or dysmorphias with involvement of the lacrimal passages have to be accessed separately, with participation of various disciplines such as radiology, ear nose throat surgery, cranial-facial surgery and neurosurgery and therefore the patients need individual management and treatment.

Morphometric analysis of collagen fibrils in skin of patients with spontaneous cervical artery dissection

BACKGROUND AND AIM

The aetiopathogenesis of spontaneous cervical artery dissection (sCAD) is largely unknown. Electron microscopic (EM) examination of skin biopsies of patients with sCAD revealed very subtle pathological changes of dermal connective tissue in about half of these patients leading to the hypothesis of an underlying connective tissue disorder. However, connective tissue abnormalities did not allow clear discrimination between patients and controls in our hands. Therefore, we sought to establish an objective basis for the assessment of connective tissue abnormalities in patients with sCAD using standardised morphometric assessment of collagen fibrils.

METHODS

In this study a blinded examination was performed of collagen in skin biopsies and it sought parameters which are able to discriminate between patients with sCAD and controls. Various morphometric parameters were compared between patients with sCAD (n = 20) and control subjects (n = 18).

RESULTS

Previously described "flower-like" collagen fibrils in skin biopsies were extremely rare in patients and controls and did not discriminate between the groups. However, they were abundant in the skin biopsy of a patient with Ehlers-Danlos syndrome type III (EDSIII) used as a reference. Morphometric parameters such as collagen fibril diameter, fibril density and relative fibril area did not discriminate between patients and controls on an individual basis, but the mean diameter of collagen fibrils in the skin was lower in patients with sCAD compared with controls while fibril density was higher resulting in nearly equal fibril areas per unit of area (relative fibril area) comparing both groups as well as individuals.

CONCLUSIONS

Blinded pathological and morphometric analysis of collagen fibres in skin biopsies was, in our hands, unable to discriminate reliably between patients with sCAD and controls on an individual basis but did show differences in collagen fibril morphometry on a group basis. Furthermore, systematic and blinded pathological studies of skin biopsies in patients with sCAD and controls are needed.

Generalized arteriopathy in patients with cervical artery dissection

OBJECTIVE

To make an ultrastructural comparison of superficial temporal artery (STA) biopsy specimens from patients with spontaneous cervical artery dissection (sCAD) and controls.

METHODS

The authors used light microscopic examination of semithin sections and electron microscopic examination of ultrathin sections of STA biopsy specimens from patients with sCAD and controls.

RESULTS

STA biopsy specimens from patients with sCAD taken around the time of the dissection showed a zone of connective tissue weakening with fissuring at the junction between the tunica media (TM) and the tunica adventitia (TA) in seven of nine specimens and erythrocyte infiltration in eight of nine specimens but in none of the control specimens. Light microscopy demonstrated transparent circular spots that, on electron microscopy, turned out to represent erythrocytes and other cellular components at different stages of degradation. Occasionally, scattered immune cells were found in specimens from patients with sCAD. In addition, smooth muscle cells of the synthetic phenotype, some of them showing extensive vacuolation were more common in the TM of STA biopsy specimens from patients with sCAD than in control specimens.

CONCLUSIONS

Signs of tissue weakening along the TM/TA junction in STA biopsy specimens of patients with sCAD but not in controls suggest the presence of a generalized arteriopathy leading to impairment of the stability of the arterial wall in patients with sCAD. Limiting factors of the study are that some control biopsies were obtained from autopsies and that the anticoagulation status of patients and controls were not completely comparable.

[MRI-controlled preoperative wire marking of uncertain breast lesions]

PURPOSE

Small suspicious breast lesions that are only visible at MR imaging were preoperatively marked with a hook wire under MR-guidance to allow the removal of the lesion with tissue-sparing surgery.

METHOD

In all patients the suspicious lesions were marked preoperatively under MR guidance with a hook wire using a commercially available stereotactic device. Interventions were performed with MR guidance on a 1.0 T and on a 1.5 T system.

RESULTS

In 19 patients 22 lesions were localized. One lesion was missed and removed in a second procedure. The mean duration for localization was 66 +/- 20 min (range 38-119 min). In two patients two lesions were localized. The mean deviation of the wire tip to the lesion was 2.0 +/- 2.6 mm. In this series, 6 of 22 lesions were malignant. The mean diameter of the lesion was 7.6 +/- 2.6 mm (range 3-14 mm).

CONCLUSION

Suspicious breast lesions detectable only in MR imaging can be accurately localized with a hook wire preoperatively under MR control to remove the lesion with a tissue-saving surgery.

[Syngeneic transplantation of nasal mucosa and azathioprine medication for therapy of cicatricial ocular mucous membrane pemphigoid. Study of 9 patients with 11 eyes]

Nine patients (11 eyes) with ocular cicatricial pemphigoid were treated with systemic azathioprine and a syngeneic nasal mucosa transplant from the inferior turbinate. Follow-up was 8-26 months (average 15 months). Grafting was successful in all cases. Treatment ameliorated the symptoms of pain in all patients and double vision in one. In 2 eyes in which simultaneous pannus resection had been performed, neither pannus nor corneal vascularization recurred. Late complications were recurrences with symblephara in two cases when azathioprine was stopped; in one patient with a serpiginous ulcer tectonic penetrating keratoplasty à chaud had to be performed; and in another a trophic ulcer was healed with a therapeutic contact lens.

Phototherapeutic keratectomy in corneal diseases

We present our clinical strategy to treat corneal diseases with the excimer laser. Nine eyes with recurrent erosion after trauma, three eyes with band keratopathy, and one eye with secondary crystalline deposits and a leukoma adherens after perforating injury underwent excimer laser phototherapeutic keratectomy (PTK). The patients with recurrent erosion had at least six episodes in the 12 months, the other patients suffered from severe pain. The recurrent erosions were treated with 15 pulses (193 nm, 180 mJ/cm2, 10 Hz) after removing the epithelium. There was only one new episode within 6 months after treatment in a patient who failed to follow the postoperative therapeutic regimen. In the patients with band keratopathy we removed the calcium deposits mechanically and then used masking fluids to obtain a smooth surface. The crystalline deposits in the patient with leukoma adherens could be removed but recurred after 4 months; the patient still suffered from glare.

[Clinical use of the excimer laser in treatment of surface corneal opacities--therapeutic strategy and case reports]

BACKGROUND

The authors report on the Phototherapeutic 193nm-Excimer Laser Keratectomy (PTK) for the treatment of superficial corneal opacities.

MATERIAL AND METHOD

In two cases with corneal opacities after contact lens wearing and after therapy resistant keratoconjunctivitis epidemica respectively the treatment strategy is presented. The epithelium and the corneal opacities are removed mechanically as far as possible. Then the Excimer laser smoothing with masking fluids of different viscosity is performed.

RESULTS

In both patients the visual acuity improved from 1/50 and 0.16 respectively to 0.7. Both eyes had an hyperopic shift. The patients were without pain within a follow-up period of 8 months after treatment.

CONCLUSION

The phototherapeutical use of the 193nm Excimer laser to treat superficial corneal opacities can be regarded as a real alternative to conventional surgical techniques.