[Wound healing following amniotic membrane, limbal stem cell and corneal transplantation]

Knowledge of wound healing processes involved in amniotic membrane, limbal stem cell and corneal transplantation enables an assessment of clinical findings and a targeted treatment. The amniotic membrane serves as a basal membrane substrate or temporary transplant in corneal epithelial wound healing. It has an anti-inflammatory effect, supports corneal wound healing and counteracts scar formation. Amniotic membranes are integrated intraepithelially, subepithelially, or intrastromally in the course of healing. Limbal epithelial stem cells express multiple genes necessary for corneal wound healing. The rho-associated, coiled-coil containing protein kinase (ROCK) inhibitor Y‑27632 can improve the proliferation of limbal epithelial cells and therefore represents a new therapeutic option for limbal stem cell deficiency. Wound healing following penetrating keratoplasty involves fibroblasts, type III and IV collagens, proteoglycans, and chondroitin-6-sulfate. A certain inflammatory reaction seems to be necessary for final corneal wound closure.

[Intense pulsed light (IPL) as a therapeutic option for Meibomian gland dysfunction]

Meibomian gland dysfunction (MGD) is a common cause of dry eye disease. Intense pulsed light (IPL) treatment is a new and approved therapeutic option for MGD. The treatment consists of 2-4 sessions where light impulses are applied to the lower lid and temporal lid margin. The IPL technique is a safe form of treatment when the required safety precautions are followed. Current studies document an improvement of patients' subjective symptoms and objectively measured clinical parameters.

[Clinical picture and diagnosis of neurotrophic keratopathy]

BACKGROUND

Neurotrophic keratopathy is characterized by corneal surface alterations, persistent corneal epithelial defects and/or corneal ulcerations associated with corneal sensory abnormalities. Due to the variable clinical picture neurotrophic keratopathy is often overlooked or diagnosed too late in the course of the disease.

OBJECTIVE

Discussion of the clinical picture of neurotrophic keratopathy and recommendations for correct diagnosis.

MATERIAL AND METHODS

Analysis of the existing literature and discussion of basic recent publications.

RESULTS

Neurotrophic keratopathy is defined as a disease related to alterations in corneal nerves leading to impairment in sensory and trophic function with consequent breakdown of the corneal epithelium affecting health and integrity of the tear film, epithelium and stroma. It can occur with infections, autoimmune diseases, after trauma or ocular surgery, with intracranial neoplasia, in systemic diseases and genetic syndromes. It is classified into three stages: mild (epithelial changes without epithelial defects), moderate (epithelial defects) and severe (stromal involvement). The clinical hallmark is reduced or absent corneal sensation. Therefore, corneal sensitivity testing is essential in the diagnosis of neurotrophic keratopathy along with the patient history, clinical examination and diagnostic tests, such as vital stains and, if possible, in vivo confocal microscopy.

CONCLUSION

The correct diagnosis and classification of neurotrophic keratopathy enable a stage-adapted step-ladder therapeutic approach with subsequent reduction of progression and complications of the disease.

[Keratitis - Infectious or Autoimmune?]

Histopathological evaluation of ocular tissues is important in differentiating between infectious and autoimmune disease. Inflammation, necrosis and keratolysis are common to most forms of keratitis. Histopathology can be of great help in identifying the causative organism, establishing a final diagnosis and/or managing the patient with herpes simplex virus keratitis, mycotic keratitis, acanthamoeba keratitis or microsporidia keratoconjunctivitis. Important pathogenetic knowledge with therapeutic relevance has been gained from histopathological studies in nummular keratitis after epidemic keratoconjunctivitis and atopic keratoconjunctivitis.

[In vivo confocal microscopy--correlation to histology]

In vivo confocal microcopy is a fascinating technique to obtain rapidly and non-invasively histological/cytological sections of the ocular surface, and observe long-term changes. It allows classification of corneal findings, facilitates the diagnosis of conjunctival lesions, and has broadened our understanding of lid margin disease. To correctly interpret in vivo confocal scans, profound knowledge of microscopic anatomy and histopathology are crucial. To reduce inter-observer variability and allow comparison of scientific studies, in vivo confocal-histopathological correlations have to be investigated, and standards for the interpretation of in vivo confocal microscopic findings must be established. In suspicious lesions of the ocular surface an excisional biopsy and histopathological examination are still the gold standard.

[Invasive squamous cell carcinoma of the conjunctiva]

We report the case of a 71-year-old male who was first diagnosed with conjunctival squamous cell carcinoma in September 2010. The lesion was excised twice and cryotherapy of the margins was performed. On histology the margins were not tumor-free but this was not followed up by further excision. After 5 months the patient was referred to this department with a growing tumor mass which had infiltrated into the anterior chamber and partly destroyed the iris. Because of this advanced finding extended enucleation was performed. The histological examination showed a well differentiated squamous cell carcinoma and no evidence of metastasis in lymph nodes or elsewhere could be found by conventional computed tomography (CT) and positron emission CT (PET-CT).

[Bacterial conjunctivitis--diagnosis and therapy update]

Acute bacterial conjunctivitis is a common health-care issue for the general practitioner and the ophthalmologist. Signs and symptoms usually allow a correct diagnosis without conjunctival swab. Primary microbiological investigations are recommended in newborns, immunocompromised patients and cases of hyperacute conjunctivitis. Of concern are methicillin-resistant Staphylococcus aureus strains which have been isolated with increasing frequency in the last few years. Studies have demonstrated the faster clinical and microbiological cure of acute bacterial conjunctivitis with topical antibiotics. However, the development of resistance of the typical germs to all of the antibiotic groups is alarming and should influence therapeutic behaviour. Fluoroquinolones show good activity in the treatment of acute bacterial conjunctivitis but should be saved for severe infections due to its broad spectrum of activity. Antibiotics such as gentamycin, tobramycin, and azithromycin should be preferred. Considering the high spontaneous healing rate of acute conjunctivitis, delayed topical antibiotics in case of persistence after 3-4 days, or treatment without antibiotics using artificial tears and eye bathings may be considered. Additive anti-inflammatory drugs are generally not recommended. Chronic-recurrent follicular conjunctivitis necessitates testing for Chlamydia, and in case of a positive result, systemic antibiotic treatment of patient and sexual partner.

[Recurrent uveitis of unknown origin in childhood]

This report describes a 12-year-old girl with diffuse infiltrating retinoblastoma. This inflammatory condition belongs to the uveitis masquerade syndromes, which comprise a group of various ocular diseases such as chronic intraocular inflammation and ocular tumors.

[Clinical presentation of zoster ophthalmicus]

BACKGROUND

Zoster ophthalmicus (ZO) is a common disease, in particular in elderly and immunocompromised patients. In addition to the characteristic dermal lesions and to the postherpetic neuralgia, the clinical appearance may include very different forms of eye involvement.

METHODS

This article reviews the clinical features of ZO as well as the typical eye complications and therapy.

RESULTS

50 % of ZO patients have eye involvement. The acute phase of ZO is characterised by lid exanthema, conjunctivitis and epithelial keratitis (up to 65 %). In the late phase, stromal keratitis (up to 25 %), anterior uveitis (up to 50 %), and acute retinal necrosis (ARN) may occur. Typical complications are eyelid malposition, neurotrophic keratopathy (up to 25 %) and glaucoma. The diagnosis is usually based on the characteristic dermal lesions. In atypical cases, immunohistochemistry and PCR are tools for virus detection. All ZO patients should immediately receive systemic antiviral therapy. Corticosteroid therapy is essential for the management of the concomitant immune reaction that is relevant for the long-term prognosis, especially in stromal keratitis, uveitis, scleritis and ARN.

CONCLUSIONS

All patients should receive systemic antiviral treatment to avoid complications and visual impairment. With appropriate medical and surgical therapy the prognosis is usually good. Postherpetic neuralgia is often the major issue in the later course. For the prevention of ZO and its complications, a vaccination is useful.

[Hepatic metastases in CUP (cancer of unknown primary) and painful amaurosis]

A 63-year-old woman presented with a 9-month history of painful amaurosis of the left eye caused by hemophthalmos. She was already undergoing chemotherapy for histopathologically proven liver metastases caused by an assumed melanoma. The location of the primary tumor was unknown. Whole-body FDG-PET/CT staging identified a lesion with characteristically malignant uptake in the region of the left eye as the primary tumor. After enucleation, a primary uveal melanoma was verified that expressed the serological marker melanoma inhibitory activity (MIA). FDG-PET/CT was able to successfully align hepatic metastases due to CUP with local ophthalmologic diagnostic findings and led to a correct diagnosis.

[Emotional tears]

Emotional tears, an exclusively human means of communication, are complex and rarely the subject of scientific research. The same nerves, receptors, and transmitters seem to be involved in their production as those used for basal and reflex tears. However, stimuli must be received in a cognitive/social context, detected by "induction centers" in the telencephalon, and forwarded to effector centers. Increased concentrations of protein, prolactin, manganese, potassium, and serotonin have been detected in emotional tears. Various theories try to explain the reason for and benefit of emotional tears. A number of factors, such as ethnic group, social status, profession, hormonal situation, gender, and individual threshold, influence whether an individual is a "crier" or a "noncrier." Manipulative tears are a strong weapon for unbalancing other people, and the expression "crocodile tears" is used for both manipulative tears and aberrant gustolacrimal tears. Pathological crying occurs during depression, but it also occurs in the context of central nervous system disease as prolonged crying fits without cause or emotion. Absent emotional tearing is observed in congenital, often syndromal, disorders.

[The situation of ophthalmic pathology in Germany: the current status]

BACKGROUND

Ophthalmic pathology with its 150 year-old tradition is a subspecialty which since its beginning has contributed substantially to progress in ophthalmology. Nevertheless, deactivation or even termination of ophthalmopathological laboratories has occurred in the past years mainly due to economic pressure. In order to evaluate the situation and future perspectives of the existing, active laboratories in Germany and to ask for the kind of support desired from the Section for Ophthalmic Pathology of the German Ophthalmological Society (DOG) a survey was carried out using a questionnaire.

RESULTS

The main results were as follows. 1. Specialised ophthalmic pathology is performed in Germany almost exclusively in laboratories integrated in university eye clinics. 2. There is close cooperation with institutes for pathology and dermatopathology. 3. The main focus is placed on the cornea, tumours of the eye and its adnexae, and the conjunctiva. 4. The number of ophthalmopathological specimens investigated per year is generally below 1000 and often below 500. 5. The diagnostic spectrum and equipment of the laboratories is generally good. 6. There are some deficits concerning ophthalmopathological education and the status of ophthalmic pathology within the clinics. 7. A considerable number of scientific publications is generated by the members of the laboratories. 8. At present there is only minimal fear that the own laboratory will be eliminated in the near future. 9. Ophthalmic pathology is established as an integral component of ophthalmology in patient care and, even more, in ophthalmic research. 10. The DOG-Section "Ophthalmic pathology" is requested to initiate stays in foreign laboratories, to initiate scientific multicentre studies, and to support activities dedicated to preserve the ophthalmopathological laboratories.

DISCUSSION

For the first time valid data concerning the situation of ophthalmopathological laboratories in Germany have been collected. The information gathered can and should be used as an argument for the preservation and, if possible, even expansion of the occupation with normal and pathologic eye morphology at eye hospitals in and beyond Germany.

Mycophenolate mofetil (MMF) following penetrating high-risk keratoplasty: long-term results of a prospective, randomised, multicentre study

BACKGROUND

The purpose of this prospective, randomised, multicentre study was to prove the efficacy and safety of mycophenolate mofetil (MMF) in preventing graft rejection and in improving clear graft survival following high-risk keratoplasty.

METHODS

In all, 98 of 140 scheduled patients were included in this study (57 MMF, 41 control). Recruitment was stopped prematurely due to a statistically significant result. The patients in the MMF group received MMF orally 2 x 1 g daily for 6 months. All of the patients received fluocortolone 1 mg/kg/day tapered over 3 weeks and topical prednisolone acetate 5 x /day tapered over 5 months. Main criteria were immune reaction-free and clear graft survival, and the occurrence of side effects.

RESULTS

The mean follow-up time was 34.9+/-16.3 (mean+/-SD) months. Eleven patients withdrew from the study (nine patients due to protocol deviation, two because of side effects). Six reversible and two irreversible graft rejections occurred in the MMF group, and five reversible and seven irreversible rejections in the control group. The Kaplan-Meier analysis revealed an immune reaction-free graft survival after the mean follow-up time of 83% in the MMF group and 64.5% in the control group (P=0.044). Graft failure occurred in 10 MMF-treated patients (two due to rejection) and in nine patients in the control group (seven due to rejection). A total of 36 of 57 MMF-treated patients experienced mostly reversible adverse events.

CONCLUSIONS

Systemic immunosuppression with MMF over 6 months is relatively well tolerated and improves rejection-free graft survival following high-risk keratoplasty statistically significant, even in the long run.

[Osmoprotection as a new therapeutic principle]

Dry eye syndrome is one of the most common disorders encountered in daily ophthalmological practice. New pathophysiological concepts have been developed over the last few years. Hyperosmolarity of the tear film is one of the key pathogenetic factors in the development of a - commonly subclinical - inflammation of the ocular surface, the lacrimal gland and the tear film in dry eye syndrome. Osmoprotective agents act through compatible solutes to prevent - at least in theory -a hyperosmolar tear film from damaging the ocular surface.

Cost Utility for Penetrating Keratoplasty in Patients with Poor Binocular Vision

PURPOSE

Cost-utility and cost-effectiveness analyses are of increasing importance to clinicians and health policy experts. This study determines the costs in Germany and other countries in relation to gain of utility for patients with bilateral poor vision owing to corneal disease undergoing penetrating keratoplasty (PK) in 1 eye.

DESIGN

A cost-utility analysis was performed using retrospective clinical data and high-level evidence-based data.

PARTICIPANTS

Sixty patients (mean age, 46.3 years) with bilateral poor vision who underwent PK for corneal disease.

METHODS

Visual acuity and utility values were obtained before and 1 year after PK and after suture removal. A 10-year graft survival rate of 80% was assumed. Expenses included costs for the corneal transplant and surgery, medication, and optical rehabilitation. A discount rate of 5% was applied for costs and quality-adjusted life years (QALYs). Cost-utility analysis encompassed a 10-year period after surgery.

MAIN OUTCOME MEASURES

The number of QALYs was calculated for the study group undergoing PK. This was divided into the cost of the procedure to get the number of euros spent per QALY gained.

RESULTS

Median binocular preoperative visual acuity was -log mean angle of resolution (-logMAR) 0.91+/-0.53 (Snellen equivalent 20/160) yielding a utility value of 0.67. After suture removal and optical rehabilitation, binocular visual acuity increased to median -logMAR 0.36+/-0.36 (20/46) with a utility value of 0.79. Over the 10 years after surgery and considering graft survival and discounting, a cost utility of 9551 euros per QALY was gained (equivalent to US11,557 dollars). One-way sensitivity analysis yielded a range from 7706 euros to 12874 euros per QALY, highlighting the robustness of the model.

CONCLUSIONS

Although an expensive procedure, PK is cost effective in patients with bilateral poor vision.

Fortschritte in der Diagnose und Therapie von Erkrankungen der Augenoberfläche: Trockenes Auge und okuläre Allergien

The 77th meeting of the Association for Research in Vision and Ophthalmology (ARVO) presented the latest developments in clinical research and practice across a range of ophthalmic disciplines. Of particular interest was the current status of research in dry eye and ocular allergy. With these conditions being very common to ophthalmologists, and the fact that they are difficult to differentiate due to the number of overlapping symptoms, there remains a need for more rapid and accurate methods for their diagnosis. Therefore, a number of new tools were presented that have the potential for use in clinical trials and practice to improve the diagnosis and assessment of dry eye and ocular allergy. Some of these tools have been developed based on a greater understanding of the pathophysiology of dry eye and ocular allergy, and the various molecular pathways involved. Indeed, a greater understanding of the molecular mechanisms involved in the pathogenesis of dry eye and ocular allergy has identified potential targets for the treatment of these conditions. Continuing research into new agents can provide ophthalmologists with a number of options that will ultimately benefit the patient.

[Ocular allergies]

Recent developments indicate that ocular allergy is more than an IgE-mediated allergic conjunctivitis. Ocular allergy is a disease affecting the entire ocular surface including conjunctiva, lids, cornea, lacrimal gland and tear film. Besides an IgE-mediated reaction, a complex chronic inflammation is involved in the pathogenesis of many ocular allergies. According to their pathogenesis and clinical picture, ocular allergies are classified into mild forms, such as seasonal and perennial allergic conjunctivitis as well as giant papillary conjunctivitis, and chronic, potentially blinding forms such as atopic keratoconjunctivitis and vernal keratoconjunctivitis. New therapeutics act on the entire inflammatory process or try to modulate the allergic reaction early and specifically. The association with non-ocular allergic symptoms requires an interdisciplinary approach.

[Ocular allergies]

Recent developments indicate that ocular allergy is more than an IgE-mediated allergic conjunctivitis. Ocular allergy is a disease affecting the entire ocular surface including conjunctiva, lids, cornea, lacrimal gland and tear film. Besides an IgE-mediated reaction, a complex chronic inflammation is involved in the pathogenesis of many ocular allergies. According to their pathogenesis and clinical picture, ocular allergies are classified into mild forms, such as seasonal and perennial allergic conjunctivitis as well as giant papillary conjunctivitis, and chronic, potentially blinding forms such as atopic keratoconjunctivitis and vernal keratoconjunctivitis. New therapeutics act on the entire inflammatory process or try to modulate the allergic reaction early and specifically. The association with non-ocular allergic symptoms requires an interdisciplinary approach.

Ocular manifestations of keratitis– ichthyosis–deafness (KID) syndrome

OBJECTIVE

Keratitis-ichthyosis-deafness (KID) syndrome is a rare congenital ectodermal dysplasia characterized by the association of hyperkeratotic skin lesions, moderate to profound sensorineural hearing loss and vascularizing keratitis. Mutations in the GJB2 gene coding for connexin 26, a component of gap junctions in epithelial cells, have been observed in several KID patients. Variable ocular manifestations of the disease in 3 patients with molecular genetically confirmed KID syndrome are reported.

DESIGN

Retrospective case series.

METHODS

Clinical examination and molecular genetic analysis for mutations in the GJB2 gene were performed in 3 patients with KID syndrome ages 5, 13, and 41 years.

RESULTS

Visual acuity ranged from normal to severe visual loss. The ocular signs included loss of eyebrows and lashes, thickened and keratinized lids, trichiasis, recurrent corneal epithelial defects, superficial and deep corneal stromal vascularization with scarring, keratoconjunctivitis sicca, and, in one patient, presumed limbal insufficiency. Whereas ocular surface integrity could be maintained with artificial tears in one patient, and an epithelial defect healed under conservative treatment in the second patient, multiple surgical procedures including superficial keratectomies, limbal allograft transplantation with systemic immunosuppression, amniotic membrane transplantation, lateral tarsorrhaphies, and lamellar keratoplasty could not preserve useful vision in the third patient.

CONCLUSIONS

KID syndrome may affect the ocular adnexae and surface with variable severity independent of the age of the patient. Lid abnormalities, corneal surface instability, limbal stem cell deficiency with resulting corneal complications, and dry eye are the main ocular manifestations.

Konfokale In-vivo-Mikroskopie bei Blepharitis

BACKGROUND

Dysfunction of the meibomian glands with inflammation and obstruction has been suggested to be an important factor in the pathogenesis of chronic blepharitis. Few objective tests are, however, available to examine the meibomian glands directly.

PATIENTS AND METHODS

Nineteen patients with anterior blepharitis, meibomitis, meibomian gland dysfunction or severe keratoconjunctivitis sicca associated with blepharitis as well as 10 patients with normal lid margins were examined with the HRTII/RCM in vivo confocal microscope. Scans of the tear film, the tarsal conjunctiva, the hair follicles and the meibomian glands were analysed by a masked observer.

RESULTS

Patients with normal lid margins exhibited a minimal round cell infiltrate in the tarsal conjunctival epithelium and largely normal ducts of the meibomian glands lined with a multilayered epithelium as well as normal gland acini. In patients with anterior blepharitis, blepharitis associated with autoimmune peripheral ulcerative keratitis and blepharitis in the context of severe dry eye, confocal microscopy disclosed normal meibomian glands. In 12 patients with blepharitis/meibomitis or meibomian gland dysfunction, profound pathology was visible with dilatation and obstruction of the meibomian gland ducts. In 15 of 19 patients with blepharitis/meibomitis, but not in meibomian gland dysfunction, an intense inflammation was observed in the tarsal conjunctival epithelium and stroma. In one patient, demodex folliculorum was evident in vivo. In patients with normal lid margins as well as in patients with blepharitis, hair follicles appeared within normal limits.

CONCLUSIONS

In vivo confocal microscopy allowed the examination of the tear film, the tarsal conjunctiva, the lid margin including the lash follicles and the meibomian glands. In patients with meibomian gland disease pathological changes could be visualised and documented objectively. The presence of an inflammatory infiltrate permitted us to differentiate between meibomitis and meibomian gland dysfunction. Changes of the lash follicles do not seem to play an important role in blepharitis. Thus, in vivo confocal microscopy represents an objective technique in the classification and follow-up of patients with blepharitis.

[What's new in ocular surface disease?]

The 76th meeting of the Association for Research in Vision and Ophthalmology (ARVO) was held in Fort Lauderdale, Florida on 25-29 April 2004. The congress focused on the latest developments in clinical and laboratory research in ophthalmology and the treatment of ocular disease. In this article the authors review new insights into dry eye, including recent treatment developments, discuss current advances in the field of ocular allergy and highlight new findings in the area of ocular infection presented at the ARVO meeting.

Diagnostik und Therapie des Lidekzems

Eyelid eczemas are clinically and therapeutically clearly delineated, but remain a pathogenetically heterogeneous entity. The anatomic and functional conditions in the periorbital region make treatment difficult. Thus, in addition to frequent resistance to therapy and a tendency to recur, they pose a considerable diagnostic and therapeutic challenge to dermatologists and ophthalmologists. Even a comparatively small area of eyelid eczema can cause substantial suffering because of the burdensome symptoms and high aesthetic significance of this body region. This interdisciplinary overview deals in particular with current pathogenetic and therapeutic aspects of eyelid eczemas.

Triple-Operation

Since the 1980s, combined perforating keratoplasty and extracapsular cataract surgery with intraocular lens implantation (triple procedure) has been performed with increasing success for patients with corneal disease and cataract. Advantages include prompt visual rehabilitation, protection of the transplanted endothelium from sequential cataract surgery, and similar up to superior functional results following triple procedures. In the following review article, the authors discuss advantages and disadvantages of triple procedures, alternative surgical techniques, problems in intraocular lens power calculation, intraoperative pitfalls, and postoperative results of combined keratoplasty, cataract removal, and intraocular lens implantation.

Peripheral visual field defects after macular hole surgery: a complication with decreasing incidence

AIM

To prospectively evaluate peripheral visual fields after vitrectomy for idiopathic macular holes.

METHODS

Goldmann perimetry was performed in 105 patients before, as well as 6 weeks and 12 months after macular hole surgery.

RESULTS

Only one patient (< 1%) with a stage III macular hole developed an asymptomatic postoperative visual field defect. The scotoma was wedge-shaped, peripherally located in the temporal quadrant, and remained unchanged during the following 12 months.

CONCLUSION

Peripheral visual field defects after macular hole surgery can be a complication of very low incidence. A rather low pressure set during air-fluid exchange as well as special aspects of the surgical technique may be responsible for this low incidence of peripheral visual field defects.

Indocyanine green selectively stains the internal limiting membrane

PURPOSE

To demonstrate whether indocyanine green stains the inner limiting membrane of the retina or residual vitreous cortex.

METHODS

We report on the intraoperative staining patterns of the vitreomacular interface in 10 eyes of 10 consecutive patients who underwent vitrectomy with indocyanine green staining for macular hole formation and diffuse diabetic macular edema.

RESULTS

In five eyes of five patients with macular holes, indocyanine green staining of the macula after posterior vitreous detachment resulted in an immediate visibility of a discernable membrane that was not previously seen. In five eyes of five patients with diffuse diabetic macular edema and adherent cortical vitreous, indocyanine green failed to stain the vitreomacular interface. After peeling off the residual vitreous cortex, however, a discernable membrane could be identified using indocyanine green dye again. Light and transmission electron microscopy revealed the inner limiting membrane as the membrane that had been stained and removed in all specimens.

CONCLUSION

Indocyanine green selectively stains the inner limiting membrane. Staining of the vitreomacular interface using indocyanine green as a vital dye enables the surgeon to distinguish between the residual vitreous cortex and the inner limiting membrane, and it allows safer and easier removal of the inner limiting membrane.

Resolution of diabetic macular edema after surgical removal of the posterior hyaloid and the inner limiting membrane

PURPOSE

To evaluate the surgical results of pars plana vitrectomy with peeling of the inner limiting membrane (ILM) in a preliminary series of 12 eyes with diffuse diabetic macular edema.

PATIENTS AND METHODS

Pars plana vitrectomy with peeling of the ILM was performed in 12 eyes with diffuse diabetic macular edema. In 10 eyes, the posterior hyaloid was attached and thickened. Six eyes had undergone macular photocoagulation previously, and two other eyes had been vitrectomized previously. Light and electron microscopy of the specimens obtained during vitrectomy was performed. Visual acuity and retinal thickening were monitored.

RESULTS

Intraoperatively, the posterior hyaloid was found to be thickened and completely attached to the macula in 10 eyes. Two previously vitrectomized eyes showed a glistening reflex of the vitreoretinal interface but no premacular membrane. The posterior hyaloid and the ILM were removed from the macula. Postoperatively, retinal thickening resolved or decreased in all eyes. Visual acuity improved by at least two lines in 11 eyes. Best-corrected postoperative visual acuity developed within 4 to 12 weeks. No recurrence or deterioration of macular edema or epiretinal membrane formation were observed during the entire period of review (mean, 16 months; range, 8-31 months). Light and electron microscopy showed the presence of the ILM associated with sparse and mostly single-layered fibrous astrocytes.

CONCLUSION

Vitrectomy including removal of the ILM leads to expedited resolution of diffuse diabetic macular edema and improvement of visual acuity without subsequent epiretinal membrane formation. Complete release of tractional forces and inhibition of reproliferation of fibrous astrocytes seem to be prudent in the eyes of patients with diabetes and advanced vitreoretinal interface disease of the macula.

[Ocular cicatricial pemphigoid. Retrospective analysis of risk factors and complications]

Cicatricial pemphigoid (CP) is a rare autoimmune disease characterized by subepidermal blistering and progressive cicatrization affecting the skin and mucosa. Ocular involvement occurs in approximately 70% of the patients.

METHODS

The course of the disease, complications and putative risk factors in patients with ocular cicatricial pemphigoid (OCP) treated at the Departments of Ophthalmology and Dermatology were analyzed retrospectively from 1986 to 1998.

RESULTS

Eighteen of 28 patients (64%) with CP demonstrated ocular involvement. The mean age of patients with OCP was 73 years; 61% were female. At the time of referral to our hospital, all patients had reached advanced stage III (83%) or IV (17%) of OCP. In 38% of patients vision was already reduced to < 20/200 at first presentation. Twenty-eight percent of patients additionally suffered from glaucoma. Two patients exhibited life-threatening extraocular manifestations of CP (larynx stricture, esophagus stricture). Conjunctival or mucosal biopsies were performed in 15 patients with OCP and showed typical immuno-deposits at the basement membrane zone in 12/15 patients. Therapy with dapsone (12 patients), oral steroids (11 patients), azathioprine (5 patients), cyclophosphamide (4 patients), colchicine (2 patients) and methotrexate (1 patient) was used concomitantly or consecutively. Complications of OCP including entropion, recurrent epithelial erosions, corneal ulcers, keratitis, and corneal perforations required multiple surgical interventions such as entropion surgery (8 patients), tarsorrhaphy (3 patients), mucous membrane grafting (1 patient), amniotic membrane transplantation (1 patient), tectonic keratoplasty (1 patient), keratoprosthesis (1 patient) and enucleation (1 patient). Despite control of the inflammatory process, further visual loss occurred in 53% of eyes. Reading visual acuity could only be maintained in 35% of eyes.

DISCUSSION

Early diagnosis and therapy can prevent ocular complications of OCP. This study indicates that advanced stages of the disease often result in irreversible visual loss despite institution of immunosuppressive therapy. Whether or not the high association of OCP with glaucoma and/or anti-glaucomatous treatment in our patients represents part of the underlying disease process or plays a role in the pathogenesis of OCP must still be clarified.

Vasculitic peripheral ulcerative keratitis

The onset of peripheral ulcerative keratitis in the course of a connective tissue disorder, such as rheumatoid arthritis, relapsing polychondritis, or systemic lupus erythematosus, may reflect the presence of potentially lethal systemic vasculitis. Moreover, peripheral ulcerative keratitis may be the first sign of systemic necrotizing vasculitis in patients with Wegener's granulomatosis, polyarteritis nodosa, microscopic polyangiitis, or Churg-Strauss syndrome. Although the exact pathogenesis of this severe corneal inflammation and destruction is not well understood, evidence points to a dysfunction in immunoregulation with immune complexes formed in response to autoantigens or to some unknown microbial antigen depositing in scleral and limbal vessels. These events lead to changes that are mainly responsible for the resulting tissue damage. In pauci-immune vasculitides positive for antineutrophil cytoplasmic antibodies, cell-mediated cytotoxicity may play an important role in the pathogenesis of peripheral ulcerative keratitis. Untreated systemic conditions such as those mentioned above may carry a grave prognosis for the eye and may also be life-threatening. Immunosuppressive therapy with corticosteroids and cytotoxic agents is, we believe, mandatory in the treatment of these multisystem disorders associated with vasculitic peripheral ulcerative keratitis.

Lepromatous uveitis diagnosed by iris biopsy

Ocular leprosy is rarely seen in developed countries. We report the long-term follow-up of a patient with bilateral uveitis, glaucoma, and keratitis. Skin, iris and aqueous humor biopsies disclosed abundant Wade-Fite-positive organisms consistent with Mycobacterium leprae. Leprosy must be considered in the differential diagnosis of keratitis and uveitis.

[Choroid neovascularization in age-related macular degeneration. Correlation of histological and fluorescence angiography findings]

BACKGROUND

Recent studies have raised confusion about the fluorescein angiographical and histopathological correlation of CNV.

MATERIAL AND METHODS

The preoperative fluorescein angiograms of four patients with subfoveal CNV due to ARMD extracted by pars plana vitrectomy were classified as wellor ill-defined CNV and were correlated to the histopathologically (in serial sections) verrified CNV-location (subneuroretinal (= type II according to Gass) versus sub-RPE (type I according to Gass)).

RESULTS

The locations of all four CNV could be classified by histopathological landmarks as there were RPE, BLD/drusen, and inner Bruchs membrane. Angiographically welldefined membranes were type II membranes according to Gass, whereas the ill-defined membrane represented type I. The CNV with well- and ill-defined borders consisted of type II and type I parts according to Gass.

CONCLUSION

We find subneuroretinal locations of the well-defined CNV examined (type II membranes according to Gass). Correspondingly, ill-defined CNV or ill-defined parts of a CNV seem to be beneath the RPE (type I). The correlation of fluorescein angiography and histopathology should be studied in greater numbers of well- and ill-defined CNV.

Ultrastructure of epiretinal membranes associated with macular holes

BACKGROUND

The role of tangential traction exerted by epiretinal membranes in the pathogenesis of macular holes is not fully understood. Furthermore, the role of glial cells in the formation and/or closure of macular holes remains to be elucidated.

METHODS

To better understand the pathogenesis of macular hole formation and to compare the ultrastructural features of epiretinal membranes associated with macular holes of primary and secondary etiology, we harvested 23 translucent epiretinal membranes associated with macular holes stages III-IV at the time of pars plana vitrectomy and examined them electron microscopically. Eighteen membranes were obtained from patients with idiopathic macular holes. 3 membranes from patients with myopic macular holes and 2 epiretinal membranes were associated with macular holes which had developed after retinal detachment surgery.

RESULTS

Eighteen membranes contained a continuous undulating piece of inner limiting lamina (ILL). Sixteen of 18 epiretinal membranes at the margins of idiopathic macular holes, 2 of 3 membranes in myopic macular holes and both membranes associated with a macular hole after retinal detachment surgery demonstrated mono- or multilayers of fibrous astrocytes with single macrophage- or fibrocyte-like cells. Vitreous and newly formed collagen occupied the space between the ILL and the glial cells. Three macular holes were surrounded by rather firmly attached acellular ILL.

CONCLUSIONS

Glial cells and newly formed collagen may play an important role in macular hole formation by exerting tangential traction regardless of the underlying disease process. Glial cells, however, may also be involved in healing of the retinal defect and pars plana vitrectomy with peeling of an epiretinal membrane, and/or the ILL may induce directed glial cell proliferation and migration. The similar ultrastructure of epiretinal membranes associated with macular holes and "simple epiretinal membranes" as described by Foos [8] suggests a common pathogenesis for macular holes and macular pucker.

[Surgical management of complete macular foramina]

Recently, good functional and anatomical results have been reported in treating full thickness macular holes. Only a few studies describe a removal of a membrane at the vitreoretinal interface after having removal of the vitreous and its cortex. To demonstrate the beneficial effects of removing this membrane at the vitreoretinal interface we present our functional and anatomical results in this retrospective study.

PATIENTS

Altogether, 42 patients (27 women, 15 men) with an average age of 66.7 years and full thickness idiopathic macular holes stage II and III/IV (21 patients respectively) were retrospectively analysed. The minimum follow-up was 6 months. To reattach the macular, an intraocular gas tamponade was used in 36 patients (15% C2F6) and 6 patients were treated with an 20% SF6 gas tamponade.

RESULTS

Six months after operation, patients in the main group (42 patients) showed visual improvement in 53% (22 patients): 26% (11 patients) showed no change in visual acuity before and after operation. A deterioration was present in 21% (9 patients). In the group of patients in which a membrane at the vitreoretinal interface had been removal 68% (22 patients) showed improved visual acuity. In all 26% (8 patients) showed no change and in one case a deterioration was noticed. After removal of a membrane at the vitreoretinal interface no further macular hole was seen in 80% (25 patients). In this group, 90% (28 patients) complained of metamorphosia before operation. In the group of patients in which were no membrane at the vitreoretinal interface had been removed (11 patients), 73% (8 patients) showed a deterioration in visual acuity, no patient showed improved visual acuity and 27% (3 patients) retained the same level of visual acuity. No macular hole was noticed 6 months postoperatively in 27% (3 patients) in this group. In all 36% (4 patients) in this group complained of metamorphopsia before operation.

CONCLUSION

Removal of a membrane at the vitreoretinal interface in patients with idiopathic macular holes stage II in IV improves functional and anatomical results. Metamorphosia is reduced significantly after removal of that membrane. According to our studies, metamorphosia is an indicator for the presence of a membrane at the vitreoretinal interface. Our results suggest that there are different types of idiopathic macular holes with a different pathogenesis in those where a membrane at the vitreoretinal interface could not be removed and those where it is possible to remove it. Cases where removal of this structure should be attempted show better functional and anatomical results. Studies using adjuvants, e.g. autologous platelet concentrate or transforming growth factor beta 2, should take into account that two different types of idiopathic macular holes exist.

[Changes in the vitreomacular border of the partner eye in macular foramina]

The incidence of a macular hole in the fellow eye of patients with macular hole stage I-IV according to Gass is observed in 3-14% of cases. The development of a macular hole over a period of 19-54 months is reported to occur in 1-22% of patients. Our clinical impression made us suspect a much higher number of changes at the vitreomacular interphase in the generally asymptomatic "second eye" already at first presentation in the hospital. We retrospectively examined 88 patients who presented with a macular hole between January and October 1994. We investigated the frequency of a macular hole or macular pucker in the fellow eye, taking into consideration that many common pathogenetic factors were described for these changes of the vitreoretinal interphase. We further examined the difference in number and appearance of macular pathology in the fellow eye between patients who had macular hole surgery in their "first eye" and patients whose "first eye" was observed. The group of patients whose "first eye" was operated on showed a macular hole stage I or stage II in 8% each in the "second eye", and a macular hole stage III/IV in 6% of cases. Patients whose "first eye" was observed were found to have only early macular holes in 18% of fellow eyes. Altogether, the fellow eye of patients with macular hole exhibited also a macular hole in 21% of patients and a macular pucker in 7% of patients. The incidence of pathological changes at the vitreomacular interface in 28% of the fellow eyes of patients with macular hole is higher than ever reported in the literature. The presence of early macular holes as well as early macular puckers supports clinically the thesis of common factors in the pathogenesis of these two disorders. As we only reviewed the incidence of pathological charges in this study, a much higher number of developing macular holes and macular puckers has to be expected in the fellow eye of patients with macular hole over a certain time period.

Referral patterns of uveitis in a tertiary eye care center

OBJECTIVE

To analyze the referral patterns and diagnosis of uveitis during the past decade in a large tertiary eye center.

DESIGN

The records of 1237 patients with uveitis referred to the Immunology Service of the Massachusetts Eye and Ear Infirmary from 1982 to 1992 were classified and analyzed. Data regarding sex, race, nationality, referral site, ages at presentation and onset of uveitis, ocular involvement, clinical characteristics, ocular condition, and systemic disease associations were obtained.

RESULTS

The mean age at onset of uveitis was 37.2 years; the male-to-female ratio was 1:1.4. Most patients were white (85.8%), born in the United States (83.1%), and referred from within New England (84.7%). Anterior uveitis was most common (51.6%), followed by posterior uveitis (19.4%), panuveitis (16.0%), and intermediate uveitis (13.0%). Chronic (58.3%), nongranulomatous (77.7%), and noninfectious (83.1%) were the most frequent types of uveitis. The most common entities included idiopathic (34.9%), seronegative spondyloarthropathies (10.4%), sarcoidosis (9.6%), juvenile rheumatoid arthritis (5.6%), systemic lupus erythematosus (4.8%), Behçet's disease (2.5%), and the acquired immunodeficiency syndrome (2.4%).

CONCLUSION

The appearance of new uveitic entities, such as the acute retinal necrosis syndrome, multifocal choroiditis and panuveitis, birdshot retinochoroidopathy, and acquired immunodeficiency syndrome-related uveitis, and the reemergence of the classic infectious causes of uveitis, tuberculosis and syphilis, have changed the way we approach the diagnosis and management of posterior and panuveitis at the Massachusetts Eye and Ear Infirmary.

[Recurrent vitreoretinal membranes in intravitreal silicon oil tamponade. Morphologic and immunohistochemical studies]

During intraocular silicon oil tamponade, recurrent vitreoretinal membranes can become clinically relevant and may need surgical excision. We investigated 40 PVR and 10 diabetic membranes which had formed during intraocular tamponade with highly purified silicone oil (5000 cs). The membranes were investigated by light and electron microscopy with respect to silicone oil-specific alterations. The participating cells were differentiated immunohistochemically. Mechanisms of intercellular growth regulation were analyzed by the use of antibodies against cell adhesion molecules and growth factor receptors (PDGFr-B). Most of the membranes showed typical signs of the underlying disease process. However, seven PVR and four diabetic membranes had specific interstitial and intracellular vacuoles which were considered to be silicone oil droplets. The phagocytosing cells were macrophages, partially embedded within vitreous residues. T-lymphocytes can be drawn to the area of macrophage activity by the expression of ICAM-1 and LFA-1. The residual parts of the membranes are typical vitreoretinal membranes. The receptors for PDGF, fibronectin and laminin were negative, but the receptors for collagen and vitronectin were positive within these membranes. The silicone oil-specific macrophage reaction might be supported by emulsified silicone oil droplets, which might get phagocytosed at a certain size. The secondary inflammatory reactions can further enhance silicone oil emulsification and start a vicious circle. Nevertheless, the underlying disease process seems to be much more important in stimulating recurrent membrane formation than silicone oil-specific cell reactions.

Destructive corneal and scleral disease associated with rheumatoid arthritis. Medical and surgical management

The onset of necrotizing scleritis (NS) and peripheral ulcerative keratitis (PUK) in the clinical course of rheumatoid arthritis (RA) may reflect the presence of systemic, potentially lethal vasculitis. In an effort to better characterize this subset of patients with severe RA-associated corneal and/or scleral inflammation and to analyze the efficacy of therapy, we reviewed our experience in the medical and surgical management of 16 tertiary referral cases (25 eyes) unresponsive to aggressive conventional therapy with topical and systemic steroids as well as with systemic nonsteroidal drugs. Cytotoxic immunosuppressive therapy was instituted in all patients with NS and/or PUK. Cyclophosphamide and methotrexate were the most successful agents used. Cytotoxic immunosuppressive drugs in conjunction with early aggressive surgical treatment halted the relentlessly progressive inflammation and preserved the integrity of the globe in 92% of eyes. Visual acuity could be stabilized or improved in 83% of patients with NS and in 68% of patients with PUK.