Agnes Derbolav

Is there a correlation between the severity of diabetic retinopathy and keratoconjunctivitis sicca

Purpose. Patients with diabetic retinopathy (DRP) seldom report symptoms of ocular surface irritation, but evaluations of dryness are pathologic. This study was designed to evaluate the correlation between the severity of DRP and dry eyes. Methods. We included 144 eyes of 72 patients. Severity of retinopathy was graded according to the Early Treatment Diabetic Retinopathy Study. The examinations for dry eyes included Schirmers test, break-up time, lipid layer thickness, fluorescein and rose bengal staining of the cornea, impression cytology, and a questionnaire. A sicca severity score was calculated using a point system of the results of these tests. Patients were divided into three groups: postpanretinal laser coagulation (PPL), postcentral laser coagulation (PCL), and those with no laser treatment (0-L). For statistics, we used the correlation coefficient to determine relationships and the unpaired Student t test for statistical difference. Results. The correlation (c) of keratoconjunctivitis sicca (KCS) and DRP after laser treatment was c = 0.24 and after central laser treatment was c = 0.22; the correlation without laser treatment was 0.54. The best correlation is 1 or −1, the worst was 0. The score of those patients with mild to moderate retinopathy was compared to that of patients with severe to proliferative disease. There was a significant statistical difference in the sicca severity score between both groups, (p < 0.006, Student t test). Conclusion. KCS represents another manifestation of diabetes mellitus and its severity—measured by a many-membered score—correlates with the severity of the DRP.

Long-term effect of phacoemulsification on intraocular pressure after trabeculectomy.

Purpose: To evaluate the effect of temporal clear corneal phacoemulsification on intraocular pressure (IOP) in eyes that have had trabeculectomy. Setting: Department of Ophthalmology, University of Vienna, Vienna, Austria. Methods: This retrospective study evaluated the IOP in 48 eyes (35 patients) that had temporal clear corneal phacoemulsification after trabeculectomy. The mean interval between trabeculectomy and phacoemulsification was 27 months ± 21 (SD) and the mean follow‐up after phacoemulsification, 23 ± 12 months. Intraocular pressure and antiglaucoma therapy before cataract surgery and at the end of follow‐up were evaluated. For statistical analysis, the paired t test, Wilcoxon test, and chi‐square test were used. Results: Thirty‐five eyes (73%) preoperatively and 25 eyes (52%) postoperatively were controlled (IOP < 22 mm Hg) without antiglaucoma therapy. The difference was statistically significant (P = .04, chi‐square test). At the end of follow‐up, the increase in mean IOP (1.6 mm Hg) and in mean number of antiglaucoma medications (0.4) was statistically significant (P = .002 and P = .05, respectively). Conclusions: Temporal clear corneal phacoemulsification after trabeculectomy was followed by a slight but statistically significant increase in IOP and the need for antiglaucoma medication after 2 years. However, the impairment in IOP control is comparable to that in the natural course of trabeculectomy.

The clinical use of viscoelastic artificial tears and sodium chloride in dry-eye syndrome.

This study was performed to test viscoelastic artificial tears (VAT) based on both subjective and clinical parameters in patients with keratoconjunctivitis sicca (KCS). Twenty-eight patients were evaluated in a randomized double-blind study. Sodium hyaluronate was used in two different concentrations (0.4%, 0.25%) and in combination with chondroitin sulfate. Each preparation was used for one week preceded by another weekly cycle using a sodium chloride solution. Before and after each cycle, clinical examinations were performed: tear film break-up time, Schirmers test, lipid-layer thickness and fluorescein staining. Patients kept a record of the drop-frequency, subjective response and side effects. After the study, they were asked to give a rating of the various preparations. The severity of KCS was expressed based on a sicca score and correlated with response to viscoelastic treatment. Both the subjective and the clinical parameters revealed no statistically significant differences between the various viscoelastic agents or between the viscoelastics and the sodium chloride solutions. Severe side effects did not occur. There was a positive correlation of response to viscoelastic treatment with severe KCS (+ 0.36) but not with mild KCS (-0.07). The VAT seems to be indicated in severe cases of dry-eye syndrome. Sodium chloride solutions may be a useful short-term alternative to other tear formulations.

Inflammation after phacoemulsification in diabetic retinopathy: Foldable acrylic versus heparin-surface-modified poly(methyl methacrylate) intraocular lenses

Purpose: To evaluate inflammation after cataract surgery in patients with nonproliferative diabetic retinopathy (NPDR) and compare results with 2 intraocular lenses (IOLs): a foldable hydrophobic acrylic and a heparin‐surface‐modified (HSM) poly(methyl methacrylate) (PMMA). Setting: Department of Ophthalmology, University of Vienna, Vienna, Austria. Methods: Patients with NPDR were randomized for implantation of an HSM PMMA IOL (811C®, Pharmacia) through a 6.0 mm sclerocorneal incision (30 patients) or a foldable hydrophobic acrylic IOL (AcrySof®, Alcon) through a 4.0 mm sclerocorneal incision (32 patients). Both IOLs had 6.0 mm optics. All patients were treated according to a standardized protocol. The degree of flare in the anterior chamber was measured with the Kowa 1000 laser flare–cell meter 1 day preoperatively and 1 day, 1 week, and 1 and 3 months postoperatively. Results: In both IOL groups, flare was highest on the first postoperative day and decreased to preoperative levels by 3 months after surgery. There was no statistically significant difference in relative flare values between the 2 groups. Conclusion: There was no difference in postoperative inflammation in eyes with a foldable hydrophobic acrylic IOL implanted through a small incision and those with a rigid HSM PMMA IOL. Postoperative inflammation results indicate that the lenses are equally suitable for the use in patients with diabetic retinopathy.

Einfluß systemischer Faktoren auf die postoperative Visusentwicklung nach Vitrektomie und Silikonöl bei traktiver diabetischer Makulaabhebung

ZusammenfassungRetrospektiv wurden 28 Augen, die aufgrund anamnestisch 2–3 Monate bestehender traktiver Makulaabhebung infolge einer proliferativen diabetischen Retinopathie einer Vitrektomie und Silikonölauffüllung unterzogen worden waren, hinsichtlich ihrer funktionellen Ergebnisse untersucht. Die Anzahl allgemeiner Risikofaktoren wie erhöhter Nüchternblutzucker, HbA1c, Hypertonie, periphere arterielle Verschlußkrankheit, Koronarerkrankung, Neuropathie, Nephropathie, Operation in Allgemeinanästhesie, Apoplexie und Hypercholesterinämie wurden summiert.In 32% der Augen kam es zu einem signifikanten Visusanstieg, während in 68% der Augen keine signifikante Verbesserung oder ein Absinken des Visus beobachtet wurde. Der Vergleich der Anzahl der erhobenen Risikofaktoren ergab im student’s t-test eine signifkant höhere Anzahl systemischer Risikofaktoren in der Gruppe mit gleichem oder schlechterem Visus (p = 0,0470).Eine höhere Anzahl an systemischen Risikofaktoren verschlechtert die Prognose der vitreoretinalen Chirurgie bei traktiver diabetischer Makulaabhebung hinsichtlich ihrer funktionellen Ergebnisse. Diesem Umstand ist bei der Aufklärung des Patienten Rechnung zu tragen.SummaryWe analysed retrospectively the functional results of 28 eyes with proliferative diabetic retinopathy operated on with vitrectomy and silicone oil implantation because of tractional retinal detachment involving the macula. We summed up the number of systemic risk factors such as fasting blood glucose, HbA1c, essential hypertension, peripheral vascular occlusion disease, coronar disease, neuropathy, nephropathy, surgery in general anesthesia, apoplectic fit and hypercholesteraemia.Visual acuity improved significantly in 32% of the eyes. In 68% of the eyes visual acuity was unchanged or decreased. The second group had a significant higher number of systemic risk factors compared to the first group in the student’s t-test (p=0,0470).A higher number of systemic risk factors worsens the prognosis of functional outcome in vitreoretinal surgery in eyes with tractional macular detachment. This circumstance should influence the patient’s preoperative information.

Orale Ganciclovirtherapie bei makulärer CMV-Retinitis

ZusammenfassungEs wird der Einsatz von oralem Ganciclovir als Erhaltungstherapie bei Cytomegalovirus (CMV)-retinitis im Bereich des hinteren Pols diskutiert. Wir berichten über einen 42 Jahre alten HIV-positiven Patienten mit einem makulären CMV-Herd. Nach der intravenösen Induktionstherapie mit Ganciclovir erhielt der Patient eine orale Erhaltungstherapie mit Ganciclovir. Nach 50 Tagen kam es trotz nur minimaler Aktivitätszeichen zu einer Progression des zentralen Herdes mit massivem Visusabfall.Unsere ersten Erfahrungen mit dem Einsatz von oralem Ganciclovir sprechen gegen die Verwendung von oralem Ganciclovir als Erhaltungstherapie bei CMV-Herden nahe der Fovea, bzw. des Sehnerven, da bei CMV-Herden nahe der Fovea und des Optikus schon eine geringe Progression einen massiven Visusabfall bedeutet.SummaryWe herein discuss the use of oral ganciclovir for the maintenance-treatment of macular cytomegalovirus (CMV)-lesions. A 42 years old patient with acquired immunodeficiency syndrome (AIDS) with a CMV-retinitis close to the fovea is presented. After induction therapy with intravenous ganciclovir the patient was treated with oral ganciclovir maintenance therapy. After 50 days of oral ganciclovir therapy CMV-retinitis progressed without signs of active borders, causing a severe loss of visual acuity. With oral ganciclovir maintenance therapy progression of retinitis might be more difficult to detect. Therefore oral ganciclovir may not be appropriate for the treatment of lesions at the posterior pole, where minimal degree of progression may have major visual consequences.

Keim- und Resistenzspektrum der reizfreien Konjunktiva bei Patienten mit diabetischer Retinopathie

ZusammenfassungDie Zielstellung dieser prospektiven Pilotstudie war die Bestimmung von Keimarten auf reizfreier Bindehaut beim Diabetiker mit diabetischer Retinopathie und anderen diabetischen Spätfolgen.Bei 37 Patienten mit Diabetes mellitus und diabetischen Spätfolgen wurden zwei Bindehautabstriche ohne Berührung des Lidrandes und Tränenpünktchens aus den unteren Fornices auf Transwab-Transportmedium gewonnen und binnen 24 Stunden auf entsprechende Anreicherungsmedien aufgetragen und kultiviert. Die Kulturen wurden auf aerobe und anaerobe Bakterien sowie Pilze untersucht.In 29 (78,4%) der Patientenproben konnten Bakterien gezüchtet werden; am häufigsten wurden koagulasenegative Staphylokokken (n = 22; 61,1%), gefolgt von anderen grampositiven Kokken (n = 10; 27,8%), gramnegativen Stäbchen (n = 3; 8,3%) und grampositiven Stäbchen (n=l; 2,8%) nachgewiesen. Die angezüchteten Keime, außer koagulasenegativen Staphylokokken, waren gegenüber Gentamicin und Tobramycin in 7% mäßig empfindlich und in 50% der Fälle resistent. Die Resistenztestung der grampositiven Bakterien zeigte die höchste Empfindlichkeit für Bacitracin (Resistenz wiesen lediglich 9% der Mikroorganismen auf), gefolgt von Chloramphenical* und Ofloxacin** (jeweils 9% resistenter Stämme sowie *9%, bzw. **36% mäßig empfindlich).Unsere Erstergebnisse deuten darauf hin, daß beim Diabetiker mit diabetischen Spätfolgen in etwa einem Drittel der Fälle pathogene oder fakultativ pathogene auf der reizfreien Bindehaut zu erwarten sind. Das relative Risiko des Vorkommens der pathogenen oder fakultativ pathogenen Keime liegt für Diabetiker mit Insulintherapie signifikant höher (exakter Cochran-Armitage Permutations-Trend-Test, p = 0,0418) als für Diabetiker mit oraler Therapie. Diese Tatsachen können eine Bedeutung für die Prävention postchirurgischer Infektionen beim Diabetiker haben.SummaryThe purpose of this prospective pilot study was to investigate the bacterial flora of non-irritated conjunctiva in diabetics with diabetic retinopathy and other late diabetic disorders.Two conjunctival smears were obtained by passing a dry culturette swab gently over the lower conjunctival fornices without touching the lower lid margin and lacrimal point from each of both eyes of 37 patients with diabetes mellitus and late diabetic disorders. The culturette swabs were brought in Transwab-transport medium and within 24 hours streaked on appropriate media. The cultures were subjected to identification for aerobic and anaerobic bacteria and fungi. Bacteria were isolated in 29 specimens (78.4%): the most frequently cultured bacteria were coagulase-negative staphylococci, occurring in 22 cases (61.1%), followed by other gram-positive cocci (10 cases; 27.8%), gram-negative rods (3 cases; 8.3%) and gram-positive rods (1 case; 2.8%). The isolated organisms except of coagulase-negative staphylococci were resistant in 50% and only intermediate sensitive in 7% of tested bacteria for Gentamicin and Tobramycin. The gram-positive bacteria were the most sensitive to Bacitracin (micro-organisms were found to be resistant in only 9%), followed by Chloramphenicol* and Ofloxacin** (resistance in 9% and intermediate sensitivity in *9% respectively in **36%).Our results indicate the occurrence of pathogenic or facultative pathogenic bacteria on the surface of the non-irritated conjunctiva in approximately one third of diabetics with late diabetic disorders. In addition, the presence of pathogenic or facultative pathogenic bacteria was found to be significantly higher in insulin treated than in orally treated diabetics (exact Cochran-Armitage permutation trend test, p = 0.0418). These findings could be important for the prevention of postsurgical infection in diabetics.

Candida-Endophthalmitis bei intravenösem Heroinabusus-Problematik bei Diagnose und Therapie

ZusammenfassungEine 22jährige Patientin zeigte nach intravenösem Heroinabusus das klinische Bild einer Candida-Endophthalmitis, obwohl die Blutkulturen, die Antigen- und Antikörperbestimmungen auf keine Infektion mit diesem Erreger hinwiesen.Eine intravenöse Fluconazoltherapie führte zu keiner Besserung der Symptome. Erst die Vitrektomie ermöglichte den Nachweis eines Candida albicans-Stammes, welcher gegen Fluconazol relativ resistent war.Die intravenöse- und intravitreale Therapie mit Amphotericin B führte zur vollständigen Abheilung der retinalen Läsionen.Bei Candida-Endophthalmitis und Heroinabusus bietet die Antigen- und Antikörperbestimmung meist keine Hilfe zur Diagnosestellung und Verlaufskontrolle. Wenn das klinische Bild primär unklar ist oder der Therapieeffekt ungenügend ist, so ist die frühe Indikation zur Vitrektomie zu stellen.SummaryA 22 year old patient presented with the clinical picture of Candida endophthalmitis after intravenous heroinabuse. Blood-cultures, antigens and antibodies of Candida albicans were negative.An intravenous fluconazole-therapy did not lead to any improvement of symptoms. Just vitrectomy and vitreous examinations proved the evidence of Candida albicans, which was relatively resistant to fluconazole.The intravenous- and intravitreal therapy with amphotericin B led to a complete scarring of the retinal lesions.In the case of Candida endophthalmitis and heroinabuse the antigen and antibody analysis offers almost no support to diagnosis and control of process. Early vitrectomy is indicated, if the clinical picture primary is unclear or if the efficiency of therapy is insufficient.