Andreas Kuchar

Long term results after surgical basal cell carcinoma excision in the eyelid region

AIMS To evaluate the data for patients with basal cell carcinoma (BCC) in the eyelid region, to demonstrate histologically controlled tumour excision, and to prove the efficacy of the treatment on the basis of long term observations. METHODS Retrospective analysis of 382 microscopically controlled BCC excisions in the eyelid apparatus (350 patients) in a follow up study over 5.7 (SD 1.1) years. Tumour location, tumour size, and histological results were recorded. The same procedure was followed for recurrences. Follow up examinations were carried out 1, 3, 6, and 12 months after the operation, and then annually for a further 4 years or longer. RESULTS A recurrence rate of 5.36% was observed after the primary operation. 60.3% of first recurrences occurred in the medial canthus, 41.2% showed in depth extension, and sclerosing types were overly represented at 35.3%. After the second operation the recurrence rate increased to 14.7% and reached 50% after a third and fourth operation. CONCLUSIONS The greatest risk of recurrence exists for BCCs of the medial canthus with in depth extension, and for sclerosing types. The recurrence rate increases after every operation. For high risk cases, consideration should be given to adjuvant treatment such as radiotherapy.

Endoscopic laser recanalisation of presaccal canalicular obstruction

AIM To document the results of erbium (Er)-YAG laser treatment in presaccal canalicular obstruction in combination with the use of a flexible endoscope. METHODS For the first time an Er-YAG laser (Schwind, Sklerostom) was attached to a flexible endoscope (Schwind, Endognost) and used to recanalise a stenosis of the upper, lower, or common canaliculus. In 17 patients (mean age 41.5 (SD 11.9) years), 19 treatments (two bilateral) were performed. In all cases the scar was observed using the endoscope and was excised by laser ablation. A silicone intubation was performed in all cases. In addition to the endoscopy an irrigation was performed to prove the intactness of the lacrimal pathway system after laser treatment. RESULTS Membranous obstructions with a maximum length of 2.0 mm (14 procedures) in the canaliculus were opened easily using the laser, and the silicone intubation was subsequently performed without difficulty. Scars thicker than 2.0 mm could not be opened safely without canaliculus penetration (five procedures). Irrigation was positive in all cases up to the end of a 6 month period, providing the tubes remained in place. The maximum follow up is now 17 months (minimum 8 months) and in 16 cases (84.2%) the canaliculi are still intact. CONCLUSION Endoscopic laser treatment combined with silicone intubation enables us to recanalise presaccal stenoses of canaliculi under local anaesthesia up to a scar thickness of 2.0 mm. Best results can be achieved in cases where much tissue can be saved. Under such conditions this procedure can substitute for more invasive surgical techniques, especially a conjunctivo-dacryocystorhinostomy (CDCR).

Circulating ICAM-1 levels in serum of uveitis patients

Intercellular Adhesion Molecule-1 (ICAM-1) is a cytokine-inducible adhesion molecule expressed on cells of multiple lineages at sites of inflammation. Recently a truncated form of ICAM-1 has been discovered to be circulating in serum. This study reports on circulating serum (cICAM-1) levels in 132 uveitis patients (HLA-B 27 pos. acute anterior uveitis (AAU); HLA-B27 neg. anterior uveitis (AU); intermediate uveitis (IU); heterochromic cyclitis Fuchs (HCF); sarcoidosis; Toxoplasmosis). Measurement of circulating ICAM-1 serum levels was performed using a monoclonal antibody based ELISA, with healthy blood donors serving as the control group. Applying multiple variance analysis and the Student Newmann-Keuls test we found a statistically significant elevation of serum cICAM-1 level in the HLA-B 27 neg. AU group (n:31), in the IU group (n:25) and in patients with sarcoidosis (n:18). Serum levels of HLA-B27 pos. AAU patients, patients with HCF and patients suffering from ocular toxoplasmosis did not differ significantly from levels of the control group.

Retrograde Dilation of Postsaccal Lacrimal Stenosis

The causes of nasolacrimal duct stenosis in adults can vary greatly. In general, the symptoms can also vary, but most cases share a tendency toward recurring inflammations in the prestenotic area. The treatment of these disorders is limited to either conservative therapy to control inflammation or surgically invasive measures. By using balloon catheters, usually applied in percutaneous transluminal coronary angioplasty (PTCA), dilation of the relative postsaccal stenosis can be performed under radiographic control. An exact diagnosis using various testing methods, including digital dacryocystography for detailed localization and documentation of any pathologic changes, is decisive to success. Only in cases of incomplete postsaccal stenosis is retrograde balloon dilation of the distal nasolacrimal duct indicated. A guide wire, designed for the PTCA balloon catheter set, is introduced via the canaliculus to the nasal cavity antegradely and caught with a thin hook and pulled from the naris, under visual control with an image converter. The balloon catheter is retrogradely threaded over the guide wire. The balloon is then placed at the site of the pathologic stenosis under radiographic control and dilated with high pressure. To ensure the permeability of the system, monocanalicular silicone intubation has to be performed immediately afterwards. This procedure has been performed successfully on 6 patients with a follow-up of 6 to 27 months. These initial results give rise to the hope that this minimally invasive, interdisciplinary technique represents a new alternative in the treatment of incomplete postsaccal lacrimal stenosis.

Die Endoskopie der ableitenden Tränen wege

ZusammenfassungIn der Diagnostik der ableitenden Tränenwege läßt die digitale Dacryocystographie die exaktesten Ergebnisse erwarten. In Kombination mit Videodokumentation kann der Kontrastmittelfüllungsvorgang reproduzierbar gespeichert werden. In ganz bestimmten Fällen kann an die Untersuchung der Tränenwege dann sofort im gleichen Raum eine Dilatation der postsaccalen Passage angeschlossen werden. Der größte Nachteil dieser Untersuchungsmethode liegt in der Aufwendigkeit des Systems und der Abhängigkeit von einer Angiographieeinheit.Seit kurzer Zeit gibt es eine neue Untersuchungstechnik der ableitenden Tränenwege. Durch Miniaturisierung der endoskopischen Geräte und Neuentwicklungen im Bereich der Fiberoptiken ist es möglich geworden, diese Miniendoskope in die Canaliculi antegrad einzuführen und so Canaliculi, Tränensack und Ductus nasolacrimalis zu untersuchen.Bei axialer Ausleuchtung des Lumen können sehr gute Darstellungen erzielt werden. Im Bereich von Biegungen und Knickstellen läßt die Qualität der Abbildung noch zu wünschen übrig. Anhand von Videobeispielen wird die Möglichkeit der Diagnostik demonstriert, und gleichzeitig werden Verbesserungen durch Weiterentwicklung skizziert.SummaryAt the moment digital dacryocystography yields the most exact results in lacrimal diagnostics.The main disadvantage lies in the dependancy of high tech X-ray system and an angiography unit.Recently a new diagnostic system of the lacrimal pathways is available. Miniaturizing of endoscopes and new developments in the fiberoptic technology made it possible to induce these miniendoscopes into the canaliculi and perform antegrade examination of canaliculi, lacrimal sac and ductus nasolacrimalis. In case of axial illumination good visibility can be achieved. In narrow areas and areas of bendings the quality is reduced by hyperreflection.

Influence of laser in situ keratomileusis and laser epithelial keratectomy on patients' reading performance

PURPOSE: To evaluate the influence of laser in situ keratomileusis (LASIK) and laser‐assisted subepithelial keratectomy (LASEK) on reading performance regarding reading acuity, reading speed based on print size, maximum reading speed, and critical print size. SETTING: Department of Ophthalmology, University of Vienna, Vienna, and Auge‐und‐Laser, Medicent Baden, Austria. METHODS: Fifty‐two eyes of 34 patients (26 eyes per group) were studied. Best corrected LogMAR visual acuity (Early Treatment Diabetic Retinopathy Study charts), reading acuity, and reading speed were tested monocularly before LASIK or LASEK and 3 weeks after surgery. Reading acuity (LogRAD) and reading speed were determined with the standardized Radner reading charts. RESULTS: Preoperatively, the distance visual acuity and reading acuity were comparable between the LASIK and LASEK patients. Reading speed measurements also showed no statistical difference. Three weeks after refractive surgery, no statistically significant differences in the preoperative measures and between the 2 surgical procedures could be found in any tested parameters. The mean distance visual acuity was LogMAR −0.02 ± 0.06 (SD) (LASIK) and LogMAR −0.05 ± 0.07 (LASEK). The mean reading acuity was LogRAD 0.00 ± 0.12 (97.7% of LogMAR) (LASIK) and LogRAD 0.04 ± 0.16 (93.7% of LogMAR) (LASEK). The mean maximum reading speed was 235 ± 35 words per minute (LASIK) and 240 ± 37 words per minute (LASEK), and the mean critical print size was at LogRAD 0.48 ± 0.19 (LASIK) and 0.49 ± 0.17 (LASEK). CONCLUSIONS: In a standardized reading test setting, no significant effects of LASIK and LASEK on individual reading performance could be evaluated. This indicates that patients can expect to retain their normal visual function after refractive surgery with these 2 procedures under full light conditions.

The treatment of congenital nasolacrimal duct obstruction: Primary sufficient therapy avoids chronic inflammation or dacryocystorhinostomy

The persistence of Hasners membrane, a thin fragile duplicate of the mucous lining at the end of the nasolacrimal duct, represents the most common cause of congenital dacryostenosis. If the tear flow is blocked tears gather in the lacrimal sac, ultimately resulting in an overflow of this system. Inspissation and bacterial (staphylococcal) invasion of the sac contents lead to infection of the lacrimal sac.In more than 90% of the newborns, Hasners membrane perforates spontaneously during the first four to six weeks, in the other children opening is still possible six to 12 months after birth. Based on this knowledge the first step of treatment must be conservative therapy, which is successful in a high percentage of cases: after microbiological examination the application of detumescent and specific antibiotic eyedrops is coupled with digital massage of the lacrimal sac area. If this does not achieve definitive success high pressure syringing according to Bangerter is necessary.In those cases where irriga...

Indikation zur perioperativen Behandlung des spastischen Entropiums mit Botulinum Toxin-A

ZusammenfassungIn jenen Fällen von Blepharospasmus, bei denen eine reduzierte Funktion der Lidretraktoren vorhanden ist, kann es durch Überwiegen der muskulären Spasmuskomponente zur Ausbildung eines Entropiums vor allem des Unterlides kommen.Die begleitende Trichiasis führt zu einem zusätzlichen Schmerzreiz, welcher per se den Blepharospasmus neuerlich verstärken kann.Die Behandlung des Blepharospasmus wird mit Botulinum Toxin-A durchgeführt, die Korrektur des zusätzlich auftretenden, spastischen Entropiums wird chirurgisch vorgenommen, wobei diese Patienten präoperativ mit Botulinum behandelt werden. Eine Woche vor der Operation wird an den gewünschten Stellen, die vom Hersteller empfohlene Dosis subkutan injiziert, sodaß zum Operationstermin die Spasmus reduzierende Wirkung bereits vorhanden ist. Die in Lokalanästhesie durchgeführte Operation wird dadurch wesentlich besser dosierbar und insgesamt erleichtert. In der postoperativen Phase kommt es aufgrund der Botulinumwirkung zu einem Verschwinden der Symptomatik oder zumindest zu einer deutlichen Besserung des Blepharospasmus, wodurch die Heilung begünstigt wird. In gleicher Weise wird die Elongation der Lidretraktoren in dieser wichtigen Phase hintangehalten.Die Technik und die Ergebnisse dieser neuen, kombinierten Behandlung werden beschrieben.SummaryIn these cases of blepharospasm with reduced function of the lid retractors an entropium, especially for the lower eye lid can be intensified by muscular spasm. The following trichiasis leads to an additional stimulus, which reinforces the blepharospasm too.The blepharospasm will be treated by Botulinum toxin-A, the correction of the entropium has to be done surgically. The recommended dosis by the manufacteur will be applied subcutaneously at the lower and upper eye lid one week before the surgical correction, so that the spasm will be reduced at surgery. Then surgery can be made in local anesthesia more easier and the correction will be more efficient.There will be no spasm or at least a distinct reduction due to the treatment with botulinum, which favours the post-operative healing. In the same way the elongation of the lid retractors will be stopped in this phase.The technique and the results of this new, combined treatment will be described.

Tränenwegschirurgie im Wandel der Zeit

ZusammenfassungDie Tränenwegschirurgie ist eine der ersten chirurgischen Behandlungen überhaupt, die sich nach historischen Quellen nachweisen lässt.Im folgenden Artikel wird ein Rückblick auf diese Methoden, beginnend 2250 Jahre vor Chr. bis zu den heutigen, modernen Methoden gegeben.Indikationsstellung, Methoden und Behandlungsstrategien werden aufgezeigt.SummaryLacrimal surgery is one of the earliest surgical methods which have been performed according to historical sources.This article should present a review of these first surgical attempts starting 2250 years a.Chr. and demonstrate the modern principles of indication, surgical techniques and strategies of lacrimal surgery.

Leitlinien der Kommission für Okuloplastik (Orbita + Dakryologie) der ÖOG

ZusammenfassungDie Leitlinien der Kommission für Okuloplastik (Orbita + Dakryologie) sollen einen systematischen Überblick über konservatives und chirurgisches Management von Lid-, Orbita-, und Tränenwegserkrankungen geben. Lidfehlstellungen sowie Tumoren der Lider und der Orbita werden klassifiziert und diagnostische Verfahren und Therapieformen der Lid-, Orbita-, und Tränenwegschirurgie werden dargestellt. Außerdem wird ein Überblick über die ästhetische Lidchirurgie und die Indikationen dafür gegeben, und die konservative und chirurgische Therapie der Endokrinen Orbitopathie beschrieben. Ein abschließendes Kapitel informiert über die aktuellen Therapiemöglichkeiten beim Trockenen Auge.SummaryThe guidelines of the committee for oculoplastic surgery offer a systematic overview of conservative and surgical methods in eyelid-, orbital-, and lacrimal surgery. Malpositions of the eyelid, eyelid tumors and orbital tumors are classified and methods of diagnosis and therapy in eyelid orbital surgery and lacrimal surgery are illustrated. Furthermore a review of aesthetic eyelid surgery and the conservative and surgical approach to graves orbitopathy is given. A concluding chapter will give information to current therapy options in dry eye disease.