Bernd Bertram

Retinal Capillary Blood Flow Measurement with a Scanning Laser Ophthalmoscope Preliminary Results

The scanning laser technique in combination with digital image analysis allows direct objective measurement of flow velocities in perimacular capillaries. In addition, the complete macular network of capillaries can be observed. By means of digital frame-to-frame picture analysis of digital recordings, blood flow velocities and morphologic data have been measured. The mean flow velocity in perimacular capillaries observed with the scanning laser ophthalmoscope in healthy subjects (n = 21) amounted to 3.28 +/- 0.45 mm/second. In patients (n = 13) with diabetes mellitus (no or background retinopathy), the mean flow velocity was significantly reduced (2.89 +/- 0.57 mm/seconds) compared with healthy subjects. Morphologic data of the perifoveal capillary bed showed a significant reduction of capillaries in patients with diabetes mellitus when compared with healthy subjects.

Hemodilution therapy in central retinal vein occlusion

Systemic hemorheologic abnormalities may play a part in the pathogenesis of central retinal vein occlusions. A statistically significant elevation of plasma viscosity was found in patients with acute central retinal vein occlusion compared with control patients. Local retinal blood flow parameters including arteriovenous passage time and mean arterial dye bolus velocity were significantly altered in the central retinal vein occlusion patients compared with age-matched controls at baseline examination. We performed a randomized, prospective, single-blind clinical investigation to determine the effect of hemorheological manipulation on the clinical course and retinal blood flow of eyes with central vein occlusion. Hemodilution included plasma expansion with hydroxyethyl-starch, withdrawal of whole blood if the hematocrit was above 42%, and rheologic manipulation with parenteral pentoxifylline. We found a statistically significant improvement in visual acuity at 1 year post-treatment for the treated group compared with the control group (increase of visual acuity of 1.5 lines vs decrease of 1.5 lines). The retinal blood flow parameters were markedly improved soon after the institution of therapy, and this may have contributed to the improvement in visual acuity in the treated group. There was no statistically significant difference between the two groups in the progression to ischemic central vein occlusion.

Perifoveal microcirculation with non-insulin-dependent diabetes mellitus

Fluorescein angiograms were performed to evaluate perifoveal capillary blood velocities (v), capillary density (perifoveal intercapillary areas: PIA) and the foveal avascular zone (FAZ) by means of the scanning laser technique (SLO-101 Rodenstock). The angiograms were digitally stored and the data quantified off-line with an image analyzing system (IBAS). In the present study 46 patients with non-insulin-dependent diabetes mellitus (NIDDM) were examined and their data compared with that of 31 healthy volunteers. The perifoveal capillary flow velocity of the NIDDM subjects (v = 2.33±0.36 mm/s) was significantly (P <0.01) decreased as compared to healthy subjects (v = 2.86 ±0.41 mm/s). The perifoveal intercapillary areas in the foveal avascular zone were significantly increased in patients with NIDDM (PIA=10029 ± 3402 μm2; FAZ = 0.415 ± 0.272 mm2) as compared with healthy subjects (PIA = 3965 ± 467 μm2; FAZ=0.221 ± 0.071 mm2). These data suggest the possibility that a decrease in perifoveal capillary blood velocities in combination with decreased capillary density (enlarged PIA) and an enlargement of the foveal avascular zone may occur in patients with NIDDM. The determination of these parameters could help in monitoring the progress of diabetic retinopathy and diabetic maculopathy.

RETINAL BLOOD FLOW IN DIABETIC CHILDREN AND ADOLESCENTS

A total of 209 diabetic children and adolescents aged 6–17 years (mean, 12.6 ± 2.3 years) were examined by ophthalmoscopy, video fluorescein angiography and hemoglobin (HbA1c) tests. Microaneurysms were found in 26% of the children (ophthalmoscopy, 11%; angiography, 23%). The prevalence of retinopathy was 16% in patients aged 6–10 years, 27% in those aged 11–13 years and 36% in those aged 14–17 years. Only five diabetics aged 11–17 years showed lesions other than microaneurysms (hard exudates, intraretinal hemorrhages or retinal capillar leakage). Retinal blood flow was quantified using video fluorescein angiography. The arm-retina time (ART) and the arteriovenous passage time (AVP) as parameters of the retinal microcirculation were obtained using an image analysing system. The mean value for ART was 9.7±2.5 s and that for AVP was 1.43±0.52 s. AVP was significantly shorter in diabetic children and adolescents with good glycemic control (HbAlc, <7%; AVP, 1.35±0.44 s) than in those with bad glycemic control (HbA1c, ≥ 9 % ; AVP, 1.65 ±0.51 s).

Blood rheology and retinopathy in adult type I diabetes mellitus

Rheological parameters (hematocrit, plasma viscosity and red blood cell aggregation index), glycosylated hemoglobin (HbAlc) and retinal arteriovenous passagetime (A vP) were measured in 93 patients with type I diabetes. The stage of diabetic retinopathy was graded by means of ophthalmoscopy and video fluorescein angiography. The mean values of hematocrit (men 46 ± 4%, women 43 ± 3 %), RBC aggregation index (13,8 ± 3,8, normals: 14,6 ± 3,2) were equal to normals. Plasma viscosity (1,33 ± 0,09 mPas, normais:l,24 ± 0,05 mPas) was increased. The groups with increasing stage of diabetic retinopathy showed no difference in hematocrit, RBC aggregation and HbAlc and an increase of plasma viscosity. In patients with bad glycemic control plasma viscosity was increased and RBC aggregation index was similar as compared with patients with good glycemic control. If retinal arteriovenous passagetime was worse plasma viscosity and RBC aggregation were more increased. This indicates, that alterated plasma viscosity and RBC aggregation may be one of the reasons for disturbed microcirculation and fundus changes ill diabetic retinopathy.

Morphologic changes of the macula in a patient with Purtscher's retinopathy

Purtschers retinopathy is a rare complication after trauma to the chest or bone fractures. We report about a patient, which we examined 6 months after a serious car accident. Visual acuity was 20/20 in both eyes. Examination with the Amsler grid revealed a paracentral scotoma in the left eye. In the fluorescein angiography of the left eye performed with a scanning laser ophthalmoscope we found capillary dropout, which corresponded well to the scotoma. Measured by digital image analysis, the area of the foveal avascular zone was eccentrically enlarged by a factor of 4. The mean perifoveal intercapillary area was also enlarged in the corresponding quadrant. This reflects that focal capillary dropout may result in scotoma rather than in a decrease in visual acuity as reported in other diseases.

Long term results after hemodilution therapy in central retinal vein occlusion

Systemic hemorheologic abnormalities may playa role in the pathogenesis of central retinal vein occlusions. A statistically significant elevation of plasma viscosity was found in patients with acute central retinal vein occlusion compared with control patients. Local retinal blood flow parameters including arteriovenous passage time and mean arterial dye bolus velocity were significantly altered in the central retinal vein occlusion patients versus age matched controls at baseline examination.We performed a randomized, prospective, single-blind clinical investigation to determine the effect of hemorheological manipulation on the clinical course and retinal blood flow of eyes with central vein occlusion. Hemodilution included plasma expansion with hydroxyethyl-starch, withdrawal of whole blood if the hematocrit was above 42%, and rheologic manipulation with parenteral pentoxifylline_ We found a statistically significant improvement in visual acuity at the last follow-up visit 36 months post-treatment for the treated group compared with the control group. The retinal blood flow parameters were markedly improved soon after the institution of therapy and may have contributed to the improved visual prognosis in the treated patient group.