Bernhard Gabler

Hypopyon after repeated transplantation of human amniotic membrane onto the corneal surface

OBJECTIVE The authors describe a localized probable immunoreaction after repeated transplantation of amniotic membrane (AM) onto the corneal surface. DESIGN Interventional case report. INTERVENTION Amniotic membrane was transplanted onto the corneal surface of a 78-year-old female with a deep trophic corneal ulcer resulting in temporary epithelial closure. A second and finally third amniotic membrane transplantation (AMT) was performed because of recurrent ulcerations. All three AMs were obtained from the same donor. RESULTS The first transplantation of the AM was without complication. However, a hypopyon developed 2 days after the second and 2 days after the third AMT, but the patient responded immediately to topical and systemic corticosteroids. CONCLUSIONS Immunologic, toxic, and hypersensitivity effects could have contributed to the hypopyon iritis that appeared after the second and third AMT, but not after the initial transplantation. In case of a repeated AMT, the use of AM from different donors may help to minimize the risk of an immediate postoperative intraocular inflammation.

Wavefront-guided Laser Epithelial Keratomileusis With the WaveLight Concept System 500

PURPOSE Laser epithelial keratomileusis (LASEK) is a technique of refractive surgery for treatment of myopia. More than 90% of patients are within the intended correction of +/-0.50 diopters (D), without any unwanted side effects. After conventional refractive surgery, higher-order aberrations are induced. To reduce these aberrations, we used wavefront-guided ablation. METHODS Twenty patients with visual problems in ambient light were included. The primary surgery was 141 to 463 days before the retreatment. LASEK was performed with the Camellin technique with 20% EtOH for 30 seconds. Before surgery, the root mean square (RMS) values were measured and the laser treatment was performed with the WaveLight Concept System 500 (WaveLight Laser Technologie AG). The preoperative spherical equivalent refraction was -1.22 D (SD 0.57 D) and the astigmatism was -0.42 D (SD 0.25 D). Preoperatively and 6 months postoperatively, a comprehensive examination was performed. RESULTS All retreatments were performed without any intra- or postoperative complications. All patients reported an improvement of vision. The 6-month postoperative refraction was 0.25 D (SD 0.36 D). RMS decreased significantly from 0.72 to 0.47. RMS fourth order also decreased significantly from 0.60 to 0.30 and the spherical aberration decreased significantly from 0.57 to 0.28. CONCLUSIONS In earlier studies, patients reported reduction of contrast vision, even after resurgery. Our patients showed a significant reduction of higher-order aberrations and better contrast vision after retreatment with wavefront guided LASEK. Retreatment with wavefront-guided LASEK has the potential to correct night vision problems after excimer laser surgery.

Laser-assisted subepithelial keratectomy enhancement of residual myopia after primary myopic LASEK: six-month results in 10 eyes

Purpose: To determine whether residual myopia after primary laser‐assisted subepithelial keratectomy (LASEK) can be corrected by repeated LASEK and whether this procedure is safe and effective. Setting: University Eye Clinic, University of Regensburg, Regensburg, Germany. Methods: Laser‐assisted subepithelial keratectomy was performed in 10 eyes that had had primary LASEK for myopia. The initial mean spherical equivalent (SE) was −6.2 diopters (D) (range −2.5 to −8.0 D), and the residual mean SE was −1.6 D (range −1.0 to −3.0 D). The retreatment ratio was 7.6%. The exposure time of the corneal epithelium to alcohol (20% ethanol) was 30 seconds plus an additional 10 to 15 seconds in cases of strong epithelial adherence. Laser ablation was performed with a Keracor 117 excimer laser (Chiron Technolas). The follow‐up after the second LASEK treatment was 6 months. Results: The epithelial flap for repeated LASEK was successfully created in all 10 eyes. The postoperative course in the eyes was uneventful. Six months after LASEK enhancement, the SE refraction was within ±0.5 D in all eyes. No eye lost more than 1 line of best corrected visual acuity, and the uncorrected visual acuity was 20/20 or better in 8 eyes. Significant haze was not observed after repeated LASEK (mean 0.35 before and 6 months after LASEK enhancement). Conclusions: Laser‐assisted subepithelial keratectomy enhancement appears to be safe and effective for the correction of residual myopia after primary LASEK. Repeated epithelial flap preparation is possible without technical modifications.

[Tolerance of a new calcium-alginate-insert for controlled medication therapy of the eye]

ZusammenfassungHintergrundBei der medikamentösen Therapie vieler Erkrankungen der Augenoberfläche ist ein konstanter Wirkstoffspiegel über eine längere Zeit erforderlich. Dies ist durch konventionelle Augentropfen häufig nicht gewährleistet. Aus diesem Grund wurde in Form eines Kalzium-Alginat-Insertes mit Hydroxyethylcellulose (HEC)-Zusatz ein neuartiges System mit kontrollierter Freisetzung zur Applikation in den Bindehautsack entwickelt. Ziel der Studie war die Untersuchung der Verträglichkeit dieses Insertes.Methode24 gesunde Probanden erhielten nach eingehender Untersuchung, Anamnese und Aufklärung jeweils ein Insert für einen Zeitraum von 5, 3, 2, oder einem Tag mit unterschiedlichen Konzentrationen HEC (0%, 5%, 30%). Die Augen wurden in bestimmten Zeitabständen nach objektiven Kriterien (Visus, Morphologie der Augenoberfläche, Break-up-time, Schirmer-Test) untersucht. Zudem wurden subjektive Parameter (Schmerzskala, Alltagsbeeinträchtigung) erhoben.ErgebnisseNach einer anfänglichen Bindehauthyperämie wurde das Insert nach objektiven Kriterien gut vertragen. Abgesehen von einem milden Fremdkörpergefühl kurz nach der Applikation wurde es auch subjektiv gut toleriert. Bezüglich objektiver und subjektiver Kriterien zeigte sich kein Unterschied zwischen den verschiedenen HEC-Konzentrationen.SchlussfolgerungDas neuartige Kalzium-Alginat-Insert als kontrolliertes Freisetzungssystem scheint bei Applikation in den Bindehautsack gut verträglich zu sein.AbstractPurposeFor an effective pharmaceutical treatment it is necessary in some cases to maintain a constant drug level over a certain period. This cannot be achieved by conventional eye drop application. Therefore, a new insert basically consisting of alginates with a different hydroxyethylcellulose (HEC) content was developed. The aim of this study was to evaluate the tolerance of these inserts applied to the conjunctival cul de sac.Methods24 healthy volunteers received the insert containing different concentrations of hydroxyethylcellulose (0%, 5%, 30%) for 1 up to 5 days. The eyes have been examined several times (including visual acuity, ocular surface morphology, break-up-time, Schirmer-Tear-Test). Subjective parameters were pain sensations or daily life disturbance.ResultsAfter an initial conjunctival hyperemia and a mild foreign body sensation, the insert was well tolerated. No variations concerning the tolerance between the different concentrations of hydroxyethylcellulose were observed.ConclusionThis study showed good tolerance of the new calcium-alginate-insert applied to the ocular surface for controlled drug release.

Alginate Inserts Loaded with Epidermal Growth Factor for the Treatment of Keratoconjunctivitis Sicca

We developed and tested ocular inserts containing epidermal growth factor (EGF) for a causal treatment of keratoconjunctivitis sicca (KCS). The inserts, consisting of different alginates with hydroxyethylcellulose (HEC) as a lubricant and release modifier, released EGF over time periods ranging from a few hours up to several days. The stability of EGF was high, having a protein half-life of approximately 548 days. A clinical pilot study suggests an amelioration of both the main symptoms and the objective criteria: tear film break-up (BUT) time and lissamine green score. Our results show that EGF treatment of KCS is highly promising.

Optical biometry before and after excimer laser epithelial keratomileusis (LASEK) for myopia

Purpose In order to select the correct intraocular lens (IOL) for implantation, it is important to measure the eye length (biometry). The IOL Master from Zeiss-Humphry is frequently used for such measurements. Because this instrument employs an optical method, any irregularities on the corneal surface or any disturbances in corneal transparency could lead to mistakes in the measurements. The aim of this study was to determine whether eye length measurements obtained at the University Eye Clinic Regensburg, Germany with the IOL Master before and after excimer laser epithelial keratomileusis (LASEK) show any changes. Methods Axial length was measured on 20 myopic eyes (–2.75 to –8.00 diopters) before and one month after LASEK using the IOL Master. Results The mean pre-operative eye length was 25.46 mm (SD±1.03) and the postoperative mean length was 25.38 mm (SD±0.99). There was a strong correlation between the pre- and post-operative eye lengths (Pearson correlation coefficient 0.998). Conclusions Although LASEK can lead to increased light scattering due to irregularities of the corneal surface and changes in corneal transparency, there is no difference in biometry pre- and post-operatively.

“Corneal Haze” nach photorefraktiver Keratektomie Einfluss der individuellen Kollagen-Typ-IV-Synthese auf die postoperative Hornhauttrübung

ZusammenfassungHintergrund. Histologische Untersuchungen an humanen Hornhäuten haben gezeigt, dass Kollagen Typ IV ein Hauptbestandteil der Hornhauttrübung nach PRK (“Haze”) ist. Die Synthese von Kollagen IV kann derzeit pharmakologisch nicht beeinflusst werden. Ziel dieser Untersuchung war es zu bestimmen, ob individuelle Unterschiede in der Expression von Kollagen IV bestehen und ob es einen Zusammenhang zwischen der Menge an Kollagen IV und der Ausprägung von Haze gibt. Dieses würde neue Optionen in der Prävention von Haze nach einer PRK eröffnen. Patienten und Methodik. Bei 26 Augen (26 Patienten) mit einer Myopie zwischen −1,5 dpt und −6,0 dpt wurde eine PRK durchgeführt. Eine Epithelbiopsie wurde unmittelbar vor jeder Operation entnommen und mittels einer speziell entwickelten PCR die Kollagen-IV-α3-mRNA bestimmt. Ergebnisse. In allen Proben konnte Kollagen-Typ IV-α3-mRNA mit Werten zwischen 0,11 und 6,42 (MW: 1,68; SD 1,64) nachgewiesen werden. Es zeigte sich eine Korrelation zwischen der Ausprägung der postoperativen Trübung und der Kollagen-IV-Menge (Korrelationskoeffizient 0,92). Schlussfolgerung. Mit Hilfe dieses PCR-Testsystems lässt sich die individuelle Kollagen-IV-mRNA-Konzentration in den kornealen Epithelzellen quantitativ bestimmen. Als Weiterentwicklung könnte ein Screeningtest etabliert werden, mit dem Patienten mit einer starken Synthesebereitschaft von Kollagen IV als Hochrisikopatienten für ein ausgeprägtes Haze herausselektiert werden könnten.AbstractPurpose. Histological studies on human corneas have shown that collagen type IV plays a major role in the development of haze after photoreactive keratectomy (PRK). Currently, there is no clinically available pharmaceutical agent which can inhibit the synthesis of collagen IV. The aim of this study was to determine if there are individual differences in the expression of collagen IV and if there is a correlation between the amount of collagen IV and haze. This would give new options to prevent haze after PRK. Patients and methods. PRK was carried out on 26 eyes (26 patients) with a myopia ran-ging between −1.50 to −6.00 D. Prior to the surgery a small sample of epithelium was taken from the cornea and the individual concentration of collagen IV a3 mRNA was quantitatively determined by a newly developed PCR test. Results. In all samples collagen IV α3 mRNA was measured with levels between 0.11 and 6.42 (mean: 1.68; SD: 1.64). There was a correlation between haze and the amount of collagen IV α3 mRNA. (r=0.92). Conclusions. With this quantitative PCR-based test we were able to measure the individual collagen IV mRNA concentration in corneal epithelial cells. Further development of this test could establish a screening test which identifies patients with a pronounced synthesis of collagen IV as high risk individuals in terms of haze.

Disciforme keratitis caused by Bartonella henselae: an unusual ocular complication in cat scratch disease

Cat scratch disease (CSD) is a common infectious disease, however, its association with disciforme keratitis is a previously unreported ocular complication. With the use of the 16S rDNA-PCR technique with subsequent DANN sequencing on corneal material obtained by corneal scrape we were able to identify Bartonella henselae in an unusual form of disciforme keratitis.

Muss bei Vorliegen einer rheumatischen Polyarthritis die Indikation für eine Amnionmembrantrans-plantation anders gestellt werden?

ZusammenfassungHintergrund. Die Transplantation von humaner Amnionmembran (AMT) zeigt gute Erfolge bei kornealen Epitheldefekten/Ulzera. Bei Patienten mit primär chronischer Polyarthritis (PCP) stellen derartige korneale Defekte eine ungleich schwierigere Situation dar, wodurch die Indikation für eine AMT hier ggf. anders gestellt werden müsste. Patienten und Methoden. Wir analysierten retrospektiv 25 AMTs, die bei 22 Patienten wegen Epitheldefekten und Ulzera der Hornhaut durchgeführt worden waren. Bei 8 Patienten (11 AMTs) lag eine PCP vor (Gruppe A). Keine PCP (Gruppe B) bestand bei 14 Patienten (14 AMTs). Ergebnisse. Ein Epithelschluss wurde in 24/25 Fällen nach durchschnittlich 24,9 Tagen erreicht. In 15/25 Fällen blieb das Epithel über mindestens 3 weitere Monate geschlossen (=erfolgreiche AMT). In Gruppe B waren 12/14 AMTs (85,7%), in Gruppe A lediglich 3/11 AMTs (27,3%) erfolgreich. Diskussion. Neben der starken Ausprägung der Keratoconjunctivitis sicca sind auch immunologisch-entzündliche Prozesse als Ursache der deutlich schlechteren Ergebnisse der AMT bei PCP-Patienten zu vermuten. Da jedoch alternative chirurgische Verfahren (z. B. Keratoplastiken) bei PCP große Probleme beinhalten, halten wir nach Versagen der konservativen Maßnahmen auch bei PCP-Patienten eine AMT bei kornealen Defekten für sinnvoll.AbstractBackground. Amniotic membrane transplantation (AMT) shows good results in corneal epithelial defects or ulcerations. However, in patients with rheumatoid arthritis (RA) these corneal defects represent a somewhat greater challenge. We address the question whether AMT has to be indicated differently in RA patients. Patients and methods. We retrospectively analysed 25 AMTs performed between October 1998 and August 2000 in 22 patients for corneal epithelial defects and ulcerations. In 8 patients (11 AMTs) RA was present (group A) and no RA (group B) was found in 14 patients (14 AMTs). Results. Epithelial closure could be achieved in 24/25 cases after a mean of 24.9 days. In 15/25 cases the epithelium remained closed over a minimum of 3 months (successful AMT). In group B, 12/14 AMTs (85.7%) were successful, but only 3/11 AMTs (27.3%) were successful in group A. Discussion. In addition to the pronounced keratoconjunctivitis sicca, immune-mediated inflammatory aspects are suspected to be the reason for the poor results of AMT in RA patients. But as alternative surgical procedures (e.g. keratoplasty) implicate specific problems in RA, we believe that after failure of conservative treatment AMT is a reasonable procedure for corneal defects even in RA patients.