Bernhard M. Stoffelns

Capsule measuring ring to predict capsular bag diameter and follow its course after foldable intraocular lens implantation.

Purpose: To evaluate the extent of capsular bag shrinkage after cataract surgery with intraocular lens (IOL) implantation and develop a regression formula to predict postoperative capsular bag size. Setting: Eye Hospital, Johannes Gutenberg‐University, Mainz, Germany. Methods: The axial length (AL), anterior chamber depth, and corneal radius in 58 eyes were measured preoperatively. Cataract surgery was by phacoemulsification followed by implantation of a 3‐piece, acrylic, posterior chamber IOL. The capsular bag diameter and anterior capsulorhexis were measured intraoperatively and 1 day and 1, 3, and 6 months postoperatively using a Koch capsule measuring ring (HumanOptics). Results: The mean capsular bag size was 10.53 mm intraoperatively, 10.31 mm at 1 day, 9.62 mm at 1 month, 9.07 mm at 3 months, and 9.01 mm at 6 months. The mean capsular bag shrinkage over the entire postoperative period was 14.8% (P<.001). Of the parameters studied, only AL had a positive correlation with capsule shrinkage. The correlation was moderate but statistically significant (P = .001). Conclusions: A correlation was found between capsular bag shrinkage and AL. Using preoperative biometric data, a regression formula of moderate validity was determined to predict capsular bag shrinkage.

Intraocular pressure during corneal flap preparation: comparison among four femtosecond lasers in porcine eyes.

PURPOSE To compare the course of intraocular pressure (IOP) during corneal flap preparation using four different femtosecond lasers in porcine globes. METHODS Forty-eight (12 in each group) enucleated globes were successfully cannulated through the optic nerve. Intraocular pressure was measured continuously through the cannula during a normal lamellar flap creation (regular procedure) using four femtosecond lasers (IntraLase, Abbott Medical Optics; VisuMax, Carl Zeiss Meditec AG; Femtec, Technolas Perfect Vision; and Femto LDV, Ziemer Ophthalmic Systems AG). In an additional measurement (worst-case procedure), the patient interface was pressed against the globe with increasing force until the applanation maneuver was automatically aborted by those devices capable of doing so. RESULTS During the regular procedure, the maximum IOP reached was 135±16 mmHg when using the Intra-Lase, 65±20 mmHg with the VisuMax, 205±32 mmHg with the Femtec, and 184±28 mmHg with the Femto LDV. During the worst-case procedure, a maximum IOP of 260±53 mmHg was reached with the IntraLase, 105±13 mmHg with the VisuMax, and 248±51 mmHg with the Femtec. CONCLUSIONS There is considerable variation in IOP among the tested femtosecond lasers during a regular lamellar flap creation and during the worst-case procedure. The VisuMax femtosecond laser seems to cause the lowest IOP rise in both settings.

Implantation of a custom intraocular lens with a 30-diopter torus for the correction of high astigmatism after penetrating keratoplasty.

We present a 62-year-old woman who had implantation of an intraocular lens (IOL) with a torus of 30.0 diopters (D) in an eye after penetrating keratoplasty. The patient presented with cataract and a best corrected visual acuity of 20/400. Penetrating keratoplasty was performed in 1975 because of decompensated keratoconus. With a clear but inferiorly decentered corneal graft, visual acuity was limited because of keratoplasty-related high corneal astigmatism of 22.5@156 that could not be successfully treated with spectacles or contact lenses. A custom toric IOL with -30.0 D of cylindrical power was implanted in the capsular bag via a sclerocorneal tunnel incision. Additionally, a spherical IOL of -15.0 D sphere was implanted in the ciliary sulcus. Six months after implantation, the IOLs were still well centered and the uncorrected visual acuity was 20/60.

Effect of contact lenses on the protein composition in tear film: a ProteinChip study

BackgroundThe aim of this study was to analyze and compare the effects of rigid gas permeable and soft contact lenses on the protein composition in the tear film of contact lens wearers.MethodsWearers of soft contact lenses (CL_S, n = 13) and rigid gas permeable contact lenses (CL_H, n = 13) were recruited for this study. Thirteen non-contact lens wearers were also included as the control. Tears were collected using Schirmer strips and frozen until use. The tears were eluted and analyzed on ProteinChips SELDI-TOF (surface-enhanced laser desorption and ionization in time of flight mass spectrometry; Bio-Rad, USA) with different chromatographic surfaces (cationic and anionic exchanger and reversed phase surface). The SELDI spectra were analyzed by multivariate statistical analysis and artificial neural networks in order to find a biomarker panel which differentiates best between the groups. In order to identify protein/peptide peaks from SELDI spectra which showed a significant difference between groups, fractionated tear samples were analyzed using MALDI-TOF MS (matrix-assisted laser desorption/ionization time-of-flight mass spectrometry). For validation of biomarkers, we used an antibody microarray approach.ResultsComplex patterns of tear proteins and peptides were detected in the control group and in both contact lens groups. The tear protein composition in both wearers of rigid gas permeable (CL_H) and soft contact lenses (CL_S) differed significantly from protein composition in non-contact lens wearers (p < 0.01). The identification of biomarkers revealed an increase of Protein S100 A8 in the group of wearers of soft contact lenses (CL_S) and a decrease of a main tear protein, lysozyme, in both contact lens groups. The identified biomarker cystatin was upregulated in the group of rigid gas permeable lens wearers (CL_H), whereas the protein intensity of secretoglobin was significantly reduced in this group. Using the microarray approach, detected alterations could be confirmed.ConclusionsContact lens wear alters the protein profiles in a complex manner. This study demonstrates that significant changes can be found in wearers of soft contact lenses (CL_S) and rigid gas permeable contact lenses (CL_H). Some biomarker intensities are significantly altered only in the group of rigid gas permeable lens wearers (CL_H).

Intravitreal ranibizumab treatment of retinal angiomatous proliferation.

Purpose:  To determine the efficacy of intravitreal injections of ranibizumab in the treatment of retinal angiomatous proliferation (RAP) in neovascular age‐related macular degeneration.

Dislocation of a plate haptic silicone intraocular lens into the vitreous following Nd:YAG capsulotomy

SummaryWe describe a case that was referred 10 months after Nd:YAG laser treatment with a posteriorly dislocated silicone intraocular lens (IOL) into the vitreous cavity. Patient: A 70-year-old white woman underwent uncomplicated phacoemulsification with in-the-bag placement of a Chiron silicone plate haptic lens through a 5.5-mm continuous circular capsulorhexis. The patient was fine until 9 months postoperatively when she complained of a decrease in visual acuity due to capsular fibrosis. A successful Nd:YAG laser capsulotomy was performed, resulting in an increase in visual acuity. Ten months later, the patient noted acute and atraumatic loss of vision, and the IOL was found to have dislocated posteriorly onto the retina. Results: The dislocated IOL was removed via the anterior chamber following pars plana vitrectomy. Perfluorocarbon liquid was used to elevate the slippery lens from the retinal surface. The IOL was removed by a Sato Knife from the anterior chamber, followed by implantation of a one-piece PMMA IOL in the ciliary sulcus. Conclusion: Silicone plate haptic IOLs seem to present special risks for dislocation. Shrinkage of the anterior capsule exerts centripetal forces on the ends of the plate haptic, causing the optic to move posteriorly and to exert pressure against the posterior capsule. If either the posterior or anterior capsule is disrupted by Nd:YAG laser treatment, the forces created by capsular contraction against the flexible lens may cause extension of radial tears and appear to be a substantial risk for further capsule-tearing, releasing the IOL into the vitreous cavity, even months later. The forces of capsular contraction can impart a spring-loading effect on plate haptic silicone lenses. Due to inadequate capsular adherence, these lenses are at risk of posterior dislocation from capsular rents following Nd:YAG laser treatment.ZusammenfassungHintergrund: Bei Kapselsackschrumpfung mit fibrotischem Nachstar nach Implantation einer Intraokularlinse (IOL) aus Silikon mit Plattenhaptik können ungewöhnliche Komplikationen nach Nd:YAG-Kapsulotomie auftreten. Wir beschreiben in dieser Kasuistik die Dislokation einer Silikonlinse in den Glaskörper 10 Monate nach Nd:YAG-Kapsulotomie. Patient: Eine 70jährige Patientin unterzog sich einer komplikationslosen Phakoemulsifikation mit Implantation einer schiffchenförmigen Silikonlinse mit Plattenhaptik durch eine zirkuläre, kreisrunde 5,5 mm-Kapsulorhexis in den Kapselsack. Die Patientin war 9 Monate postoperativ beschwerdefrei und bemerkte dann eine zunehmende Sehverschlechterung durch eine Kapselfibrose. Die erfolgreich durchgeführte Nd:YAG-Kapsulotomie führte zu einer Visusverbesserung. 10 Monate später trat eine akute Sehverschlechterung ohne erkennbares Trauma auf. Die IOL war nach hinten in den Glaskörper disloziert und lag bei 6 Uhr auf der Retina. Nach Elevation der dislozierten IOL von der Retina in die Vorderkammer mittels Perfluorkarboninstillation im Rahmen einer Pars-plana-Vitrektomie wurde die IOL über die Vorderkammer explantiert und eine einstückige PMMA-IOL in den Sulcus ciliaris implantiert. Schlußfolgerung: Silikonlinsen mit Plattenhaptikdesign scheinen unter bestimmten Umständen ein spezielles Risikoprofil für eine Dislokation aufzuweisen. Die Schrumpfung der vorderen Kapsel übt zentripetale Kräfte von den Enden der Plattenhaptik ausgehend aus, die eine Bewegung der Optik nach posterior verursachen und somit einen Druck auf die Hinterkapsel ausüben. Falls die Hinterkapsel mit dem Nd:YAG-Laser durchtrennt wird, können die Kräfte auf die flexible Silikonintraokularlinse durch die Kapselkontraktion eine Ausdehnung von radiären Einrissen und somit auch Monate nach der Laserbehandlung eine Dislokation der IOL in den Glaskörper hervorrufen. Aufgrund fehlender Kapseladhärenz bergen diese Silikonlinsen ein Risiko für die posteriore Dislokation aus dem Kapselsack.

Chorioretinopathia serosa centralis (CSC) und Kortikosteroide

BACKGROUND Corticosteroids are under suspicion of playing an important role in the development of central serous chorioretinopathy (CSC). PATIENTS AND METHODS In a prospective study the course of CSC was evaluated in a consecutive series of 46 patients, who received the diagnosis of CSC in the period 4 / 2004 - 12 / 2005. Data analysis was focused on the complete medical and ocular history and the ocular course of this disease. RESULTS 27 patients had been taking exogenous corticosteroids (oral, intravenous, inhalative, cutaneous and intraarticular) within 4 weeks before onset of symptoms. Additionally, one case with Cushings disease and 2 pregnant women were included. These 30 / 46 patients with steroid association presented bilateral involvement in 21 cases (70 %) and angiographically more than one leakage point in 10 cases (33 %). In 16 / 46 patients without history of taking exogenous corticosteroids bilateral involvement was seen in 2 / 16 cases (13 %) and multiple leakages in only one case (6 %). CSC resolved spontaneously in 25 / 46 patients within 2 - 6 months. In 21 / 46 patients recurrences were documented either in the eye, which was primarily affected or in the other one. In this group of recurrent CSC all 8 patients were included who did not discontinue the use of systemic corticosteroids. CONCLUSIONS These results strongly support the association of steroid use with CSC. Unter systemic treatment with corticosteroids bilateral involvement and multilocular leakages seem to be more likely than without use of steroids. All patients in need of corticosteroids by any systemic route of administration should be informed of the associated risk.

Idiopathische makuläre Teleangiektasie (IMT) – Verlaufsbeobachtung mit und ohne Laserphotokoagulation

PURPOSE The aim of this study was to evaluate the effectiveness of laser photocoagulation for idiopathic macular telangiectasia (IMT) by using the revised and simplified classification of Yannuzzi 2006. PATIENTS AND METHODS The Yannuzzi classification was used for a retrospective analysis of the medical records of all patients with idiopathic macular telangiectasia as diagnosed consecutively in the University Eye Clinic of Mainz in the time period from 1 / 02 to 12 / 06. Laser treatment was indicated only in those eyes which presented with a visual acuity below 10 / 20 (follow-up interval in median 37 months, minimum 13 months). RESULTS 12 patients with unilateral macular telangiectasia (IMT type I) and 30 patients with bilateral macular telangiectasia (IMT type II) were recruited. In type I disease 9 / 12 patients were male with an average age of 41 years (range: 28 to 47). 10 / 12 eyes showed macular oedema. After focal laser photocoagulation in 6 / 10 eyes the macular oedema decreased in 4 / 6 eyes and visual acuity improved in 3 / 6 eyes. In type II disease 17 / 30 patients were male and the average age was 56 years (range: 45 to 63). All 60 eyes showed macular oedema. In 40 eyes, which did not receive a laser photocoagulation, the ocular findings did not change during the follow-up examinations. In 16 / 20 eyes the macular oedema has successfully been reduced by laser photocoagulation, however without significant visual improvement. In 2 of these 16 treated eyes the development of a subfoveal choroidal neovascularisation with central loss of vision was noted. CONCLUSIONS In IMT type I laser photocoagulation was able to achieve a visual improvement. In IMT type II, however, a laser photocoagulation indication should be considered very carefully because in this group no visual improvement was reached and a secondary induction of subretinal neovascular membranes seems likely.

Pars Plana Vitrectomy for Visually Disturbing Vitreous Floaters in Pseudophacic Eyes

BACKGROUND The aim of this study was to evaluate the role of vitrectomy in patients with visually disturbing vitreous opacities. PATIENTS AND METHODS A retrospective analysis of the patient characteristics and the outcome of all pseudophacic eyes, which consecutively received in the decade 1996 to 2005 20 G pars plana vitrectomy for visually disturbing floaters, was carried out at the Mainz University Eye Clinic. RESULTS Forty-one eyes of 32 patients (63 % university graduates, median age: 64 years) were included in the study. The mean axial length of the globe was 25.3 mm (range: 22.8 to 28.9 mm). Additional pathologies having influence on the vitreous condition were history of laser or cryo retinopexy (12 ×), buckle surgery (5 ×), complicated cataract surgery (16 ×) and Nd:YAG laser capsulotomy (4 ×). Vitreous floaters were considered to be the result of posterior vitreous detachment alone in 61 %, of asteroid hyalosis accompanied by posterior vitreous detachment in 17 %, and vitreous syneresis in 15 % of the eyes. Intraoperatively retinopexy with endolaser or cryo was performed in 6 % of cases. A secondary retinal detachment occurred in one eye (2 %). Thirty-one of 32 patients reported to be very satisfied with the postoperative result. Objectively, their visual acuity was better than or equal to preoperative acuity in 95 % of the eyes. CONCLUSION Pars plana vitrectomy provides a highly effective treatment for visually disturbing vitreous floaters. In an era in which the expectations and demands of individuals on the quality of vision and life have increased significantly, with careful case selection the benefits of the surgical intervention may outweigh the surgical risks.

Akute Retinanekrose Silikonölendotamponade bei Netzhautablösungen

Background: Because retinal necrosis syndrome seldom occurs, we present our results of silicone oil tamponade for associated retinal detachment.Patients and methods: Thirteen eyes from 13 patients undergoing retinal reattachment surgery for retinal detachment associated with acute retinal necrosis in a consecutive series between January 1988 and June 1995 were followed up. Patients were 25 to 56 years of age. Four patients had acquired immune deficiency syndrome (AIDS). Five eyes that were operated on with cryopexy and scleral buckling received vitrectomy, membrane peeling, silicone oil tamponade and endolaser treatment in a second operation. Eight eyes were primarily operated on with cryopexy, encircling buckle, vitrectomy with membrane peeling, silicone oil tamponade and endolaser treatment. All patients were treated with acyclovir.Results: Postoperative complete reattachment was observd in 12 eyes and persistence of a peripheral detachment in one eye. Vision improved in eight eyes, but only five eyes achieved 20/200 or better vision. Limited functional results in our series were caused by retinal ischemia, optic atrophy and macula scars. After a median of 9.3 months silicone oil was removed in nine eyes. No retinal redetachment or recurrent retinitis was observed during a follow-up time of at least 6 months.Conclusions: Vitrectomy and silicone oil tamponade allowed all cases of retinal detachment associated with acute retinal necrosis to be successfully repaired. Further studies must be conducted to find out how we can improve the visual outcome – perhaps by earlier therapy with acyclovir or earlier vitrectomy.Einführung: Da Studien zur Behandlung der akuten Retinanekrose (ARN) inzidenzbedingt kleine Fallzahlen haben und alle verfügbaren Daten zusammengetragen werden müssen, berichten wir über unsere operativen Ergebnisse bei Netzhautablösungen durch ARN.Patienten und Methode: Nachuntersucht wurden 13 Augen von 13 Patienten mit Netzhautablösung bei ARN, die konsekutiv in unserer Klinik zwischen Januar 1988 und Juni 1995 operiert wurden. Das Patientenalter betrug 25 – 56 Jahre. Vier Patienten waren HIV-positiv, 9 Patienten immunkompetent. Bei 5 Patienten, die primär mit segmentalen Plomben versorgt worden waren, wurde eine Vitrektomie mit Membrane peeling, Silikonölendotamponade und Endolaserbehandlung als Zweiteingriff durchgeführt. Acht Patienten wurden einzeitig mit Cerclage, Vitrektomie mit Membrane peeling, Silikonölendotamponade und Endolaserkoagulation versorgt. Zusätzlich wurden alle Patienten systemisch mit Acyclovir behandelt.Ergebnisse: Postoperativ wurde unter Silikonöl eine komplette Netzhautanlage in 12 Augen und eine periphere, durch Lasereffekte abgeriegelte Traktionsamotio in 1 Auge beobachtet. Eine Visusverbesserung zeigten 8 Augen, aber nur 5 Augen erreichten eine Sehschärfe von 0,1 oder besser. Ursächlich für die schlechte Funktion waren retinale Ischämie, Optikusatrophie und Makulanarben. Nach im Mittel 9,3 Monaten erfolgte in 9 Augen eine Silikonölentfernung. Eine Kataraktoperation wurde 3mal einzeitig mit der Silikonölentfernung und 6mal zweizeitig durchgeführt. Reamotiones oder Retinitisrezidive wurden bei einer Nachbeobachtungszeit von mindestens 6 Monaten nicht beobachtet.Schlußfolgerung: Bei komplizierten Netzhautablösungen durch ARN sind durch Cerclage, Vitrektomie mit Membrane peeling, Silikonölendotamponade und Laserbehandlung gute anatomische Ergebnisse möglich. Zukünftig ist zu prüfen, ob die funktionellen Ergebnisse verbessert werden können, z. B. durch frühzeitige hochdosierte Acyclovirtherapie und frühzeitige Vitrektomie.