Bert Engels

Primary phacoemulsification and intraocular lens implantation for acute angle-closure Glaucoma

OBJECTIVE To evaluate the safety and efficacy of primary phacoemulsification and intraocular lens implantation (PPI) for acute angle-closure glaucoma (ACG). STUDY DESIGN Prospective, nonrandomized comparative trial. PARTICIPANTS AND INTERVENTION Forty-three eyes of 43 patients with acute ACG and uncontrolled intraocular pressure (IOP) were treated by PPI. Thirty-two eyes of 32 patients treated by conventional surgical iridectomy (CSI) constituted the control group. MAIN OUTCOME MEASURES Postoperative visual acuity, IOP, number of antiglaucoma medications, complications, and secondary surgical interventions, if any, required for IOP control. RESULTS Glaucoma control was achieved in 31 eyes (72%) in the PPI group and in 11 (35%) in the CSI group (P = 0.01). Mean preoperative IOP was 40.5 +/- 7.6 mmHg (standard deviation) and 39.7 +/- 7.8 mmHg, respectively (P = 0.46). Mean postoperative IOP was 17.8 +/- 3.4 mmHg (PPI group) and 20.1 +/- 4.2 mmHg (CSI group) after a mean follow-up of 10.2 +/- 3.4 months (P = 0.03). Postoperatively, the mean number of ocular hypotensive medications was 0.18 +/- 0.45 (PPI group) and 0.45 +/- 0.62 (CSI group) (P = 0.0001). Relative increase in postoperative best-corrected visual acuity (logarithm of the minimum angle of resolution) was 0.52 +/- 0.29 (PPI group) and 0.19 +/- 0.21 (CSI group), respectively (P = 0.0001). Additional surgery was necessary in 5 eyes (11.5%) in the PPI group and in 20 eyes (63%) in the CSI group (P = 0.01). Intraoperative and postoperative complications were few and manageable. CONCLUSIONS CSI in patients with acute ACG was effective in reducing IOP initially but was associated with multiple surgical reinterventions. Conversely, primary PPI turned out to be safe and effective in reducing IOP and improving visual acuity. These results affirm that lens extraction may be considered the better procedure in uncontrolled ACG when faced with options of CSI or PPI.

Ultrasound biomicroscopy and its value in predicting the long term outcome of viscocanalostomy.

Aims: To examine whether the early postoperative morphology at the site of sclerectomy, as visualised by ultrasound biomicroscopy (UBM), is an indicator of the mechanisms that lower intraocular pressure (IOP) and/or predictors of the long term outcome of viscocanalostomy. Methods: 15 eyes of 14 patients with medically uncontrolled open angle glaucoma and no history of surgery underwent viscocanalostomy according to Stegmann’s technique. Ultrasound biomicroscopy was performed during the first month after surgery. The following parameters were assessed: dimensions of the intrascleral “lake,” presence of a filtering bleb, presence of a subconjunctival cavity or a suprachoroidal hypoechoic area, and the thickness of the residual trabeculocorneal membrane. A complete ophthalmological examination was performed the day before and the day after surgery. Follow up visits were scheduled 1 week, 4 weeks, 6 months, and 12 months after surgery. Results: At 1 year successful control of IOP (<20 mm Hg) was achieved without further manipulation or medication in six of 15 eyes. The size of the intrascleral “lake” (average 0.62 mm3) did not correlate with later IOP; however, a visible route under the scleral flap and accidental perforation of the trabeculocorneal membrane were associated with long term lowering of IOP. Normal thickness of the trabeculocorneal membrane (0.10–0.15 mm) was indicative of IOP control with and without medication. When UBM showed an early collapse of the intrascleral cavity, control of IOP was not achieved. Other UBM findings did not predict long term function. Conclusion: In accordance with previous studies, the authors found that UBM examination is a useful method to evaluate outflow mechanisms after glaucoma surgery. This study shows that UBM imaging of external filtration during the early postoperative period can be used to predict the success of viscocanalostomy. However, to establish conclusively what parameters of UBM predict successful viscocanalostomy a larger number of patients must be studied.

Ultrasound Biomicroscopy In Chronic Ocular Hypotony: Its Impact on Diagnosis and Management

Purpose To determine the value of ultrasound biomicroscopy (UBM) in the assessment of ocular hypotony in cases where the underlying pathologic mechanism remains unclear after extensive clinical examination. Methods In a retrospective study, the records of 60 patients who had undergone UBM to elucidate the underlying structural abnormalities of chronic ocular hypotony (intraocular pressure of 0–8 mmHg) were evaluated. Most patients (47 of 60 eyes) had a history of intraocular surgery or of other ocular diseases (e.g., uveitis), and after careful clinical examination, the cause had remained unclear. All patients were observed up for a minimum of 12 months. Results The associated pathoanatomy of the hypotony was demonstrated by UBM in 95% of the cases. Ciliary body abnormalities were present in 80% of the eyes. Therapeutic intervention was associated with restoration of normal ocular pressure in 50% of the cases. Often more than one intervention was necessary. A long duration of hypotony did not impede reaching the therapeutic goal of normalizing intraocular pressure and preventing phthisis. Conclusions Ultrasound biomicroscopy is a new tool for detecting the underlying structural abnormalities in ocular hypotony. In cases where clinical examination is not sufficient it can be of great help in deciding on a course of treatment.

Effect of trabecular aspiration on early intraocular pressure rise after cataract surgery

Purpose: To evaluate the efficacy of a new trabecular aspiration technique on intraocular pressure (IOP) immediately after cataract surgery. Setting: University Eye Hospital of Cologne, Germany. Methods: This prospective, double‐masked study comprised 48 of 100 patients having extracapsular cataract extraction (ECCE) who were randomly assigned to a study group. In these patients, 180 degrees of the inferior circumference of the chamber angle was treated with negative suction pressure ranging between 100 and 200 mm Hg. The other 52 patients served as a control group. Intraocular pressure was measured preoperatively and early (5 to 7 hours) and late (12 to 48 hours) postoperatively. Results: There was a significant mean increase in IOP from the preoperative to early postoperative period in both the control group (20.8 mm Hg) and the treatment group (7.4 mm Hg). There was no significant difference between preoperative and late postoperative pressures in either group. A one‐way analysis of covariance of the changes in pressure from the preoperative to early postoperative period showed significantly less increase (P = .0041) in the aspiration than in the control group. Conclusion: Trabecular aspiration was effective in reducing the amount of IOP increase in the immediate period after ECCE.

Ultrasound biomicroscopic patterns after glaucoma surgery in congenital glaucoma

OBJECTIVE This study aimed to demonstrate specific morphologic patterns in congenital glaucoma after various surgical procedures by means of ultrasound biomicroscopy (UBM) and to investigate correlations between UBM morphology and the effectiveness of glaucoma surgery in reducing intraocular pressure. DESIGN Observational case series. PARTICIPANTS AND INTERVENTIONS Thirty four eyes of 18 consecutive patients, not older than 18 years, with congenital glaucoma and with a history of previous antiglaucomatous surgery underwent UBM examination of the anterior chamber angle in the treatment area and in an untreated region. MAIN OUTCOME MEASURES The morphology of the anterior chamber angle region and the tissue reflectivity were analyzed. RESULTS Specific UBM patterns of the anterior chamber angle in congenital glaucoma were observed after goniotomy, trabeculotomy, trabeculectomy, deep sclerectomy, and cyclodialysis. In the first months after surgery, a limited correlation was found between morphology and the success of filtering surgery. Adhesions of the iris or the ciliary processes to the trabeculectomy cleft were detected in 19 of 25 eyes after filtering procedures. CONCLUSIONS In cases of cloudy cornea and unknown previous glaucoma surgery, UBM can be used to identify the type and localization of previous surgery in congenital glaucoma, thus assisting surgical planning for subsequent glaucoma management. The correlation between UBM morphology and the effectiveness of filtering surgery is less convincing than previously demonstrated in adults, possibly underlining the importance of individual nonsurgical factors for prognosis in congenital glaucoma.

Typical Ultrasound Biomicroscopic Findings Seen in Ocular Hypotony

Detailed imaging of the ciliary body region by means of ultrasound biomicroscopy can provide information that is crucial for further treatment whereas clinical evaluation and 10-MHz standard B scan are less helpful. Background: To evaluate the suitability of ultrasound biomicroscopy (UBM) for elucidating the causes of ocular hypotony. Patients and Methods: A retrospective chart review was performed to determine the usefulness of UBM in the evaluation of ocular hypotony. UBM, B scan, and a detailed clinical examination had been performed. Sixty patient charts with prolonged ocular hypotony of different causes were reviewed from January 1994 to December 1998. The information obtained by the UBM was classified into three groups: ‘diagnostic’ (group 1), ‘helpful’ (group 2), ‘not helpful’ (group 3). Results: Of the 60 eyes, 45 UBM examinations (75%) were in group 1, 9 eyes (15%) were assigned to group 2 and 6 eyes (10%) were in group 3. The duration of hypotony had no influence. Conclusion: In cases of ocular hypotony, the cause was related to ciliary body pathologies in 80%. Only UBM could distinguish tractional from dehiscence ciliary body detachment which required a different management approach. UBM with its high resolution imaging of the anterior segment – including the ciliary body – is highly suitable for diagnostic clarification.

The suitability of the ultrasound biomicroscope for establishing texture in giant cell arteritis

AIM To establish whether ultrasound biomicroscope (UBM) is a helpful tool in locating the arterial segment responsible in patients with segmental attacks in giant cell arteritis METHODS The superficial temporal arteries of 19 patients with suspected giant cell arteritis were examined with the UBM before biopsy. RESULTS 20 specimens provided the histological proof of giant cell arteritis in five patients. Side differences, a dark perivascular halo, and high reflexivity of the intra-arterial space were found. CONCLUSION it is assumed that there are two types of arteritic inflammation: (1) the occlusion of intra-arterial space due to intimal fibrosis (UBM: high reflexive “filling”), and (2) inflammation of the perivascular zone with oedematous thickening and infiltration of the media (UBM: dark halo) and its combination. UBM is helpful in obtaining an indication of the side and segment for biopsy.

Changes of Hemorheological and Biochemical Parameters after Plasma Perfusion Using a Tryptophan-Polyvinyl Alcohol Adsorber Leading to Clinical Improvement in Patients Suffering from Maculopathy

Background: Selective adsorption is an extracorporeal treatment able to reduce high-molecular-weight proteins and lipids. We evaluated its efficacy in lowering hemorheological parameters to achieve a better microcirculation of the retina. Patients and Methods: Ten patients suffering from maculopathies of various origin underwent a selective plasma adsorption procedure using the TR-350. Plasma and whole blood viscosity, erythrocyte aggregation and proteins and lipids were determined before and 24 h after therapy. Results: Selective adsorption therapy reduced the high-molecular-weight proteins and lipids. Plasma viscosity, standardized whole blood viscosity and erythrocyte aggregation were significantly lowered to 87, 88 and 65%, respectively, of their values prior to treatment. An improvement of visual acuity was achieved in 6/10 patients. Minor side effects were noted in 2/10 patients. Conclusions: Selective adsorption using the TR-350 adsorber is a safe technique, showing a high impact on blood rheology. The changes of hemorheological parameters led to clinical improvement in 6/10 patients suffering from retinal disorders.

Primary phacoemulsification and intraocular lens implantation for acute angle-closure glaucoma 1

OBJECTIVE To evaluate the safety and efficacy of primary phacoemulsification and intraocular lens implantation (PPI) for acute angle-closure glaucoma (ACG). STUDY DESIGN Prospective, nonrandomized comparative trial. PARTICIPANTS AND INTERVENTION Forty-three eyes of 43 patients with acute ACG and uncontrolled intraocular pressure (IOP) were treated by PPI. Thirty-two eyes of 32 patients treated by conventional surgical iridectomy (CSI) constituted the control group. MAIN OUTCOME MEASURES Postoperative visual acuity, IOP, number of antiglaucoma medications, complications, and secondary surgical interventions, if any, required for IOP control. RESULTS Glaucoma control was achieved in 31 eyes (72%) in the PPI group and in 11 (35%) in the CSI group (P = 0.01). Mean preoperative IOP was 40.5 +/- 7.6 mmHg (standard deviation) and 39.7 +/- 7.8 mmHg, respectively (P = 0.46). Mean postoperative IOP was 17.8 +/- 3.4 mmHg (PPI group) and 20.1 +/- 4.2 mmHg (CSI group) after a mean follow-up of 10.2 +/- 3.4 months (P = 0.03). Postoperatively, the mean number of ocular hypotensive medications was 0.18 +/- 0.45 (PPI group) and 0.45 +/- 0.62 (CSI group) (P = 0.0001). Relative increase in postoperative best-corrected visual acuity (logarithm of the minimum angle of resolution) was 0.52 +/- 0.29 (PPI group) and 0.19 +/- 0.21 (CSI group), respectively (P = 0.0001). Additional surgery was necessary in 5 eyes (11.5%) in the PPI group and in 20 eyes (63%) in the CSI group (P = 0.01). Intraoperative and postoperative complications were few and manageable. CONCLUSIONS CSI in patients with acute ACG was effective in reducing IOP initially but was associated with multiple surgical reinterventions. Conversely, primary PPI turned out to be safe and effective in reducing IOP and improving visual acuity. These results affirm that lens extraction may be considered the better procedure in uncontrolled ACG when faced with options of CSI or PPI.

Book Reviews · Livres nouveaux · Buchbesprechungen

Conjunctival inflammation is one of the most frequent conditions presenting to the ophthalmologist. While in the past decades, bacterial infections of the conjunctiva have become much easier to diagnose and treat, the non-infectious disorders still pose confounding problems. Inflammatory Diseases of the Conjunctiva provides an in-depth review of the pathological mechanisms causing these diseases. The strength of this book lies in its presentation of immunological knowledge which is indispensable for the understanding of conjunctival inflammation. As immunology is a very dynamic field of research, the authors put great emphasis on giving up-to-date information on basic research findings and putting them in perspective regarding their clinical relevance. In this the book is of great value for the clinician. It is also very well structured, dealing with individual disease entities in separate chapters and providing sections on laboratory investigations, differential diagnosis and treatment options in each of them. Some topics are given special consideration in ‘focus’ sections, among them dry eye syndrome, laboratory investigations of conjunctival inflammation and apoptosis in the conjunctiva. Dr. Holger Baatz, Frankfurt G.A. Fishman, D.G. Birch, G.H. Holder, et al.