C. Faschinger

Opacification of a silicone intraocular lens caused by calcium deposits on the optic

We describe opacification of a plate-haptic silicone intraocular lens (IOL) caused by calcification in a diabetic patient with asteroid hyalosis. The IOL was explanted 48 months after uneventful phacoemulsification because opacification of the posterior surface was causing significant visual disturbance. Light and scanning electron microscopy and x-ray spectrometry of the explanted IOL showed the opacification consisted mainly of calcium and phosphate, presumably hydroxyapatite, in the form of precipitations on the posterior surface of the optic.

Complete capsulorhexis opening occlusion despite capsular tension ring implantation.

An 89-year-old woman and an 86-year-old woman had continuous curvilinear capsulorhexis, phacoemulsification, and implantation of a silicone plate-haptic intraocular lens. Because of presumed weak zonules (high age, pseudoexfoliation), a poly(methyl methacrylate) capsular tension ring was also implanted. Despite this, both patients reported deterioration in visual acuity that was the result of complete occlusion of the anterior capsule opening by fibrotic tissue 4 and 3 months postoperatively, respectively.

[Corneal melting in both eyes after simultaneous corneal cross-linking in a patient with keratoconus and Down syndrome].

Corneal cross-linking is one of the options for treatment of progressive keratoconus. Following the published standards regarding indication and treatment schedules, it seems to be a highly safe and effective operation. Only a very few severe complications, such as stromal scarring and bacterial keratitis, have been reported.We describe a patient with keratoconus and Down syndrome who was treated with corneal cross-linking on both eyes simultaneously. One week after the operation he developed central corneal melting without signs of infection in his right eye, and 1 month after the operation in his left eye. Penetrating keratoplasties had to be performed on both eyes and were successful. A possible reason for the corneal melting might have been a corneal stroma that was thinner than the proposed limit of 400 µm at the centre. The published recommended standards should be met.

Beidseitiges Einschmelzen der Hornhaut nach beidseitigem simultanen Kollagen-Crosslinking bei Keratokonus und Down-Syndrom

Corneal cross-linking is one of the options for treatment of progressive keratoconus. Following the published standards regarding indication and treatment schedules, it seems to be a highly safe and effective operation. Only a very few severe complications, such as stromal scarring and bacterial keratitis, have been reported.We describe a patient with keratoconus and Down syndrome who was treated with corneal cross-linking on both eyes simultaneously. One week after the operation he developed central corneal melting without signs of infection in his right eye, and 1 month after the operation in his left eye. Penetrating keratoplasties had to be performed on both eyes and were successful. A possible reason for the corneal melting might have been a corneal stroma that was thinner than the proposed limit of 400 µm at the centre. The published recommended standards should be met.

Kontinuierliche 24-h-Aufzeichnung von Augendruckschwankungen mittels drahtlosem Kontaktlinsensensor Triggerfish™

BACKGROUND For many years researchers have been striving for a non-invasive 24 h continuous method of ambulatory intraocular pressure monitoring. A wireless device with a contact lens sensor is now on the market for clinical use, which is not a quantitative measurement of the intraocular pressure but is at least a recording of qualitative changes. These changes of corneal curvature due to changes of the intraocular pressure result in a distinct profile which gives information about fluctuations of the intraocular pressure, the behaviour during supine sleeping time and the 24 h efficacy of glaucoma therapy. We investigated the practicability and tolerability of this device. METHOD The sensor is embedded in a soft silicone contact lens and consists of 4 strain gauges. Additionally there is an antenna made out of gold and a microchip. A second antenna is fixed around the eye which sends impulses to the microchip and receives data from the microchip. The data are sent to a recorder via a wire. Measurements are made for 90 s every 8.5 min resulting in 144 measurements within 24 h. Of the 4 strain gauges 2 sense changes in the corneal curvature due to changes of the intraocular pressure. This device was used in 11 patients with ocular hypertension or glaucoma. RESULTS The result of the 24 h continuous measurement is a pressure profile which may be flat, fluctuating and with no, some or many spikes. We describe 2 examples of profiles from patients with glaucoma. The changes in the profiles were mostly during the sleeping hours in a supine position. Due to the lack of validation of the results it is not known if intermittent spikes are true spikes or artefacts. Practicability was simple and tolerability was reported to be good by all patients. CONCLUSIONS For the first time a practicable, well tolerated, non-invasive device for continuous 24 h monitoring of changes of the corneal curvature due to changes of the intraocular pressure is available. It is not a direct measurement of the intraocular pressure. The resulting profile gives additional information about the behaviour of the intraocular pressure, especially during out-of-office times and night times. Disadvantages are the high cost of the contact lens sensor and the lack of validation of the results and reproducibility in patients.

Nekrotisierende ulzerierende Keratopathie nach Lokalanästhetikamissbrauch

ZusammenfassungHintergrund. Lokalanästhetikamissbrauch ist ein seltenes Erkrankungsbild und klinisch manchmal schwer zu diagnostizieren. Patient. Ein 45-jähriger Arzt mit 30-jähriger Kontaktlinsenanamnese und rezidivierenden kornealen Erosionen wurde mit dem klinischen Bild einer ringförmigen Keratitis mit massiven Schmerzen vorgestellt. Es wurde die Diagnose “Akanthamöbenkeratitis” gestellt und eine Therapie mit Gentamycin, Pentamidin isethionat und Hexamidin eingeleitet. Sechs Wochen nach Therapiebeginn wurde eine perforierende Keratoplastik durchgeführt. Postoperativ entwickelte sich ein zunehmendes Ectropium uveae mit fehlender Irismotilität und dichter Katarakt. Erneut auf eine Eigenmedikation angesprochen, gab der Patient zu, “sporadisch” Lokalanästhetika verwendet zu haben. Die histologische Untersuchung ergab ein Hornhautulkus mit geringem frischen entzündlichen Infiltrat. Im Stroma waren wenige vitale Zellen erkennbar, ebenso im Endothel. Akanthamöben konnten keine nachgewiesen werden. Schlussfolgerung. Lokalanästhetikamissbrauch kann das Bild einer Akanthamöbenkeratitis vortäuschen, und bei Patienten mit Ringkeratitiden und massiven Schmerzen ohne ein Ansprechen auf die Therapie sollte auch an Lokalanästhetikamissbrauch gedacht werden.AbstractBackground. Topical anesthetic abuse is rare, but difficult to diagnose since most patients deny its use and the clinical changes are very similar to other corneal diseases. Case report. A 45-year-old medical doctor with a 30-year history of soft contact lens wear and recurrent corneal erosion was admitted to our clinic with a ring-shaped keratitis and intense ocular pain. A corneal smear was negative for bacterial infections and acanthamoeba but the contact lens box contained a few dead acanthamoeba and many cocci. Due to the clinical findings and the acanthamoeba found in the contact lens box acanthamoeba keratitis was diagnosed and threatment with gentamycin, pentamidine isethionat (Brolene®) and hexamidine (Desomedine®) was started. The clinical appearance did not change for 6 weeks after onset of treatment and a perforating corneal transplantation was performed for pain relief and visual rehabilitation. An iris ectropion lacking iris motility and dense cataract developed within 5 weeks and the patient admitted on direct questioning to having taken topical anesthetic (oxybuprocain) by self-medication. The histological investigation revealed few inflammatory cells. The epithelium was largely missing and few vital cells could be found in the stroma and the endothelial cell layer. Acanthamoeba could not be detected in the tissue. Conclusion. Topical anesthetic abuse can mimic different corneal diseases and be difficult to diagnose if the patient denies its use. In cases of keratitis with no response to treatment and strong ocular pain, topical anesthetic abuse should be considered.

Phototherapeutic keratectomy of a corneal scar due to presumed infection after photorefractive keratectomy

This case involves a 25-year-old patient who suffered from corneal ulceration several days after photorefractive keratectomy (PRK). A central scar developed, resulting in discomfort and reduction in visual acuity. Four months later, the scar was treated by phototherapeutic keratectomy (PTK) (25 microns depth, 5 mm ablation zone). Some scar tissue was left, but it cleared slowly and steadily over the next few years. The induced hyperopia decreased from 5.00 to 1.37 diopters spherical equivalent within 28 months postoperatively. Best corrected visual acuity increased from 20/60 preoperatively to 20/20 at 28 months postoperatively. Surgeons can encourage patients with postinfectious scars after PRK to try at least 1 PTK treatment.

Fetal development of the human orbit

The development of the orbits in 70 human fetal skulls was investigated by measuring the width and height of the orbital entrance, as well as the volume and depth of the orbital cavity and the interorbital width. For determination of the orbital volume, we used the imprint method; the remaining parameters were estimated. Our measurements showed a linear growth rate for the orbital width, height, and depth. After transformation to the cubic root, the values of the orbital volume also demonstrated a linear increase. The orbital index (height/width × 100) expressed the change in the oval outline of the orbital entrance during fetal development from a flat, wide form to a nearly round form at birth. No statistically significant difference between the right and left orbit was found.

Das Grazer Modell der Facharztausbildung, Teil 1: Die Struktur

ZusammenfassungHintergrundZiel dieser Arbeit ist der Vorschlag einer strukturierten Facharztausbildung, die sowohl an einer Augenabteilung als auch einer Universitätsklinik praktiziert werden kann. Das International Council of Ophthalmology (ICO) hat anlässlich des letzten Kongresses in Sydney 2002 Richtlinien für eine Facharztausbildung bzw. Ausbildung zum Spezialisten erlassen, die in dieses Curriculum einflössen. Die einzelnen Länder in verschiedenen Kontinenten sind nun aufgerufen, diese Richtlinien umzusetzen.Material und MethodeBasis für ein Curriculum ist ein detaillierter, schriftlich festgelegter Lernzielkatalog. Während das ICO Mindestrichtlinien vorgibt und jedem Land die praktische Umsetzung freistellt, wird nun in unserem Curriculum jedes Lernziel detailliert festgelegt. Die Lernziele werden in zu erlernendes Wissen (im ICO alsKnowledge beschrieben) und in Fertigkeiten (skills) unterteilt. Die Fertigkeiten können weiter indiagnostische undtherapeutische Fertigkeiten gegliedert werden.Grundvoraussetzung für das Erlernen vonpraktischem Wissen undFertigkeiten ist die Möglichkeit einerRotation auf einer Augenabteilung wie auch Universitätsklinik. Neben der Bettenstation zum Erlernen der basalen Fähigkeiten zu Beginn der Ausbildung ist ein Schwerpunkt dieses Curriculums die Tätigkeit in der Ambulanz. Ein zweiter Schwerpunkt ist dieBegleitung des jungen Assistenten durch einen älteren Assistenten, übergeordnet und letztverantwortlich findet sich der Facharzt, Stationsführer, Oberarzt oder Leiter einer Abteilung oder Klinik.Großer Wert wird auf daspraktische,begleitende Lernen von Anfang an gelegt. Nach einer kurzen Phase des Erlernens der einfachen Untersuchungstechniken wie subjektive Sehprobe für Ferne und Nähe, Spaltlampenuntersuchung, Tonometrie und direkte wie indirekte Fundusuntersuchung werden die Krankheitsbilder am Patienten erlernt. Der junge Assistent versucht, die Untersuchung alleine durchzuführen, erst danach tritt je nach Ausbildungstand der ältere Assistent — die ältere Assistentin, oder die Fachärztin, der Facharzt — in Aktion. Das erlernte Wissen wird im Sinn einerEvidenz basierten Medizin (EbM) mittels Lehrbuch kontrolliert, ergänzt und sinnvollerweise nochmals mit dem Facharzt (Oberarzt) diskutiert. Entscheidend scheint neben der Momentaufnahme (Erstuntersuchung oder Kontrolluntersuchung) derKrankheitsverlauf des Patienten.DiskussionZiel dieses Curriculums ist, dem Assistenten vom ersten Tag seiner Facharztausbildung einenschriftlichen Leitfaden für seine Ausbildung zur Verfügung zu stellen. Die Verantwortung der Ausbildung liegt nicht nur beim Ordinarius oder Primär, sondern auch beim erfahrenen Assistenten — der erfahrenen Assistentin — oder der Fachärztin (dem Facharzt). Entscheidend ist ein begleitendes, kontrolliertes Lernen über die gesamte Zeit der Ausbildung, an dessen Ende die Facharztprüfung steht. Dieses Curriculum soll die Basis für eine Facharztausbildung darstellen, ergänzt durch die Module der ÖOG, Lehrbücher oder auch Leitartikeln von Zeitschriften (z. B. Der Ophthalmologe).SummaryBackgroundAim of this paper is a suggestion for a residency in ophthalmology at a university eye clinic in Austria. The International Council of Ophthalmology (ICO) has introduced curriculum guidelines during the last annual meeting in Sydney 2002. Part of these guidelines were included into our curriculum. The ICO guidelines are not all inclusive, but were introduced to be adapted in each country to meet the local requirements.MethodOur curriculum should serve as a guideline for resident and specialist education at the University Eye Clinic in Graz. In order to achieve maximum efficacy the resident should rotate during his (her) education into subspecialities in regular intervals. First of all basic diagnostic skills like slit slamp exam, tonometry, direct and indirect ophthalmoscopy should be learned at the ward. Practise in the outpatient clinic is important to see the emergency cases residents have to deal with during their first duties. The main focus of our curriculum is the supervision of the resident by an elder resident, fellow or assistent professor. After having learned the basic diagnostic skills the young resident tries to complete his (her) exam at his (her) own responsibility, his diagnostic and therapeutic suggestions are supervised by the tutor.In difficult cases or in doubt the knowledge is double-che-ckedcked by means of a book (Kanski) or Pubmed to fulfil the requirements of Evidence based medicine (EbM).DiscussionOur curriculum provides the resident with a written framework for his residency from the very beginning of his training. He is supervised by an elder resident, by a fellow or an assistant professor. This curriculum is complemented by an annual continuing education during the annual meeting of the Austrian Ophthalmological Society.

Wartelistenmanagement und Tageschirurgie bei Kataraktpatientinnen an der Universitäts-Augenklinik Graz

ZusammenfassungEs wird das neue Wartelistenmanagement für Kataraktoperationen dargestellt, welches aufgrund überlanger Wartezeiten dringend notwendig wurde. Zwingend damit einher geht die Einführung von tageschirurgischen Kataraktoperationen, begonnen am 1. 7. 2004 als Projekt, um bei gleichbleibender Qualität ein Mehr an Operationen durchführen zu können. Die einzelnen Projektschritte und diesbezügliche Prozessabläufe werden neben der LKF-Bepunktung und Personalbedarfsberechnung dargestellt. Die eigenen Erfahrungen an der Universitäts-Augenklinik sind sehr gut, eine Ausweitung des Projektes und damit weitere Anpassung an ökonomische und gesundheitspolitische Vorgaben ist vorgesehen.SummaryThe new management of the waiting list for cataract patients, which was necessary due to overwhelming waiting times for cataract surgery, will be described. These changes had to be combined imperatively with the introduction of day case cataract surgery as a project started on July 1, 2004. The aim was an increase in cataract surgeries in the same high standard of quality. The single processes, the LKF-point system and the amount of additional employees is described. The experiences in the Department of Ophthalmology at Graz are excellent, so we will enlarge this successful project in the future to fulfill economical and political targets.