Christoph Althaus

Successful treatment of ocular invasive mould infection (fusariosis) with the new antifungal agent voriconazole

Editor,—Voriconazole is a new, highly potent, triazole with broad spectrum activity against fungi, including moulds as well as fluconazole resistant Candida spp.1 Like other azole antifungal agents it interferes with ergosterole biosynthesis. Its antifungal activity has been shown in several experimental as well as clinical studies.2-5 ### CASE REPORT In November 1998, a 16 year old girl was transferred to the university eye hospital in Duesseldorf with a severe ulcerative hypopyon keratitis in the left eye, from which she had been suffering for 3 months after swimming in a lake in Italy. Smears, scrapings, and serology gave no hint of the aetiology. Despite intensive topical antibacterial, anti-acanthamoebal, antifungal, and antiherpetic therapy, as well as cryoapplication, her clinical situation had deteriorated continuously before admission to our hospital. As an optical rehabilitation was unlikely, owing to the severely …

Mycophenolate mofetil versus cyclosporin A in high risk keratoplasty patients: a prospectively randomised clinical trial

BACKGROUND/AIMS The requirement for an effective, minimally toxic immunosuppressive agent remains a major obstacle to performing high risk corneal transplantation. Although therapy with cyclosporin A (CSA) allows superior graft survival, its use is limited because of a wide range of side effects. Mycophenolate mofetil (MMF) has been shown to be a safe and effective immunosuppressive agent following renal transplantation. This prospective, randomised clinical trial was carried out to investigate the efficacy and safety of MMF in preventing corneal allograft rejection. METHODS Recipients of corneal transplants who were at high risk for graft failure were randomly assigned to either CSA or MMF immunosuppressive therapy. CSA was given in doses to achieve whole blood trough levels of 120–150 ng/ml. MMF was given in a daily dose of 2 g. Both therapy groups additionally received oral corticosteroids (fluocortolone 1 mg/kg) which were tapered and discontinued within the first 3 postoperative weeks. Patients were monitored closely for evidence of corneal graft rejection and adverse side effects. Drug efficacy was measured, primarily, by the number of patients who experienced at least one episode of clinical graft rejection. Safety analysis focused on reported adverse side effects and laboratory measurements. RESULTS 41 patients were enrolled in the study. There was no statistically significant difference between the two groups. 20 patients received CSA and 21 patients received MMF. Two patients in each group showed evidence of acute graft rejection which could be treated effectively by corticosteroids. All corneal grafts remained clear throughout the follow up. CONCLUSIONS In this study it was shown that MMF is just as effective as CSA in preventing acute rejection following high risk corneal transplantation. Mycophenolate mofetil represents a promising alternative therapeutic option in patients who are at high risk for corneal graft failure.

Impressions- und Applanationstonometrie bei pathologischen Hornhäuten im Vergleich mit der intraokularen Nadeldruckmessung

ZusammenfassungHintergrund. In der Vergangenheit konnten wir mit Einsatz der elektronischen intraokularen Nadeldruckmessung zeigen, dass die Applanationstonometrie bei pathologischen Hornhäuten ganz überwiegend falsch niedrige Werte liefert. Ziel dieser Studie war es zu untersuchen, ob bei diesen Hornhäuten die Impressions-Tonometrie genauere Ergebnisse liefert, als die Applanations-Tonometrie. Patienten und Methoden. Bei 75 glaukomverdächtigen Augen mit verschiedenen Hornhautveränderungen wurde nach Applanations- und Schiötz-Tonometrie (jeweils 5,5 g, 7,5 g und 10 g Gewicht) erneut applanatorisch gemessen, um einen möglichen Tonographie-Effekt abzuschätzen. Anschließend wurde eine intraokulare Nadeldruckmessung durchgeführt. Ergebnisse. Die applanatorisch ermittelten Druckwerte lagen durchschnittlich 4,1±5,3 mmHg unter den tatsächlichen intraokularen Werten. Die Schiötz-Tonometrie ergab für alle Gewichte ebenfalls eine falsch niedrige Messung um 4,3± 6,8 mmHg (5,5 g), 4,3±6,4 mmHg (7,5 g) und 4,8±7,0 mmHg (10 g). Der Unterschied zur Applanationstonometrie war dabei für kein Gewicht statistisch signifikant. Die Messwerte aller extraokularen Verfahren lagen statistisch signifikant unter den elektronisch intraokular gemessenen Werten (p<0,001). Schlussfolgerung. Die Impressions-Tonometrie ist bei pathologischen Hornhautveränderungen der Applanationstonometrie nicht überlegen. Beide Verfahren liefern durchschnittlich die gleichen falsch-niedrigen Werte.AbstractPurpose. During the past 4 years we have demonstrated in eyes with corneal pathology that applanation tonometry (Goldmann, Perkins) generally delivers falsely low measurements in comparison to intraocular needle tonometry. The aim of this study was to evaluate whether impression tonometry (Schioetz) is more precise than applanation tonometry in determinating the intraocular pressure in eyes with corneal disorders. Patients and methods. In 75 eyes with suspected glaucoma and various corneal disorders, we performed applanation tonometry and impression tonometry before intraocular needle tonometry. Applanation tonometry was repeated after impression tonometry to unveal a possible tonography effect. Intraocular needle tonometry was performed thereafter. Results. Applanation tonometry results were 4.1±5.3 mmHg below intraocular pressure as determined by intraocular needle tonometry. Impression tonometry results were also lower: 4.3±6.8 mmHg (5.5 g), 4.3±6.4 mmHg (7.5 g), and 4.8±7.0 mmHg (10.0 g). The differences between applanation tonometry and impression tonometry were statistically not significant. In contrast, all the differences between extraocular tonometry procedures and intraocular needle tonometry were statistically highly significant (P<0.001). Conclusion. In corneal pathology both, applanation tonometry and impression tonometry do not deliver reliable results on an average. Only intraocular needle-tonometry delivers reliable results in these eyes.

Intraoperative Intraocular Endoscopy in Transscleral Suture Fixation of Posterior Chamber Lenses: Consequences for Suture Technique, Implantation Procedure, and Choice of PCL Design

BACKGROUND Transscleral suture fixation of posterior chamber lenses (PCLs) in the absence of capsular support causes minimal long-term alteration of the blood-aqueous barrier, if two requirements are fulfilled: 1) the transscleral suture has to penetrate exactly through the ciliary sulcus, and 2) the PCL haptics have to be directed into the sulcus and secured there. METHODS The surgical results of our standard techniques were controlled intraoperatively by means of intraocular endoscopy in every patient since May 1991. Different alterations were necessary to improve the incidence of sulcus penetration and implantation. RESULTS With our conventional suture techniques, the needle penetrated the ciliary processes in the majority of eyes. Best results were achieved by passing the needle from the outside into the eye before opening the globe. When the eye was already hypotonic, the ciliary processes tended to prolapse in front of the needle tip, resulting in pars plicata fixation. With perforating keratoplasty, passing the needle from the inside out by feeding ones way into the sulcus with the needle tip gave good results. Even correct needle penetration through the sulcus did not guarantee correct positioning of the PCL haptics in the sulcus. CONCLUSIONS Selecting a suitable PCL design and a new implantation technique which reduces the angle of PCL implantation, the rate of correctly positioned PCLs in transscleral suture fixation is increased considerably.

More than 4 years' experience with electronic intraocular needle tonometry

SummaryBackground: Applanation tonometry in eyes with pathological corneae can often not be performed or delivers rather questionable results. We report on our 4-year experience with electronic intraocular needle tonometry. Patients and methods: After since 1994 developing and calibrating a system for intraocular needle tonometry, we have performed 395 measurements in 252 eyes with irregular corneae and suspicion of glaucoma. If applanation tonometry values could be obtained, they were compared with the true intraocular pressure. Results: Depending on the kind of corneal pathology, applanation tonometry values were lower and sometimes much lower than true intraocular pressure. No serious complications occurred as a result of intraocular needle tonometry. Conclusions: Intraocular needle tonometry is a safe procedure and is the only way to measure intraocular pressure precisely in eyes with pathological corneae.ZusammenfassungHintergrund: Die Augeninnendruckmessung mittels Applanation an pathologisch veränderten Hornhäuten ist oft nicht möglich oder ihre Ergebnisse sind äußerst zweifelhaft. Wir berichten über unsere mehr als vierjährige Erfahrung mit der elektronischen intraokularen Nadel-Druckmessung bei irregulären Hornhäuten. Patienten und Methode: Nach Entwicklung und Eichung des intraokularen Nadel-Druckmessverfahrens wurden seit 1994 an 252 Augen mit irregulären Hornhäuten und Glaukomverdacht 395 Messungen durchgeführt. Die Ergebnisse der intraokularen Messungen wurden mit den nur bei einem Teil der Patienten applanatorisch ermittelbaren Werten verglichen. Ergebnisse: Die applanatorisch erhobenen Werte lagen meist tiefer und je nach Hornhautpathologie manchmal sehr viel tiefer als die tatsächlichen intraokularen Werte. Ernsthafte Komplikationen der intraokularen Messung wurden bisher nicht beobachtet. Schlußfolgerung: Die intraokulare Druckmessung ist sicher und ermöglicht die exakte Ermittlung des intraokularen Druckes auch in Augen mit pathologisch veränderten Hornhäuten.

Experience with transscleral fixation of posterior chamber lenses

A total of 83 eyes with transsclerally sutured PCLs were followed for an average of 10.5 months (range 2–23 months). The vast majority of patients benefitted considerably from the procedure; 8% of cases experienced a reduction in visual acuity and 2% suffered monocular visual loss. General vascular risk factors seemed to be important in bringing about long-term complications. Patients presenting such a risk must be better identified in the future. The solution of some remaining surgical problems and questions will also add to the safety of the procedure in the future.

Prophylactic argon laser coagulation for rhegmatogenous retinal detachment in AIDS patients with cytomegalovirus retinitis

Abstract · Background: The incidence of cytomegalovirus (CMV) retinitis in patients with acquired immunodeficiency syndrome (AIDS) reaches 20–45%. Despite aggressive medical treatment, rhegmatogenous retinal detachments develop in up to 30% of the affected eyes. Surgical repair is often difficult due to multiple, large and hardly visible retinal holes with vitreal traction. Pars plana vitrectomy with instillation of silicone oil is the procedure of choice, giving limited functional results with anatomical reattachment. · Methods: We performed prophylactic laser coagulation in AIDS patients with medically treated CMV retinitis to prevent a progressive retinal detachment. Twenty-two quiescent CMV lesions in 22 eyes of 20 patients were treated with argon green laser coagulation. Each CMV lesion was completely surrounded with a double or triple row of laser spots (500–600 μm; 0.2 s; gray-white lesions). · Results: The duration of follow-up was 2–24 months. Histopathologic evaluation was possible in two eyes of one patient. Reactivated or smoldering CMV retinitis crossed the laser scars in 11 eyes, making additional laser coagulation necessary. In four eyes retinal holes in the CMV scar tissue led to retinal detachment, which stopped at the laser scar. In three eyes the detachment is still controlled by the laser scar. In one eye, the detachment stopped at the laser scar for 6.5 months and then slowly progressed across it. There were no complications associated with our laser treatment. · Conclusion: Prophylactic argon laser coagulation in quiescent CMV retinitis seems to reduce the rate of progressive retinal detachment with no need for vitrectomy and silicone oil tamponade.

Argon laser photocoagulation to prevent rhegmatogenous retinal detachment in patients with acute retinal necrosis (ARN) syndrome

SummaryBackground: ARN syndrome follows severe intraocular infection by herpes viruses and primarily affects the peripheral retina. Following scar formation, despite antiviral treatment, rhegmatogenous retinal detachment occurs very often. Prophylactic argon laser photocoagulation has therefore been proposed. We report our experience. Patients: We treated five patients presenting clinically with advanced unilateral ARN with acyclovir. All eyes received a prophylactic confluent double row of argon laser treatment (500 μm, 0.2 s, gray-white lesions) central to the affected area as soon as was possible, depending on the vitreous clouding. Four patients were treated with Aspirin. Results: One of the five patients had a peripheral rhegmatogenous retinal detachment that was limited by the argon laser row. Another patient had a tractional detachment needing vitreoretinal surgery. Two eyes developed vitreal hemorrhage of unknown origin. Conclusion: A lower rate of rhegmatogenous retinal detachments than expected occurred post-laser treatment. Vitreal hemorrhage was more frequent than previously reported. The bleeding probably originated from anterior retinal neovascularization and may have been enhanced by Aspirin treatment. We recommend early prophylactic argon laser photocoagulation in all ARN patients in agreement with the results of previous studies.ZusammenfassungHintergrund: Das akute Retinanekrose (ARN)-Syndrom wird durch eine Infektion der peripheren Netzhaut mit Viren der Herpesgruppe verursacht. Nach narbiger Abheilung unter antiviraler Therapie treten sehr häufig rhegmatogene Amotiones auf, weshalb eine prophylaktische Argon-Laserkoagulation (ALK) empfohlen wird. Wir berichten über unsere Erfahrungen. Patienten und Methoden: Fünf Patienten mit ausgedehnter unilateraler ARN wurden systemisch mit Aciclovir behandelt. Alle Augen erhielten eine prophylaktische ALK mit einer konfluierenden Doppelreihe (500 μm, 0,2 s, grau-weiße Herde), sobald und soweit der Einblick es ermöglichte. Vier Patienten erhielten prophylaktisch Acethylsalicylsäure. Ergebnisse: Ein Patient entwickelte eine periphere rhegmatogene Netzhautablösung, die nicht über die ALK-Doppelreihe hinaus ging. Bei einer Patientin kam es zu einer flachen peripheren Traktionsamotio, die einen vitreoretinalen Eingriff erforderte. Bei zwei Augen kam es zu einer Glaskörperblutung. Eine Blutungsquelle war nicht erkennbar. Schlußfolgerungen: Es traten nach prophylaktischer Laserkoagulation seltener rhegmatogene Netzhautablösungen auf als erwartet. Glaskörperblutungen waren jedoch häufiger als bisher beschrieben. Wahrscheinlich handelt es sich um Blutungen aus anterioren retinalen Neovaskularisationen, die möglicherweise durch Acethylsalicylsäure begünstigt wurden. Wir empfehlen eine frühzeitige prophylaktische ALK bei allen ARN-Patienten in Übereinstimmung mit anderen Studien.

Cystoid macular edema following immune recovery and treatment with cidofovir for cytomegalovirus retinitis.

Abstract · Background: Cytomegalovirus (CMV) retinitis is the most common opportunistic ocular infection in AIDS patients. Cidofovir has proved to be highly effective in treatment of CMV retinitis. Iritis and bulbar hypotony are known as the major complications after intravenous and intravitreal use of this antiviral drug. Cystoid macular edema (CME) after intravenous application of cidofovir has not been reported. · Methods: We analyzed retrospectively the incidence of CME after intravitreal or intravenous application of cidofovir and its correlation with CD4 cell counts of the patients. · Results: Two (22.2%) of 9 eyes in the intravenous and 3 (18.8%) of 16 eyes in the intravitreal injection group developed CME. It occurred between 3 and 48 weeks after cidofovir administration. In all eyes CMV retinitis was inactive. All patients received highly active antiretroviral treatment (HAART). CME was correlated with a rapid and sustained improvement in CD4 cell counts. · Conclusion: We interpret the occurrence of CME as an immune recovery phenomenon for the following reasons. All CMEs were seen in eyes with inactive CMV retinitis and the unaffected contralateral side never developed CME. The time range of appearance between 3 and 48 weeks after cidofovir administration makes direct toxicity of cidofovir unlikely. All patients had a sustained improvement of CD4 cell counts due to HAART. No CME was reported during the use of cidofovir before the HAART era.

Radiotherapy in age-related macula degeneration

PURPOSE To ascertain the benefit from radiotherapy in age-related macula degeneration in a single-arm longitudinal study. METHODS AND MATERIALS From 1997 to 1998, 39 patients with occult and 33 patients with classic choroidal neovascularization (CNV) were irradiated with 16 Gy. Fluorescein angiography and measurements of visual acuity were performed before and 3, 6, and 12 months after irradiation. RESULTS Complete follow-up data for 1 year were available from 69 patients. The mean patient age was 72 years (range 49-92). Vision decreased in 43, was stable in 18, and improved in 8 cases. The mean vision deteriorated significantly (p = 0.02, Wilcoxon test), particularly within the first 3 months. Patients with occult CNV did significantly better than did those with classic CNV (p = 0.03). The proportion of patients retaining vision > or = 0.2 fell from 65% to 42% (p <0.01), for classic and occult CNV from 50% to 23%, and for occult CNV from 77% to 56% (p < 0.02), respectively. CNV size increased in 30 patients and was stable in 38. Neither age (p = 0.17) nor gender (p = 0.21, chi-square test) influenced prognosis. Four patients reported transitional complaints. CONCLUSION Low-dose fractionated radiotherapy with 16 Gy is well tolerated. However, vision and reading ability were not preserved in most patients.