Claudia Kuhli-Hattenbach

Intravenous Thrombolysis With Low-dose Recombinant Tissue Plasminogen Activator in Central Retinal Artery Occlusion

PURPOSE To evaluate the beneficial effect of intravenous thrombolysis aiming at rapid restoration of blood flow during the early hours of a central retinal artery occlusion (CRAO). DESIGN Interventional case series. METHODS In the present study, we prospectively evaluated the visual outcome after thrombolytic treatment with low-dose (50 mg) rt-PA (recombinant tissue plasminogen activator) and concomitant intravenous heparinization in patients with acute CRAO, best-corrected visual acuity (BCVA) < or = 20/100, and onset of symptoms within 12 hours prior to treatment. RESULTS Twenty-eight patients (28 eyes) were included in this study. Final visual acuity was improved three or more lines in nine eyes (32%), stable in 18 (64%), and worse in one eye. Time to treatment < or = 6.5 hours was associated with a better gain of lines of vision (P = .004). Seven of 17 eyes (41%) that received thrombolytic treatment within the first 6.5 hours achieved a final BCVA > or = 20/50, compared to none in the subgroup of patients with onset to treatment >6.5 hours (P = .023). We observed no serious adverse events. CONCLUSIONS Our findings indicate that thrombolytic treatment with intravenous low-dose rt-PA is of value for an improved visual recovery in patients with acute CRAO, if administered within the first 6.5 hours after the onset of symptoms.

Risk Factors for Complications After Congenital Cataract Surgery without Intraocular Lens Implantation in the First 18 Months of Life

PURPOSE To determine individual risk factors for the development of postoperative complications after pediatric cataract surgery in the first 18 months of life. DESIGN Interventional, consecutive case series. METHODS We retrospectively reviewed the records of 71 eyes of 46 children who underwent surgery for congenital cataract within the first 18 months of life. A limbal approach bimanual lens aspiration, posterior capsulorrhexis, and anterior vitrectomy without intraocular lens implantation was performed in all children. We examined the interrelationships of operative and postoperative complications with other variables such as patient age, family history, or ocular abnormalities. The mean follow-up period was 39 months. RESULTS The most frequent postoperative complications were late-onset open-angle glaucoma (10.8%) and vitreous hemorrhage (10.8%), whereas early-onset glaucoma (4.6%) was less common. Secondary cataract was observed in seven eyes (9.2%). We determined a family history of aphakic glaucoma in first-degree relatives (P = .007) as well as cataract surgery in the first three months of life (P = .039) and nuclear cataracts (P = .0009) to be strong predictors of late-onset glaucoma. Secondary cataract formation was associated strongly with lensectomy in the first five months of life. The diagnosis of postoperative hemorrhages was associated significantly with the presence of persistent fetal vasculature (P < .0001). CONCLUSIONS Patients with preoperative predictors at presentation such as young age at the time of surgery, a family history of aphakic glaucoma, nuclear cataract, or persistent fetal vasculature syndrome offer a clear target for extensive postoperative care after congenital cataract surgery.

Subretinal hemorrhages associated with age-related macular degeneration in patients receiving anticoagulation or antiplatelet therapy.

PURPOSE To evaluate the incidence of and risk factors for subretinal hemorrhages in age-related macular degeneration (AMD) patients on anticoagulation or antiplatelet therapy. DESIGN Retrospective, observational case series. METHODS We retrospectively reviewed the medical and photographic records of 71 consecutive patients who sought treatment at our institution with acute subretinal hemorrhages complicating age-related macular degeneration. The size of the subretinal hemorrhage was measured in standardized Macular Photocoagulation Study disc areas. Data on the use of medications and medical indications for anticoagulation and antiplatelet therapy were obtained. RESULTS Overall, patients receiving antithrombotic therapy had a significantly larger subretinal hemorrhage size (mean, 9.71 disc areas) than patients not receiving anticoagulant or antiplatelet therapy (mean, 2.99 disc areas). Subgroup analysis revealed that both antiplatelet (P < .0001) and anticoagulant therapy (P = .003) were associated with a significantly larger bleeding size. Moreover, subgroup analysis among patients with arterial hypertension revealed that individuals receiving antithrombotic therapy had a statistically significantly larger hemorrhage size than hypertensive patients who did not receive anticoagulants or antiplatelet agents (P < .0001). CONCLUSIONS Our results indicate that anticoagulants and antiplatelet agents are strongly associated with the development of large subretinal hemorrhages in AMD patients. Moreover, arterial hypertension is a strong risk factor for large subretinal hemorrhages in AMD patients receiving anticoagulants or antiplatelet agents. Physicians should be aware of an increased risk of extensive subretinal hemorrhage in AMD patients when deciding on the initiation and duration of anticoagulant and antiplatelet therapy.

Accessibility of Health Information on the Internet to the Visually Impaired User

Purpose: Web sites containing health information should be accessible to visually impaired persons. Methods: 139 web sites containing medical information addressing laymen or patients were evaluated with respect to their accessibility. A quantitative checklist which is based upon the Web Content Accessibility Guidelines of the World Wide Web Consortium (W3C) was used. Results: Only 18% (15 sites) achieved WAI (Web Accessibility Initiative) level A or AA. WAI level AA was reached by only 1% (1 site) of the web sites. None of the web sites reached level AAA; 82% of the assessed web sites offering consumer health information are not fully accessible to visually impaired persons. Conclusion: The accessibility of web-based health content to visually impaired users should be improved. Health information on the web should at least meet the requirements of priority 1 (level A), preferably priority 2 (level AA) of the W3C guidelines.

Selective thrombophilia screening of patients with nonarteritic anterior ischemic optic neuropathy

BackgroundTo date, the question whether there is a relationship between thrombophilic disorders and the development of nonarteritic ischemic optic neuropathy (NAION) remains controversial. We sought to investigate the prevalence of various coagulation defects among NAION patients <65 years of age, and to provide clinical guidelines for a selective thrombophilia screening.MethodsA cohort of 35 patients <65 years of age with NAION and 70 controls matched for age and sex were prospectively screened for thrombophilic risk factors.ResultsOverall, thrombophilic defects were found to be present in 18 of 35 patients (51.4%) and in 12 of 70 (17.1%) controls (P = 0.0005). The most frequent coagulation disorders were increased levels of factor VIII (P = 0.015) and lipoprotein (a) (P = 0.005). Patients without cardiovascular risk factors had a statistically significant higher frequency of coagulation disorders than patients with these risk factors (P = 0.0059). There was a strong association of coagulation disorders and a personal or family history of thromboembolism (P = 0.028). Moreover, we determined the age of ≤55 years at the time of the first thromboembolic event or NAION as a strong predictor of underlying thrombophilia (P = 0.0002).ConclusionsOur results indicate that thrombophilic disorders are associated with the development of NAION in specific subgroups of patients. Selective screening of young patients, subjects with a personal or family history of thromboembolism, and patients without cardiovascular risk factors may be helpful in identifying NAION patients with thrombophilic defects.

Time between symptom onset and assessment in age-related macular degeneration with subfoveal choroidal neovascularization.

Background: Therapy delay in neovascular age-related macular degeneration (NV-AMD) is associated with risk of visual deterioration. Methods: Retrospective cross section analysis including patients with NV-AMD who received fluorescein angiography (FA). The time elapsed from symptom onset to assessment was analysed in relation to different factors. Inclusion criteria were: age >50 years, symptom onset within 6 months before assessment, no previous AMD therapy, indication for vascular endothelial growth factor inhibitor treatment. Results: Mean duration of symptoms was 2.272 ± 1.683 months (n = 220); percentiles 25, 50, 75 and 90 corresponded to 1, 2, 3 and 5.383 months. A significant increase (p = 0.033) in mean symptom duration was found between age groups 65–74, 75–84 and over 84 years. Privately insured persons (assessment 1.242 ± 1.060 months after symptom onset; n = 14) received FA 1.083 months earlier (p = 0.0089) than patients with a statutory health insurance (assessment 2.325 ± 1.661 months after symptom onset; n = 194). Conclusion: In order to avoid progressive visual deterioration in patients with NV-AMD earlier assessment of these individuals should be aimed for.

Selective thrombophilia screening of young patients with retinal vein occlusion

BACKGROUND The potential impact of coagulation abnormalities on retinal vascular occlusive diseases, individually and in combination with cardiovascular risk factors, remains unclear. PATIENTS AND METHODS In a prospective case-control study a cohort of 74 young patients with central, hemicentral or branch retinal vein occlusion (RVO) (<or= 45 years at the time of the RVO or a previous thromboembolic event) and 74 subjects matched for age and sex were prospectively screened for thrombophilic risk factors. RESULTS Overall, thrombophilic defects were found to be present in 38 of the 74 patients (51.4 %) and in 8 of 74 (10.8 %) controls (p < 0.0001). We found a strong association between the presence of thrombophilic disorders and a family history of thromboembolism (p < 0.0001). Patients without cardiovascular risk factors had a statistically significant higher frequency of coagulation disorders than patients with these risk factors (p = 0.0025). CONCLUSIONS Our results indicate that thrombophilic disorders are associated with the development of retinal vein occlusion. Selective screening of young patients, patients with a personal or family history of thromboembolism, and patients without cardiovascular risk factors may be helpful in identifying retinal vein occlusion patients with thrombophilic defects.

Clinical Effectiveness of Balloon Dacryocystoplasty in Circumscribed Obstructions of the Nasolacrimal Duct

Purpose: Balloon dacryocystoplasty (DCP) is known to have limited clinical success rates. In a previous publication, we tried to define subgroups that could benefit from interventional treatment of tear duct stenoses. The purpose of this study was to evaluate the clinical effectiveness of DCP performed with limited indication confined to patients with circumscribed stenosis or distal occlusion of the nasolacrimal duct (NLD). Patients and Methods: Twenty-nine patients with severe epiphora due to dacryocystographically proven postsaccal obstruction of the lacrimal draining system were treated by means of DCP and were available for a telephone interview after a median follow-up period of 40 months (5–75 months). A standardized questionnaire covered the individual history of epiphora before and after interventional treatment. All patients had circumscribed stenoses of the lower lacrimal sac or the NLD or presented with short-distance occlusions of the distal NLD. Patients with canalicular, high saccal or diffuse lesions as well as cases with active dacryocystitis, suspicion of dacryocystolithiasis or posttraumatic stenosis were excluded from DCP. Failures or recurrences with no major improvement compared with the initial status were taken as a study endpoint. Results: We dilated 21 partial and 8 complete obstructions and post-DCP control dacryocystograms showed a widening of the ductal lumen or improvement of flow. In 25 out of 29 patients, regression of clinical symptoms occurred during the first week after treatment, 4 cases remained unchanged. Ten out of 25 patients with initial improvement reported recurrence of severe epiphora after a median period of 5 months. Five patients of all treated patients (n = 29) received additional operative dacryocystorhinostomy (DCR) after failure of DCP or due to severe recurrences. One patient received DCR during the 1st week after DCP (n = 1). Four out of 25 patients with initial improvement underwent DCR. Overall, 15 of the 29 treated patients had durable improvement of epiphora by DCP alone. Conclusion: Even patients with circumscribed obstructions of the NLD and exclusion of factors potentially associated with poor outcome of tear duct stenosis after DCP balloon dilatation showed a limited clinical success and high recurrence rate. The main argument to continue DCP as first or second line treatment in selected patients with duct obstructions is its lack of invasiveness. Even patients with increased risk of general anesthesia can be treated and approximately half of the operations may be avoided.

Thrombophiliediagnostik und Abklärung systemischer Risikofaktoren bei Patienten mit venösen retinalen Gefäßverschlüssen

Over the past years there has been a dramatic increase in the number of identifiable causes of thrombophilia. However, as retinal vein occlusions (RVO) have a strong pathogenic correlation with the presence of hypertension or arteriosclerosis and the average age of affected patients is usually within the sixth or seventh decade of life, thrombophilia screening of RVO patients poses a particularly difficult diagnostic challenge. It is clear that to use medical resources appropriately and improve the level of interdisciplinary patient care in RVO, subgroup analysis is required. Just recently, some studies have demonstrated the significant role of coagulation disorders in specific subgroups of RVO patients and have provided recommendations for clinical practice. These results indicate that thrombophilic risk factors are significantly more prevalent among patients equal or less than 45 years of age at the time of RVO or a previous thromboembolic event, among patients with a remarkable family history of thromboembolism prior to the age of 45 years, or among patients without cardiovascular risk factors. According to these data, thrombophilia screening should be considered in these selected subgroups.

Predictability of intraocular lens calculation using the Holladay II formula after in-the-bag or optic captured posterior chamber intraocular lens implantation in paediatric cataracts.

Purpose: To assess the predictability of postoperative refraction using the Holladay II-formula in paediatric patients randomized to undergo 2 different surgical procedures. Methods: Fourty cataractous eyes of 29 patients (age 2.31–11.75 years) were operated with in-the-bag intraocular lens implantation. Randomly, either an anterior vitrectomy (group A, 19 eyes) or posterior optic capture without vitrectomy (group B, 21 eyes) was performed. Randomization was done in 4 separate age groups, in accordance with 4 target refractions (0, 1, 2 and 3 dpt) to compensate for the anticipated myopic shift. Results: The predicted refraction correlated with the achieved postoperative refraction (total group, p = 0.019), closer in group A (p = 0.033) than in group B (p = 0.265); however, the results of groups A and B were not significantly different (p = 0.324). There was a tendency for postoperative targeted hyperopia being underachieved in the youngest patients. Conclusion: The Holladay II formula provides reliable intraocular lens calculation in paediatric cataracts. The tendency to underachieve the target refraction in younger patients needs further investigation.