Franz Josef Steinkogler

Endoscopic laser recanalisation of presaccal canalicular obstruction

AIM To document the results of erbium (Er)-YAG laser treatment in presaccal canalicular obstruction in combination with the use of a flexible endoscope. METHODS For the first time an Er-YAG laser (Schwind, Sklerostom) was attached to a flexible endoscope (Schwind, Endognost) and used to recanalise a stenosis of the upper, lower, or common canaliculus. In 17 patients (mean age 41.5 (SD 11.9) years), 19 treatments (two bilateral) were performed. In all cases the scar was observed using the endoscope and was excised by laser ablation. A silicone intubation was performed in all cases. In addition to the endoscopy an irrigation was performed to prove the intactness of the lacrimal pathway system after laser treatment. RESULTS Membranous obstructions with a maximum length of 2.0 mm (14 procedures) in the canaliculus were opened easily using the laser, and the silicone intubation was subsequently performed without difficulty. Scars thicker than 2.0 mm could not be opened safely without canaliculus penetration (five procedures). Irrigation was positive in all cases up to the end of a 6 month period, providing the tubes remained in place. The maximum follow up is now 17 months (minimum 8 months) and in 16 cases (84.2%) the canaliculi are still intact. CONCLUSION Endoscopic laser treatment combined with silicone intubation enables us to recanalise presaccal stenoses of canaliculi under local anaesthesia up to a scar thickness of 2.0 mm. Best results can be achieved in cases where much tissue can be saved. Under such conditions this procedure can substitute for more invasive surgical techniques, especially a conjunctivo-dacryocystorhinostomy (CDCR).

Retrograde Dilation of Postsaccal Lacrimal Stenosis

The causes of nasolacrimal duct stenosis in adults can vary greatly. In general, the symptoms can also vary, but most cases share a tendency toward recurring inflammations in the prestenotic area. The treatment of these disorders is limited to either conservative therapy to control inflammation or surgically invasive measures. By using balloon catheters, usually applied in percutaneous transluminal coronary angioplasty (PTCA), dilation of the relative postsaccal stenosis can be performed under radiographic control. An exact diagnosis using various testing methods, including digital dacryocystography for detailed localization and documentation of any pathologic changes, is decisive to success. Only in cases of incomplete postsaccal stenosis is retrograde balloon dilation of the distal nasolacrimal duct indicated. A guide wire, designed for the PTCA balloon catheter set, is introduced via the canaliculus to the nasal cavity antegradely and caught with a thin hook and pulled from the naris, under visual control with an image converter. The balloon catheter is retrogradely threaded over the guide wire. The balloon is then placed at the site of the pathologic stenosis under radiographic control and dilated with high pressure. To ensure the permeability of the system, monocanalicular silicone intubation has to be performed immediately afterwards. This procedure has been performed successfully on 6 patients with a follow-up of 6 to 27 months. These initial results give rise to the hope that this minimally invasive, interdisciplinary technique represents a new alternative in the treatment of incomplete postsaccal lacrimal stenosis.

Heparin Surface Modified PMMA Lenses in a Prospective Double Blind Study

Objective: To determine if heparin surface modification of polymethylmethacrylate (PMMA) lenses increases biocompatibility by a measurable amount. Study Design: Prospective double blind study of postoperative results at 1 week, 1, 2 and 6 months after surgery. Setting: Second University Eye Clinic, Vienna. Patients: Forty adult patients were divided into two groups: in 20 cases heparin surface modified (HSM) PMMA lenses were implanted, in the other 20 patients PMMA lenses of the same type but without surface modification were implanted. Main Outcome Measures: Intraocular irritation, macrophage deposits on the lens, visual acuity, tension and postoperative cortisone dosage. Results: All patients with age appropriate fundus achieved a postoperative visual acuity of 0.8 to 1.25. Twenty per cent of the non-HSM lenses were covered with foreign body giant (FBG) cells but no FBG cells were found in the HSM group. Conclusions: There was little difference between the two groups, except in the foreign body giant cell deposits on the lens surface. This suggests that hydrophilization positively influences the compatibility of the artificial lens in the eye.

In-the-bag Implantation of Heparin Modified Posterior Chamber Lenses

In a prospective study, heparin surface modified posterior chamber lenses were implanted into the capsular bag in 50 patients with an average age of 74.1 years. The exact positioning of the biconvex, one-piece lens in-the-bag is a prerequisite for good centration and an optimal result. The hydrophilization of the originally hydrophobic PMMA material is achieved by heparin surface modification and results in decreased inflammation. The aim of this study was to investigate the postoperative behaviour of the HSM posterior chamber lens implanted in the bag, with special consideration given to intraocular inflammation. In the postoperative follow-up time of 5 to 10 months, 100% of the patients with physiological fundus reached a postoperative visual acuity of 0.7 or better.

Videodocumentation in digital dacryocystography

The digital dacryocystography proved to be the optimum method of X-ray diagnostics in obstructions of the lacrimal pathways. The examination was performed with a computer controlled X-ray unit with a C-arc coupled to an image intensifier tv-system. In the study the advantages of this technique were combined with the advantages of modern videotechnique. A nonionic water soluble contrast medium was used. The bilateral contrast medium filling process was registrated and the findings were recorded on videotape concurrently. The videocassettes, marked with the data of the patients and the date of examination, are stored in a video-tape library. This provides an always repeatable diagnostic documentation and it is also an excellent base for scientific analyses. The technique and the results of the examinations, performed with 18 patients, are described.

Leitlinien der Kommission für Okuloplastik (Orbita + Dakryologie) der ÖOG

ZusammenfassungDie Leitlinien der Kommission für Okuloplastik (Orbita + Dakryologie) sollen einen systematischen Überblick über konservatives und chirurgisches Management von Lid-, Orbita-, und Tränenwegserkrankungen geben. Lidfehlstellungen sowie Tumoren der Lider und der Orbita werden klassifiziert und diagnostische Verfahren und Therapieformen der Lid-, Orbita-, und Tränenwegschirurgie werden dargestellt. Außerdem wird ein Überblick über die ästhetische Lidchirurgie und die Indikationen dafür gegeben, und die konservative und chirurgische Therapie der Endokrinen Orbitopathie beschrieben. Ein abschließendes Kapitel informiert über die aktuellen Therapiemöglichkeiten beim Trockenen Auge.SummaryThe guidelines of the committee for oculoplastic surgery offer a systematic overview of conservative and surgical methods in eyelid-, orbital-, and lacrimal surgery. Malpositions of the eyelid, eyelid tumors and orbital tumors are classified and methods of diagnosis and therapy in eyelid orbital surgery and lacrimal surgery are illustrated. Furthermore a review of aesthetic eyelid surgery and the conservative and surgical approach to graves orbitopathy is given. A concluding chapter will give information to current therapy options in dry eye disease.

Macrophages incorporate PTFE-material of explanted polytetrafluoroethylene lacrimal prosthesis

In a 29 year old patient suffering from complete posttraumatic obstruction of the lacrimal system a PTFE-vascular graft was implanted as a bypass between conjunctival and nasal mucosa. The bypass was patent and well tolerated for 2 1/2 years before it had to be removed because of a therapy refractive naso-cutaneous fistula. Light- and electronmicroscopy of the explanted material showed an accumulation of inflammatory cells and fibrovascular tissue growing into the internodal spaces from both the outer and luminal surface. Numerous activated macrophages, the phagosomes containing amorphous material of different, partly fibrillary shape presumed to be degraduated PTFE, could be detected. The smooth inner surface was not covered by epithelial cells.

Die Okuloplastische Chirurgie

ZusammenfassungEinleitungDer historische Hintergrund soll beschrieben werden und moderne Entwicklungen der Diagnostik und Behandlung von Liderkrankungen zur Darstellung kommen.Historischer HintergrundDer historische Hintergrund beginnt schon 2000 Jahre vor Christus, wo in Indien und Ägypten Beschreibungen von Augenliderkrankungen und deren Behandlung gefunden worden waren. Die weitere Entwicklung verschiedener Operationsmethoden und diagnostischer Verfahren bis hin zur heute üblichen kausalen Therapie werden skizziert.MethodeKongenitale wie erworbene Liderkrankungen werden mit modernen Techniken erfolgreich diagnostiziert und behandelt. Die klassischen chirurgischen Instrumente werden mit neuen Systemen wie Laser- oder Surgitrontechnologie kombiniert.Die kausale Chirurgie führt zu den besten Ergebnissen, wenn die funktionelle Wiederherstellung des Lidapparates erforderlich ist.In der Tumorchirurgie ist die histologische Kontrolle unerlässlich und stellt die Basis für die sichere und vollständige Entfernung des Tumors dar.SchlussfolgerungLiderkrankungen belästigen unsere Patienten nicht nur, sie stellen auch eine Beeinträchtigung des Sehvermögens dar und können im Fall einer Tumorinvasion zum Verlust des Auges führen.Lidfehlstellungen müssen vor jedem intraokularen Eingriff saniert werden, um eine Gefährdung des Auges zu vermeiden.SummaryPurposeTo schemetize the historical background and to describe the development of modern diagnosis and treatment of eyelid diseases.Historical backgroundFirst descriptions of eyelid disorders and surgical therapy have been found in India and Egypt more than 2000 years before Christ.The development of different surgical methods and the necessary surgical instruments have been described mainly in the latter centuries especially in Europe and were leading to the modern diagnostic techniques and causal surgical concepts being used in the 21st century.MethodsCongenital disorders as well as aquired eyelid diseases can sufficiently be diagnosed and treated by means of modern techniques and equipment.The classical surgical instruments are still used and combined with new systems like Lasertechnology or Surgitron.Fibrin sealing technique has revolutionized specially the fixation of free skin transplants and improved the postoperative healing process.Causal surgical treatment is important in repair of malpostions of the eyelids to sufficiently restore the function of the eyelid apparatus.Tumor surgery must not be performed without histological control and newly developed reconstruction techniques make better results possible.ConclusionEyelid problems are not only annoying for our patients they also affect the visual acuity, endanger the eyeball and can even lead to the loss of the eye and so they have to be cured by causal surgical therapy.Before performing an intraocular operation eyelid disorders have to be cured to avoid intraocular infection and severe damage of the eye.

Volumsersatz der Orbita mit Bioplastique

ZusammenfassungNach Enukleation ohne, oder mit zu kleinem Orbitaimplantat entsteht häufig ein Post-Enukleations Socket Syndrom, welches sich aus Enophthalmus, tiefer Oberlidfalte, Ptosis und Lax Lower Lid konstituiert. Die Hauptursache ist im Volumsverlust in der Orbita zu sehen. Als Therapie konnte bisher nur eine Sekundärimplantation der Orbita oder ein Wechsel des Orbitaimplantates bei zu kleinen volumsinsuffizienten Implantaten durchgeführt werden. Dies bedeutete jeweils eine Eröffnung der Orbita und damit meist einen Eingriff in Narkose. Seit kurzem steht uns ein neues strukturiertes, Kopolimer als injizierbares Material zur Verfügung, dessen biphasisch inerte Mikropartikel weder im Gewebe wandern, noch vom Organismus absorbiert werden. In Verbindung mit einem bioextrahierbarem Gel als Vehikel kann dieses Material über eine spezielle stumpfe Applikationskanüle in das Gewebe (in die Orbita) in Lokalanästhesie eingebracht werden und wird dort von Bindegewebe umwachsen. Bei 12 Patienten mit Post-Enukleations Socket Syndrom wurde dieses neue Material (Bioblastique®) weltweit erstmals in der Orbita angewendet und zeigte bei exakter Indikationsstellung und bei vorsichtig dosierter Anwendung gute Ergebnisse, wobei die Nachbeobachtungszeit mit 2 Jahren noch relativ begrenzt ist.SummaryEnucleation without using an orbital implant often causes enophthalmus, deep upper eyelid sulcus, ptosis and laxity of the lower lid. These signs constitute the post-enucleation socket syndrome.In order to cope with it, mainly the volume deficit of the orbit has to be filled with an intraorbital implant.A new technique provides injecting Bioplastique®, a new textured copolymer microparticle, into the orbit thus substituting the deficiency of soft tissue after removal of the globe.The new textured, micronized, inert, biphasic copolymer particles neither migrate nor become absorbed by the body. The particles are textured, of critical dimension, and when mixed with a bioexcretable gel vehicle, can be implanted using a special blunt-tipped cannula.This technique was first used in twelve patients with Post Enucleation Socket Syndrome (PESS). The first results of this new method after a limited follow up time of 2 years are described.

Digitale Dacryocystographie mit Videodokumentation

ZusammenfassungDie digitale Dacryocystographie (DDCG) stellt die derzeit optimale Methode in der Röntgendiagnostik der Tränenwege dar. Die Untersuchung erfolgt mittels einer computergesteuerten Röntgenanlage mit C-Bogen, die an eine Bildverstärker-Fernsehkette gekoppelt ist. Die Vorteile dieser Technik werden nun mit den Vorteilen moderner Videodokumentation kombiniert.Der bilaterale Kontrastmittelfüllungsvorgang wird simultan auf Videoband aufgezeichnet, sodaß dieser dynamische Untersuchungsvorgang, auch dynamisch reproduzierbar dokumentiert ist.Die Ergebnisse werden in Form einer DDCG-Videothek sortiert und aufbewahrt, wodurch eine gute diagnostische Dokumentation gegeben ist. Daneben kann mit dieser Methode eine Basis für weitere wissenschaftliche Arbeiten geschaffen werden.SummaryThe digital dacryocystography proved to be the optimum method of X-ray diagnostics in obstructions of the lacrimal pathways. The examination is performed with a computer controlled X-ray unit with a C-arc coupled to an image intensifying TV-system. The advantages of this technique are combined with the advantages of modern videotechnique.The bilateral contrast medium filling process is registered and the findings are recorded on videotape concurrently.The videocassettes, marked with the data of the patients and the date of examination, are stored in a video-tape library.This provides an always repeatable diagnostic documentation and it is a base for further scientific analyses.