Gabriele C. Gusek-Schneider

Measurement of accommodation after implantation of an accommodating posterior chamber intraocular lens.

Purpose: To analyze techniques of measuring accommodation after implantation of an accommodating posterior chamber intraocular lens (PC IOL). Setting: Department of Ophthalmology and University Eye Hospital, University Erlangen‐Nürnberg, Erlangen, Germany. Methods: This prospective study analyzed 23 eyes of 23 patients (aged 41 to 87 years) after cataract surgery and PC IOL implantation (1 CU®, HumanOptics) 4 weeks and 3 and 6 months after surgery. The results were compared to those in an age‐matched control group (n = 20) 6 months after surgery. The following methods were used to measure accommodation: dynamic with objective techniques (PlusOptix PowerRefractor® videorefractometry, streak retinoscopy) and subjective techniques (subjective near point [push‐up test, accommodometer], defocusing); static with pharmacologic stimulation after pilocarpine 2% eyedrops directly (conventional refractometry); indirectly (change in the anterior chamber depth [ACD] with Zeiss IOLMaster®). Results: Results at 6 months, given as mean ± SD (range), in the study and control groups, respectively, were as follows: near visual acuity (Birkhäuser reading charts at 35 cm) with distance correction, 0.32 ± 0.11 (0.20 to 0.60) and 0.14 ± 0.10 (0.05 to 0.30); accommodation amplitude (diopters) by PowerRefractor, 1.00 ± 0.44 (0.75 to 2.13) and 0.35 ± 0.26 (0.10 to 0.65), by retinoscopy, 0.99 ± 0.48 (0.13 to 2.00) and 0.24 ± 0.21 (–0.13 to +0.75), by subjective near point, 1.60 ± 0.55 (0.50 to 2.56) and 0.42 ± 0.25 (0.00 to 0.75), and by defocusing, 1.46 ± 0.53 (1.00 to −2.50) and 0.55 ± 0.33 (0.25 to 0.87). The mean ACD decrease (mm) was 0.78 ± 0.12 (0.49 to 1.91) and 0.16 ± 0.09 (0.00 to 0.34) after pilocarpine 2% eyedrops, indicating a mean accommodation of 1.40 D and 0.29 D, respectively, based on Gullstrands model eye (P = .001). The lowest fluctuation between follow‐ups was with the subjective near point and the defocusing techniques followed by ACD decrease with the IOLMaster. Conclusions: Accommodation after implantation of an accommodating PC IOL should be assessed with several techniques, including subjective and objective, to differentiate true pseudophakic accommodation from pseudoaccommodation. Researchers should be aware of the different variability and consistency of measurements with each technique over time.

Implantation of a new accommodative posterior chamber intraocular lens.

PURPOSE A new, potentially accommodative posterior chamber lens (PCIOL) was designed based on principles elaborated by Hanna using finite element computer simulation methods. We report 3-month postoperative results in patients. METHODS In a prospective study, 12 eyes of 12 patients (age 45 to 87 yr) underwent phacoemulsification for cataracts and PCIOL implantation. The PCIOL, 1 CU, has haptics designed for anterior optic movement following ciliary muscle contraction. Patients were examined postoperatively after 1 and 2 days, 1, 2 and 6 weeks, and 3 months, and results were compared with a control group of 12 eyes that received standard PMMA or acrylic PCIOLs. RESULTS Surgery was uncomplicated and all PCIOLs were well-tolerated and stable with good centration in the capsular bag. The results were (mean +/- SD [range] and median; 1 CU versus control PCIOL): near visual acuity (Birkhäuser reading chart at 35 cm) with best distance correction 0.34 +/- 0.17 (0.2 to 0.6), 0.3 (J10-J1, median J7) versus 0.15 +/- 0.07 (0.1 to 0.3), 0.15 (J16-J7, median J13), P=.001; subjective near point 59 +/- 10 cm (40 to 100 cm), 53.5 cm versus 93 +/- 20 cm (64 to 128 cm), 86 cm, P=.004; retinoscopic accommodative range 1.2 +/- 0.4 D (0.63 to 1.5 D), 1.2 D versus 0.2 +/- 0.19 D (-0.25 to 0.5 D), 0.25 D, P < .001; decrease of anterior chamber depth after 2% pilocarpine 0.63 +/- 0.16 mm (0.40 to 0.91 mm), 0.63 mm versus 0.15 +/- 0.05 mm (0.08 to 0.20 mm), 0.17 mm, P < .001. CONCLUSIONS The new PCIOL appears to be safe at short to medium term. Our results indicate pseudophakic accommodation secondary to focus shift with this PCIOL. Additional larger and long-term studies are necessary for exact evaluation of safety and accommodative power of this new PCIOL.

Zwei Jahre Erfahrung mit der akkommodativen Hinterkammerlinse 1 CU

ZusammenfassungNachdem die optische Rehabilitation von Patienten mit Katarakt dank moderner mikrochirurgischer Techniken und der Entwicklung von faltbaren Hinterkammerlinsen (HKL) heute hervorragend ist, stellt die Therapie der Presbyopie nunmehr eine der großen ungelösten Fragen der Ophthalmologie dar. In den letzten Jahren wurde, basierend auf Konzepten von K.H. Hanna, mit Hilfe von Finite Elemente Computersimulationstechniken die akkommodative Hinterkammerlinse 1 CU entwickelt. Diese soll die verbliebenen Kontraktionskräfte des Ziliarmuskels in eine anteriore Bewegung der Kunstlinsenoptik im Auge umwandeln (Optik-Shift-Prinzip). Nach der Erstimplantation im Juni 2000 haben wir die 1 CU inzwischen bei über 90 Patienten implantiert. Die bisherigen Erfahrungen und Studien zeigen eine gute und sichere Implantierbarkeit, gute Zentrierung, fehlende kunstlinsenspezifische Komplikationen und guten Fernvisus. Im Vergleich zu Kontrollgruppen konnte bei Patienten mit der 1-CU-HKL ein signifikant besserer fernkorrigierter Nahvisus, eine größere Akkommodationsamplitude sowie mit dem IOL-Master (Zeiss) eine signifikant größere anterior-posteriore Bewegung der Kunstlinsenoptik nach medikamentöser Stimulation bzw. Lähmung des Ziliarmuskels nachgewiesen werden. Diese Ergebnisse können als Bestätigung des Konzeptes des Optic-Shift-Prinzips der 1-CU-HKL interpretiert werden. Insgesamt erscheint das Konzept akkommodativer Kunstlinsen attraktiv und zukunftsträchtig. Weitere Studien hinsichtlich Langzeitverträglichkeit und Akkommodationsleistung, vor allem randomisierte maskierte multizentrische Studien, sind erforderlich und in Vorbereitung.AbstractAfter marked improvement of optical rehabilitation of cataract patients during the last decades due to small incision surgery and foldable intraocular lenses (IOL), presbyopia is now one of the great unsolved questions in ophthalmology. During recent years a new accommodative IOL, the 1CU lens, has been developed based on the concepts of K.D. Hanna and on finite element computer simulation models. The 1CU IOL is designed to transform contracting forces of the ciliary muscle into anterior movement of the IOL optic (optic-shift concept). After the first implantation of a 1CU IOL in Erlangen in June 2000, we have now successfully implanted the 1CU IOL in over 90 patients. Our experiences and the results of several clinical studies indicate good and safe implantability, good centration, no IOL-specific complications, and good distance visual acuity. In comparison to control groups with conventional IOL, patients with the 1CU enjoyed significantly better distance-corrected near visual acuity, a larger accommodative range, and increased anterior and posterior axial movement of the lens optic after medical stimulation or inhibition of the ciliary muscle. We interpret our results as confirmation of the optic-shift concept of the 1CU IOL. Overall, the concept of accommodative IOL appears attractive and may have a great potential in the future. Additional studies including randomized blind multicenter evaluation of the 1CU IOL are necessary to further evaluate long-term and accommodative results.

Endokrine Orbitopathie: Vergleich der Langzeitergebnisse und Klassifikationen nach Radiotherapie

ZusammenfassungHintergrundDiese Studie vergleicht vier verschiedene Klassifikationen bei Patienten mit fortgeschrittener, therapierefraktärer endokriner Orbitopathie und untersucht deren prognostische Wertigkeit.Patienten und MethodeVon 1984 bis 1994 wurden 60 konsekutive Patienten (49 Frauen, elf Männer) wegen progredienter, therapierefraktärer endokriner Orbitopathie bestrahlt (Linac 6 MV, 10mal 2 Gy). Im Verlauf wurden die Symptome und funktionellen Einschränkungen nach vier Klassifikationen bewertet: Werner-Score, modifizierter ATA-Score, Standford-Score und Ophthalmopathieindex (OI) nach Grussendorf [26, 27]. Außerdem notierten alle Patienten das subjektive Ansprechen auf einer linearen Skala (0 bis 100%).ErgebnisseIm Verlauf eines Jahres nach Radiotherapie besserten sich der Werner-Score bei 28 (47%) Patienten um ≥1 Kategorie, nach modifizierten ATA-Score 48 (80%), nach Stanford-Score 47 (78%) und nach OI-Score 55 (92%) Patienten (Reduktion um >2 Punkte). Der Werner-Score korrelierte kaum mit den anderen Scores (Koeffizient r<0,5), während diese untereinander hoch korrelierten (r ∼0,9). Der modifizierte ATA-Score besserte sich in den einzelnen Symptomkategorien zwischen 47% (Stadium VI) und 87% (Stadium V). Der OI-Score reduzierte sich im Mittel um sechs Punkte. Das subjektive Befinden besserte sich um +70±25%. Akute oder chronische Nebenwirkungen traten nicht auf. In multivariater Analyse waren das „männliches Geschlecht” (p=0,08)., die „Symptomdauer vor Radiotherapie >1 Jahr” (p=0,14) und die „hohe Symptomkategorie” (p=0,11) tendenziell negative Prognosefaktoren.SchlußfolgerungDie Radiotherapie ist auch bei schwerer progredienter endokriner Orbitopathie effektiv. Zur Bewertung sind mindestens zwölf Monate Nachbeobachtung und einheitliche Bewertungskriterien erforderlich.AbstractBackgroundThis study compares 4 classifications in patients with progressive refractory Graves orbitopathy (GO) and examines their prognostic value in long-term follow-up.Patients and MethodsFrom 1984 to 1994, 60 consecutive patients (49 female, 11 male) received 20 Gy (10×2 Gy) radiotherapy with 6 MV Linac photons. Ocular symptoms and functional impairment was evaluated according to 4 GO-classification systems: Werner-, modified ATA- and Stanford-Score and Ophthalmopathy-Index (OI) according to Grussendorf [26, 27]. In addition, all patients noted their subjective response on a linear scale (0 to 100%).ResultsImprovement was achieved within 1 year after radiotherapy according to the Werner-Score in 28 (47%) patients in ≥1 symptom category, according to the modified ATA-score in 48 (80%), the Stanford-score in 47 (78%) and the OI-Score in 55 (92%) patients (reduction of >2 points). The Werner-Score correlated less to the other scores (coeffizient r<0.5) than the other scores among themselves (r ∼0.9). The ATA-Score improved in the different symptom categories between 47% (stage VI) and 87% (stage V). The OI-Score was reduced by a mean of 6 points. The patients reached a mean subjective improvement of +70±25%. Acute or chronic side effects were not observed. In multivariate analysis the “male gender” (p=0.08), a “symptom duration prior to radiotherapy >1 year” (p=0.14) and a “high symptom category” (p=0.11) indicated a negative prognostic trend.ConclusionsExternal radiotherapy is effective for severe, progressive GO after pretreatment. A minimum follow-up of at least 12 months and standardized classification and success criteria are required.

Annular crystalline keratopathy in association with immunoglobulin therapy for pyoderma gangrenosum.

Purpose. To report on a patient with a clinical presentation of annular crystalline keratopathy after immunoglobulin therapy for pyoderma gangrenosum. Methods. Case report of a 6-year-old boy with biopsy-proven history of pyoderma gangrenosum who had undergone several cycles of systemic immunoglobulin therapy. The literature on ocular manifestations associated with pyoderma gangrenosum was reviewed. Results. One year after the last cycle, the patient complained of the sudden onset of photophobia. Slit-lamp biomicroscopy revealed bilateral symmetric crystalline deposits in an annular region of the cornea. Because visual acuity was not reduced, specific therapy was not initiated. Symptoms could be reduced by the prescription of medical edged filter lenses. Conclusions. Annular crystalline corneal deposits may be associated with immunoglobulin therapy or represent a hitherto unknown ocular complication of pyoderma gangrenosum.

Results Following Eye Muscle Surgery for Secondary Sensory Strabismus

Purpose: To provide a longer follow-up after strabismus surgery for secondary sensory strabismus. Patients and Methods: We investigated the follow up of 26 patients operated on for secondary strabismus: 7 convergent (SSC), 19 divergent (SSD). Inclusion criteria were fellow eye without any morphological disorder, and exclusion criteria were possible motility disorders or mechanical restriction: The mean follow-up time after surgery was 5 years 8 months ± 4 years (1 year 8 months to 12 years 8 months) for SSC and 5 years 10 months ± 3 years, 8 months (7 months to 13 years 3 months) for SSD, with p = 0.86. A statistical analysis of the results was performed with SPSS version 11.5 (Statistical Products and Service Solutions, SPSS Inc., United States). All statistical tests were 2-sided, and the threshold of significance was set to p ≤ 0.05. Main Results: The angle of deviation for far distance was reduced from 20 ± 9 (11 to 35) to −2 ± 4 (–8 to 6)° for SSC and from −21 ± 8 (−42 to −10) to −2 ± 5 (−15 to 4)° for SSD. A correlation between the postoperative angle in far distance and the visual acuity (lg visus) of the affected eye was not found for SSC: r = −0.5, p = 0.24, but was observed for SSD: r = 0.52, p = 0.02. In patients with perforating injury, a correlation of the postoperative angle in far distance to the age at injury of the affected eye was found (r = 0.6, p = 0.05). Two of the seven patients with SSC and one of 19 with SSD complained of double vision pre- and post-operatively. All patients with SSC and with SSD were satisfied with the postoperative angle of deviation. Conclusion: The results of this study indicate that, in general, we can recommend eye muscle surgery in secondary strabismus.

Posttranscriptional Regulation of LOXL1 Expression Via Alternative Splicing and Nonsense-Mediated mRNA Decay as an Adaptive Stress Response

Purpose Alternative mRNA splicing coupled to nonsense-mediated decay (NMD) is a common mRNA surveillance pathway also known to dynamically modulate gene expression in response to cellular stress. Here, we investigated the involvement of this pathway in the regulation of lysyl oxidase-like 1 (LOXL1) expression in response to pseudoexfoliation (PEX)-associated pathophysiologic factors. Methods Transcript levels of LOXL1 isoforms were determined in ocular tissues obtained from donor eyes without and with PEX syndrome. Pseudoexfoliation-relevant cell types, including human Tenons capsule fibroblasts (hTCF) and trabecular meshwork cells (hTMC), were exposed to puromycin, caffeine, TGF-β1, homocysteine, IL-6, retinoic acid, UV-B radiation, oxidative stress, and mechanical stress for up to 48 hours. Western blot analysis was carried out using antibodies against LOXL1, (phosphorylated-) eukaryotic initiation factor 2-α (eIF2-α), and regulator of nonsense transcripts 2 (UPF2). RNA interference was used to knockdown UPF1-3 and Serine/threonine-protein kinase (SMG1). Results Constitutive expression of wild-type LOXL1 and alternatively spliced LOXL1-a transcripts was detected in all ocular tissues showing highest levels in trabecular meshwork and differential expression between PEX and control specimens. LOXL1-a transcripts were upregulated in hTCF and hTMC by NMD inhibitors puromycin and caffeine (≥6-fold; P < 0.01) or after knockdown of NMD core factors (≥2-fold; P < 0.05), whereas mRNA and protein levels of LOXL1 were reduced (≤0.8 fold; P < 0.05). Exposure of cells to various PEX-associated (stress) factors, including TGF-β1, UV-B light, oxidative stress, mechanical stress, and retinoic acid enhanced LOXL1-a transcript levels (≥1.5-fold; P < 0.05), while partially downregulating LOXL1 levels (≤0.7-fold; P < 0.05). Stress-induced inhibition of NMD was dependent on phosphorylation of eIF2α. Conclusions These findings provide evidence for a functional role of alternative splicing coupled to NMD in the posttranscriptional regulation of LOXL1 gene expression and suggest this mechanism to represent a dynamic mode of adapting LOXL1 expression to PEX-associated environmental and nutritional cues.

Erste Sechs-Monats-Ergebnisse der Implantation einer neuen akkommodativen Hinterkammerlinse (1 CU)

ZusammenfassungHintergrundNach Entwicklung einer neuen, potentiell akkommodativen Hinterkammerlinse (HKL) 1 CU (HumanOptics AG) konnte bisher eine gute Implantierbarkeit und frühpostoperative Komplikationsfreiheit im Patientenauge gezeigt werden. Vor einer generellen Verbreitung der neuen HKL muss jedoch auch die längerfristige Verträglichkeit und Funktion nachgewiesen werden, weshalb wir in der vorliegenden Studie erste 6-Monats-Ergebnisse analysierten.Patienten und MethodikIm Rahmen einer prospektiven Studie untersuchten wir 12 Augen mit Katarakt von 12 Patienten (8 Männer, 4 Frauen, Alter 41 bis 87 Jahre), bei denen konsekutiv zwischen August 2000 und Februar 2001 die neue HKL von einem Operateur implantiert worden war. Die postoperativen Kontolluntersuchungen beinhalteten Biomikroskopie, Bestimmung des bestkorrigierten Fernvisus und des Nahvisus mit Fernkorrektur mit Birkhäuser-Lesetafeln in 35 cm Abstand, Bestimmung des subjektiven Nahpunktes mit einem Akkommodometer, Messung der Nah- und Fernrefraktion mittels Strichskiaskopie und die optische Messung der Vorderkammertiefe mit dem IOLMaster (Zeiss) vor und nach Gabe von 0,5% Tropicamid und 1% Cyclopentolat-Augentropfen.ErgebnisseNach problemloser intra- und frühpostoperativer Phase war auch der weitere Verlauf während der Nachbeobachtung bis zu 6 Monaten komplikationslos. Die HKL zeigte bei allen Patienten eine gute Zentrierung ohne stärkere Fibrose der vorderen Linsenkapsel. Nur bei einem 41jährigen Patienten fand sich ein beginnender axialer proliferativer Nachstar (Visus 0,63). Nach 6 Monaten betrug der bestkorrigierte Fernvisus im Median 1,0 (0,63 bis 1,25), der Nahvisus mit Fernkorrektur in 3,5 cm lag zwischen 0,2 und 0,6 (Median 0,3), der subjektive Nahpunkt mit Fernkorrektion bei durchschnittlich 72 ± 43 cm (39 bis 200 cm, Median 60,5 cm), die mittlere skiaskopisch bestimmte Differenz zwischen Nah- und Fernrefraktion war 1,57 ± 0,55 D (0,5 bis 2,5 D, Median 1,56), und die Abnahme der Vorderkammertiefe nach Tropicamid-Augentropfen im Mittel 0,47 ± 0,19 mm (0,20 bis 0, 66 mm, Median 0,55 mm).SchlussfolgerungenDie Ergebnisse unserer prospektiven Studie bestätigen die kurz- und mittelfristige Sicherheit der neuen HKL und zeigen pseudophake Akkommodation nach 6 Monaten. Weitere Studien hinsichtlich Langzeitverträglichkeit und Akkommodationsleistung, vor allem randomisierte multizentrische Studien mit Vergleichsgruppen, sind erforderlich und in Vorbereitung.SummaryPurposeA new, potentially accommodative PCIOL (1 CU, HumanOptics AG, Erlangen) has been designed after principles elaborated by K.D.Hanna using finite element computer models. Initial clinical studies have shown intra- and early postoperative safety of the new PCIOL. This study investigated first six-month-results.Patients and methodsIn a prospective study that was approved by the ethics committee of our university, 12 eyes of 12 patients (8 males, 4 females, age range 41 to 87 years) with senile or presenile cataract underwent phacoemulsification and implantation of the new PCIOL by one surgeon between August 2000 and February 2001. Postoperative examinations included slit lamp biomicroscopy, recording of distance visual acuity and near visual acuity obtained with best distance correction using Birkhäuser charts in 35 cm, determination of subjective near point, measurement of distance and near refraction by streak retinoscopy, and measurement of anterior chamber depth with the IOLMaster (Zeiss) before and after cycloplegia with 0.5% tropicamide and 1% cyclopentolate eye drops.ResultsThe postoperative course was uncomplicated in all patients with good and stable centration of the PCIOL without excessive fibrosis of the anterior lens capsule. Mild posterior capsular opacification was observed in only one 41-year-old patient. Visual acuity improved in all patients to values between 20/16 and 20/24 (median 20/20). After six months we observed: Near visual acuity with best distance correction 0.2 to 0.6, median 0,3 (corresponding to J 10 — JH1, median J 7); mean subjective near point 72 ± 43 cm, 39–200 cm, median 60.5 cm; mean retinoscopic accommodative range 1.57 ± 0.55 D, range 0.5–2.5 D, median 1.56 D; mean increase of anterior chamber depth after 0.5% tropicamide eye drops 0.47 ± 0.19 mm (range 0.20–0.66 mm, median 0.55 mm).ConclusionsOur results confirm that the new PCIOL is safe for up to six months and indicate pseudophakic accommodation secondary to focus shift. These encouraging findings should be confirmed by additional larger and long-term studies.

Kirschroter Fleck bei einem 13 Monate alten Mädchen

Ein 13 Monate altes Mädchen wurde aus derKinderklinikzurkonsiliarischenMitbetreuung bei Entwicklungsrückschritten vorgestellt. Im Alter von 7 bis 9 Monaten habe sie bereits frei sitzen können, diese Fähigkeit aber bereits wieder verloren. Zudem sei sie extrem schreckhaft auf akustische Reize und könne nicht mehr fixieren. Wenn die Mutter das Mädchen hinlege, sei ihr ein horizontaler Nystagmus aufgefallen. Nach einer unauffälligen Schwangerschaft war das Mädchen bei protrahiertem Geburtsverlauf mittels Vakuumextraktion entbunden worden. Die postnatale Adaptation und der Nabelschnur-pH-Wert waren unauffällig. Allgemeinerkrankungen seien nicht bekannt.

Sinus-cavernosus-Thrombose als seltene Ursache eines Exophthalmus im Kindesalter

Complications of acute bacterial sinusitis mostly occur in children and adolescents. In particular, intracranial spread of the infection can lead to severe even fatal courses of the disease. This article is a case report about a 13-year-old boy suffering from left-sided headache, meningismus and exophthalmos as presenting symptoms. Cranial magnetic resonance imaging (MRI) showed merely right-sided sphenoid sinusitis; however, the diffusion-weighted MRI sequence indicated a left-sided cavernous sinus thrombosis, which could be confirmed by computed tomography (CT) angiography. Cerebrospinal fluid diagnostics showed significant leukocytosis confirming secondary meningitis. Finally, exophthalmos was explained by parainfectious cavernous sinus thrombosis and periorbital edema. This case report highlights the importance of extended and specific diagnostic imaging in cases of clinically suspected complications in children and adolescents with sinusitis and the diagnostic significance of diffusion-weighted MRI.