Gangolf Sauder

Cataract surgery under systemic anticoagulant therapy with coumarin

Purpose To evaluate clinical outcome of cataract surgery under systemic anticoagulant therapy using coumarin. Methods This clinical interventional comparative nonrandomized study included 441 patients (441 eyes) consecutively undergoing standard phacoemulsification with clear cornea incision and topical anesthesia. The study group consisted of 21 (4.8%) patients for whom systemic coumarin therapy was continued despite surgery. The control group included 420 patients without anticoagulant coumarin therapy prior to surgery. Study group and control group did not vary significantly in age, preoperative visual acuity, axial length, refractive error, preoperative intraocular pressure, or surgeon. Results Frequency of intraoperative or postoperative hemorrhages, intraoperative complications such as posterior capsule rupture, postoperative visual acuity, and intraocular pressure did no vary significantly (p>0.30) between study group and control group. Conclusions For patients under systemic coumarin therapy, the rate of surgical complications may not markedly be increased compared to patients without coumarin therapy, when standard phacoemulsification with clear cornea incisions is performed with topical anesthesia. Systemic coumarin therapy does not have to be stopped prior to cataract surgery.

Bevacizumab for occult subfoveal neovascularization in age-related macular degeneration.

Purpose To report on the treatment of exudative age-related macular degeneration by intravitreal bevacizumab (Avastin). Methods A 78-year-old patient experienced a progressive loss of visual acuity in her right eye due to an occult subfoveal neovascular membrane in age-related macular degeneration. She received an intravitreal injection of 1.5 mg bevacizumab. Results Within 4 weeks after the injection, visual acuity improved from 0.40 to 0.60 with complete resolution of subretinal and intraretinal leakage and edema as shown on optical coherence tomography. Pre-existing metamorphopsias disappeared. Intraocular pressure remained in the normal range. During the follow-up, there were no sings of intraocular inflammation or any other intraocular pathology induced by the intravitreal injection. Conclusions Intravitreal bevacizumab may potentially be helpful in the treatment of exudative age-related macular degeneration and may deserve further evaluation.

Sympathetic ophthalmia in vater association combined with persisting hyperplastic primary vitreous after cyclodestructive procedure.

Purpose To report on the occurrence of histology-proven sympathetic ophthalmia in a patient with VATER association and persisting hyperplastic primary vitreous (PHPV) after a cyclodestructive procedure was performed to treat secondary angle-closure glaucoma. Methods The left eye of a 13-year-old boy with VATER association was microphthalmic from birth and had been diagnosed with PHPV at age 1 year. It developed iris neovascularization and secondary angle-closure glaucoma, which was treated by combined cyclocryocoagulation and cyclophotocoagulation. Six weeks later, a bilateral fibrinous iritis developed. Despite intensive topical and systemic steroid treatment, the iritis persisted so that the left blind eye was enucleated. Results Histology of the enucleated eye showed a marked intraocular inflammation with lymphocytes, epithelioid cells, and multinuclear giant cells grouped around remnants of melanin-bearing cells. Conclusions Sympathetic ophthalmia may occur in patients with VATER association and PHPV after a secondary angle-closure glaucoma is treated by a combined cyclocryocoagulation and cyclophotocoagulation.

Factors influencing visual outcome after penetrating keratoplasty combined with intraocular lens implantation

Purpose To establish which factors influence visual outcome after penetrating keratoplasty combined with intraocular lens implantation. Methods This retrospective noncomparative clinical interventional case series study included 135 consecutive patients (mean age 70.2 ± 13.6 years) who underwent central penetrating allogenic keratoplasty combined with intraocular lens (IOL) implantation, all operated by the same surgeon. There were 79 triple procedures, 33 keratoplasties combined with an exchange of IOL, and 23 penetrating keratoplasties combined with a secondary implantation of a posterior chamber lens. Mean follow-up was 28.3 ± 18.7 months (range 3.3–112 months). Reasons for keratoplasty were herpetic or traumatic corneal scars or defects (46), Fuchs corneal endothelial dystrophy (22), pseudophakic or aphakic bullous keratopathy (49), corneal endothelial decompensation due to other reasons (15), and keratoconus (3). Main outcome measures were postoperative visual acuity and gain in visual acuity. Results Mean postoperative visual acuity and mean gain in visual acuity were 0.33 ± 0.21 (median 0.30) and 0.25 ± 0.20 (median 0.20), respectively. Compared with the preoperative measurements, mean visual acuity increased in 129 patients (129/135, 95.6%). Factors influencing postoperative visual outcome and gain in visual acuity were preoperative visual acuity (p<0.005), reason for keratoplasty (p<0.005), and diameter of the graft (p = 0.046). Postoperative visual outcome was independent of age, sex, right or left eye, presence of diabetes mellitus, preoperative refractive error, length of follow-up, duration of surgery, and preoperative intraocular pressure. Conclusions The most important factors influencing visual outcome after central penetrating allogenic keratoplasty combined with IOL surgery are preoperative visual acuity, graft size, and reason for keratoplasty. Other factors such as age, sex, diabetes mellitus, and preoperative refractive error do not substantially influence postoperative visual outcome.

Topical anesthesia for transpupillary silicone oil removal combined with cataract surgery

PURPOSE: To assess safety of topical anesthesia for transpupillary silicone oil removal in combination with cataract surgery. SETTING: Department of Ophthalmology Mannheim, University of Heidelberg, Mannheim, Germany. METHODS: The clinical interventional study included 37 consecutive patients having transpupillary silicone oil removal combined with cataract surgery. Without exception, surgery was carried out in topical anesthesia for all patients. During the study period, there were no patients having transpupillary silicone oil removal in another type of local anesthesia than topical anesthesia. Topical anesthesia was achieved with oxybuprocaine 0.4% eyedrops installed 4 to 5 times prior to surgery. Cataract surgery was performed using the clear cornea technique with implantation of a foldable intraocular posterior chamber lens. Silicone oil was released through a planned posterior capsulotomy during cataract surgery prior to implantation of the intraocular lens (IOL). RESULTS: For all patients, surgery could be carried out in topical anesthesia without switching to peribulbar or any other type of anesthesia. None of the patients complained about severe pain intraoperatively or postoperatively. No severe complications such as expulsive hemorrhage, luxation of the IOL, or iris incarceration were encountered in any of the surgeries. CONCLUSION: Transpupillary silicone oil through a planned posterior capsulotomy during cataract surgery may be performed in topical surgery.

Retrobulbar catheter anesthesia as a routine technique for retinal and vitreoretinal surgery.

To determine whether prone postoperative near visual acuity following macular hole surgery can be used as a reliable indicator of successful hole closure, data from 21 patients undergoing macular hole surgery were collected. Seventeen of the 18 patients with hole closure and all 3 patients with persistent macular holes had a Rosenbaum acuity better than preoperative visual acuity, yielding 94% sensitivity, 0% specificity, 85% positive predictive value, and 0% negative predictive value. Fourteen of the 18 patients with macular hole closure and all 3 patients with persistent macular holes had a Rosenbaum acuity better than 20/40, yielding 78% sensitivity, 0% specificity, 82% positive predictive value, and 0% negative predictive value. Although postoperative near visual acuity can predict macular hole closure with 94% sensitivity, the test is not clinically useful to predict hole closure because of the high surgical success rate of macular hole surgery. The test could be useful in encouraging patients to maintain head prone positioning and alleviate patient anxiety.