Georg Häring

Stereoacuity and aniseikonia after unilateral and bilateral implantation of the Array refractive multifocal intraocular lens

PURPOSE To evaluate stereoacuity and aniseikonia in eyes with unilateral and bilateral implantation of the Allergan Array refractive multifocal intraocular lens (MIOL). SETTING Department of Ophthalmology, University Hospital, Kiel, Germany. METHODS This study comprised 31 patients with a unilateral MIOL and a phakic fellow eye and 29 patients with bilateral MIOLs. In all pseudophakic eyes, an Array MIOL had been implanted between 1991 and 1994 during a prospective clinical trial. In the present study, patients were re-examined. Near and distance visual acuity were tested; binocular functions were assessed using Bagolini lenses, the Worth 4-dot test, the Lang random-dot test, and the Titmus fly chart. Aniseikonia was evaluated using Aulhorns phase-difference haploscope. Mean follow-up was 43 months in both groups. RESULTS After unilateral implantation 87.1% of patients and after bilateral implantation 93.1% of patients correctly perceived the stereograms of the Lang random-dot test. The mean subjective height of the measured Titmus fly was 4.2 cm after unilateral and 4.3 cm after bilateral implantation. The stereoacuity tests revealed no statistically significant differences between the groups. Distance and near aniseikonia were significantly less after bilateral than after unilateral implantation. CONCLUSION Despite the simultaneous formation of multiple retinal images, the Array MIOL allowed good binocular vision including random-dot stereopsis. Functional aniseikonia developed but did not interfere with normal binocular vision.

Long-term results after scleral buckling surgery in uncomplicated juvenile retinal detachment without proliferative vitreoretinopathy.

Purpose: To evaluate long‐term anatomic and functional results of scleral buckling surgery in retinal detachment without proliferative vitreoretinopathy in juvenile patients. Methods: A total of 33 eyes of 31 patients were operated on. Surgical techniques included segmental buckle (23 eyes), radial buckle (5 eyes), encircling band (4 eyes), and temporary balloon buckle (1 eye). The average age at time of surgery was 15.3 years and the average follow‐up time was 8.9 years. Retinal detachment was associated with the following risk factors: myopia (14 eyes), blunt trauma (8 eyes), and aphakia (3 eyes). In 9 eyes, no risk factors were present. Fifteen eyes had a detached macula. In addition to anterior and posterior segment examination, binocular functions and ocular motility were evaluated. Results: Retinal reattachment required one operation in 29 eyes, two operations in three eyes, and three operations in one eye. In one eye, pars plana vitrectomy had to be performed to reattach the retina. At the end of follow‐up, retinal reattachment was achieved in all eyes. Visual acuity of 20/40 or better was achieved by 39.4% preoperatively and 60.6% postoperatively; in 52.4%, binocular functions were normal. Conclusion: Scleral buckling procedures allow favorable anatomic and functional results in juvenile retinal detachment without proliferative vitreoretinopathy.

Ultrasound biomicroscopic imaging in intermediate uveitis

BACKGROUND Clinical examination of the region of the eye mainly affected in patients with intermediate uveitis is difficult and often hampered by media opacities. In that perspective ultrasound biomicroscopy (UBM) promises to be a valuable additional diagnostic tool. METHODS UBM was performed at a sound frequency of 50 MHz on 26 eyes of 13 patients with intermediate uveitis in order to determine configuration of pars plana, peripheral retina, and vitreous. Findings of ophthalmoscopy with scleral indentation and UBM were compared. RESULTS In 18 of 26 eyes pathological structures such as membraneous or fluffy vitreous condensations were identified by UBM. Among these UBM revealed pathological findings which were not visible on funduscopy in nine eyes. Most importantly, vitreoretinal adhesions with traction on the retina were imaged in four eyes. However, in three eyes vitreous opacities being visible on funduscopy were not identified by UBM. CONCLUSION UBM seems to be a valuable diagnostic technique for the evaluation of patients with intermediate uveitis. Longitudinal studies will have to determine the relevance of UBM findings for the individual clinical course and their influence on therapeutic decisions.

Einfluss der Phakoemulsifikation und HKL-Implantation auf den Intraokulardruck bei Patienten mit und ohne Offenwinkelglaukom

ZusammenfassungHintergrund. Bei vielen der bisherigen Studien, die über eine Senkung des Intraokulardrucks nach Kataraktchirurgie berichten, handelt es sich um retrospektive Untersuchungen mit einem z. T. sehr heterogenen Patientenkollektiv. Ziel unserer Untersuchung war es daher, prospektiv unter standardisierten Bedingungen bei Patienten mit und ohne Offenwinkelglaukom den mittel- und langfristigen Einfluss der Phakoemulsifikation und Hinterkammerlinsen-(HKL-)Implantation auf den Intraokulardruck (IOD) zu bestimmen. Material und Methode. Bei 52 Patienten wurde an 36 Augen mit Normaldruck und 16 mit Offenwinkelglaukom eine Kataraktoperation in standardisierter Technik durchgeführt. Ergebnisse. Bei den Normaldruckpatienten fand sich präoperativ ein durchschnittlicher Augeninnendruck von 15,1 mmHg. Sechs Monate postoperativ war durchschnittlich eine Senkung des IOD um 11,9% (1,8 mmHg +/−3,8; p=0,027), nach 12 Monaten um 18,5% (2,8 mmHg +/−3,5; p=0,0001) feststellbar. Die Patienten mit Offenwinkelglaukom wiesen präoperativ einen Augeninnendruck von 17,3 mmHg auf. Postoperativ war nach 6 Monaten bei den Glaukompatienten eine IOD-Senkung um 23,7% (4,1 mmHg +/−6,0; p=0,017) feststellbar, nach 12 Monaten um 22,6% (3,9 mmHg +/−4,5; p=0,005). Bei 6 von 16 Patienten konnte postoperativ auf eine drucksenkende Lokaltherapie verzichtet werden. Schlussfolgerung. Als positiver Nebeneffekt ist bei der Phakoemulsifikation mit HKL-Implantation eine signifikante Minderung des IOD festzustellen, was besonders bei der Indikationsstellung bei Patienten mit geringem Glaukomschaden und leicht erhöhtem Intraokulardruck berücksichtigt werden sollte.SummaryBackground. Many of the previous studies which dealt with the influence of cataract surgery on intraocular pressure, were performed retrospectively and based on heterogenous groups of patients. Therefore, the purpose of our study was to prospectively assess the effect of phacoemulsification and posterior chamber intraocular-lens (IOL)-implantation on intraocular pressure (IOP) under standardized conditions in patients with and without open-angle-glaucoma. Patients and methods. Overall 52 patients were recruited for the study. 34 eyes with normal IOP and 16 eyes with open-angle-glaucoma were operated with the same technique. Results. Mean IOP in patients with cataract and without glaucoma was preoperatively 15,1 mmHg. 6 months postoperatively these patients showed a mean decrease of IOP of 11,9% (1,8 mmHg+/−3,8; p=0.027) ; after 12 months IOP showed a decrease of 18,5% (2,8 mmHg+/−3,5; p=0.0001). In patients with glaucoma mean IOP was preoperatively 17,3 mmHg. IOP was reduced by 23,7% (4,1 mmHg+/−6,0; p=0.017) 6 months after cataract surgery and 22,6% (3,9 mmHg+/−4,5; p=0.005) 12 months after the operation. In 6 of 16 eyes the antiglaucoma medication could be suspended. Conclusion. Reduction of IOP is a positive side effect of phacoemulsification and posterior chamber IOL implantation and should be considered when indicating cataract surgery in patients with glaucoma and only slight elevation of IOP.

Effect of folding on the multifocal silicone intraocular lens: scanning electron microscopic study.

PURPOSE To evaluate whether the surface of the refractive zonal multifocal silicone intraocular lens (IOL) is altered by different folding and implantation instruments and is more sensitive to manipulation during folding than the surface of a monofocal IOL. SETTING Department of Ophthalmology, University Hospital, Kiel, Germany. METHODS Evaluated were the refractive multifocal silicone IOL (SA-40N, Array) and an otherwise identical monofocal IOL (SI-40NB) from the same manufacturer (Allergan Inc.). Different folding devices (folding blocks, folding and implantation forceps, and an injector system) were used. The IOLs were kept folded for 60 seconds; 24 hours later, scanning electron microscopy (SEM) was performed. In addition, the cartridges of the injector system were examined by SEM. RESULTS Overall, regardless of the folding and implantation instruments used, both the multifocal and monofocal IOLs had discrete surface alterations. The cartridges of the injector system had a rough surface at the tip, while the proximal portion appeared smooth. CONCLUSION There were no signs of lesions particularly affecting the surface of multifocal IOLs.

Schwere intra- und postoperative suprachorioidale Blutungen

ZusammenfassungHintergrund: Ziel unserer Untersuchung war es, Risikofaktoren, therapeutisches Vorgehen sowie funktionelle und anatomische Ergebnisse nach schweren suprachorioidalen Blutungen zu analysieren. Patienten und Methode: Seit 1989 kam es achtmal intraoperativ und dreimal postoperativ zur Blutung. Sie traten bei folgenden operativen Eingriffen auf: Perforierende Keratoplastik (5 ×), extrakapsuläre Kataraktextraktion (3 ×), Pars-plana-Vitrektomie (2 ×), intrakapsuläre Kataraktextraktion (1 ×). Ergebnisse: Neun Eingriffe wurden in Intubationsnarkose, zwei in Retrobulbäranästhesie durchgeführt. Bei sechs Augen kam es zur expulsiven Blutung mit Verlust intraokularer Gewebeanteile. Spezielle okuläre Risikofaktoren wie z. B. Voroperationen und ¶-erkrankungen, Verletzungen oder Myopie, sowie allgemeine Risikofaktoren (kardiovaskuläre Erkrankungen, Diabetes, etc.) wurden erfaßt. Am Ende der Nachbeobachtungszeit war der Visus gegenüber dem präoperativen Befund bei 7 Patienten schlechter, bei 3 Patienten besser und bei 1 Patienten unverändert. 4 Augen waren amaurotisch, wovon 2 enukleiert wurden. Schlußfolgerung: Auch mit modernen operativen Methoden bleibt die Prognose massiver suprachorioidaler Blutungen ernst. Betroffen sind nahezu ausschließlich Patienten, die eine Vielzahl okulärer und allgemeiner Risikofaktoren auf sich vereinigen.SummaryBackground: The aim of this study was to analyze risk factors, therapeutic strategies, and functional and anatomic results of eyes with severe suprachoroidal hemorrhage. Patients: Eight of 11 bleeding episodes occurred intraoperatively and 3/11 postoperatively. Bleeding was associated with the following surgical procedures: perforating keratoplasty (5 ×), extracapsular cataract extraction (3 ×), pars plana vitrectomy (2 ×), intracapsular cataract extraction (1 ×). Results: Nine operations were performed with general anesthesia, two after retrobulbar injection. Ocular risk factors (e. g., prior operations, ocular diseases) and general risk factors (e. g., cardiovascular diseases, diabetes) were analyzed. At the end of the follow-up time visual acuity had improved in three eyes, and it was unchanged in one eye and worse in seven eyes. Four eyes were amaurotic; two of them had to be enucleated. Conclusions: In spite of using state-of-the-art surgical techniques the prognosis of suprachoroidal bleeding remains serious. Patients who have a combination of several ocular and general risk factors almost exclusively are the ones who afflicted by this complication.

Bilateral simultaneous acute amaurosis as primary manifestation of encephalomyelitis disseminata

SummaryBackground: Bilateral simultaneous acute amaurosis as a primary manifestation of demyelinating disease is extremely rare. Patient: The clinical course of a 24-year-old patient who initially presented with a bilateral complete loss of vision is demonstrated. Morphologically both optic discs appeared slightly blurred and prominent. Otherwise there were no anterior and posterior segment abnormalities. Examination of the cerebrospinal fluid revealed an increased number of cells and protein without oligoclonal bands. On MRI multiple white matter lesions were visible. Laboratory tests showed no specific abnormalities, especially with respect to infectious or vasculitic diseases. Under intensive steroid therapy (initially 1000 mg prednisolone/day), visual acuity recovered almost completely. Nine months after onset of the disease visual acuity was 1.0 in both eyes. Conclusions: Even in patients with a fulminant onset of the disease almost complete visual recovery is possible. Differential diagnosis should rule out vasculitic autoimmune optic neuritis, infections, tumors, processes of the paranasal sinuses, toxic, and hereditary causes.ZusammenfassungHintergrund: Eine beidseitige simultane akute Amaurose im Rahmen einer Neuritis nervi optici als Erstmanifestation einer Encephalomyelitis disseminata ist außerordentlich selten. Kasuistik: Es wird ein Krankheitsverlauf eines 24 jährigen Patienten dargestellt, der sich initial wegen eines binnen 24 Stunden eingetretenen vollständigen beidseitigen Visusverlustes vorstellte. Morphologisch zeigten sich die Papillen diskret randunscharf und prominent bei ansonsten unauffälligem Befund. Neurologisch wurde im Liquor eine erhöhte Zellzahl und eine Eiweißvermehrung ohne oligoklonale Banden festgestellt. Im MRT fanden sich multiple Entmarkungsherde, serologisch ergab sich kein Anhalt für eine Infektion bzw. eine Vaskulitis. Unter hochdosierter Steroidgabe (initial 1000 mg Prednisolon/Tag) kam es zu einer nahezu vollständigen Visuserholung. Neun Monate nach Krankheitsbeginn betrug der Visus beidseits 1,0. Weitere Krankheitsschübe sind bisher nicht aufgetreten. Schlußfolgerung: Auch bei einem fulminanten Krankheitsbeginn ist eine weitgehende Visuserholung möglich. Differentialdiagnostisch gilt es, vaskulitische Neuritiden, Infektionen, Tumoren, Nasennebenhöhlenprozesse und toxische oder hereditäre Ursachen auszuschließen.

Schwere intra- und postoperative suprachorioidale Blutungen@@@Severe intra- and postoperative suprachoroidal hemorrhage: Risikofaktoren, Therapie, Ergebnisse

ZusammenfassungHintergrund: Ziel unserer Untersuchung war es, Risikofaktoren, therapeutisches Vorgehen sowie funktionelle und anatomische Ergebnisse nach schweren suprachorioidalen Blutungen zu analysieren. Patienten und Methode: Seit 1989 kam es achtmal intraoperativ und dreimal postoperativ zur Blutung. Sie traten bei folgenden operativen Eingriffen auf: Perforierende Keratoplastik (5 ×), extrakapsuläre Kataraktextraktion (3 ×), Pars-plana-Vitrektomie (2 ×), intrakapsuläre Kataraktextraktion (1 ×). Ergebnisse: Neun Eingriffe wurden in Intubationsnarkose, zwei in Retrobulbäranästhesie durchgeführt. Bei sechs Augen kam es zur expulsiven Blutung mit Verlust intraokularer Gewebeanteile. Spezielle okuläre Risikofaktoren wie z. B. Voroperationen und ¶-erkrankungen, Verletzungen oder Myopie, sowie allgemeine Risikofaktoren (kardiovaskuläre Erkrankungen, Diabetes, etc.) wurden erfaßt. Am Ende der Nachbeobachtungszeit war der Visus gegenüber dem präoperativen Befund bei 7 Patienten schlechter, bei 3 Patienten besser und bei 1 Patienten unverändert. 4 Augen waren amaurotisch, wovon 2 enukleiert wurden. Schlußfolgerung: Auch mit modernen operativen Methoden bleibt die Prognose massiver suprachorioidaler Blutungen ernst. Betroffen sind nahezu ausschließlich Patienten, die eine Vielzahl okulärer und allgemeiner Risikofaktoren auf sich vereinigen.SummaryBackground: The aim of this study was to analyze risk factors, therapeutic strategies, and functional and anatomic results of eyes with severe suprachoroidal hemorrhage. Patients: Eight of 11 bleeding episodes occurred intraoperatively and 3/11 postoperatively. Bleeding was associated with the following surgical procedures: perforating keratoplasty (5 ×), extracapsular cataract extraction (3 ×), pars plana vitrectomy (2 ×), intracapsular cataract extraction (1 ×). Results: Nine operations were performed with general anesthesia, two after retrobulbar injection. Ocular risk factors (e. g., prior operations, ocular diseases) and general risk factors (e. g., cardiovascular diseases, diabetes) were analyzed. At the end of the follow-up time visual acuity had improved in three eyes, and it was unchanged in one eye and worse in seven eyes. Four eyes were amaurotic; two of them had to be enucleated. Conclusions: In spite of using state-of-the-art surgical techniques the prognosis of suprachoroidal bleeding remains serious. Patients who have a combination of several ocular and general risk factors almost exclusively are the ones who afflicted by this complication.

Severe intra- and postoperative suprachoroidal hemorrhage

ZusammenfassungHintergrund: Ziel unserer Untersuchung war es, Risikofaktoren, therapeutisches Vorgehen sowie funktionelle und anatomische Ergebnisse nach schweren suprachorioidalen Blutungen zu analysieren. Patienten und Methode: Seit 1989 kam es achtmal intraoperativ und dreimal postoperativ zur Blutung. Sie traten bei folgenden operativen Eingriffen auf: Perforierende Keratoplastik (5 ×), extrakapsuläre Kataraktextraktion (3 ×), Pars-plana-Vitrektomie (2 ×), intrakapsuläre Kataraktextraktion (1 ×). Ergebnisse: Neun Eingriffe wurden in Intubationsnarkose, zwei in Retrobulbäranästhesie durchgeführt. Bei sechs Augen kam es zur expulsiven Blutung mit Verlust intraokularer Gewebeanteile. Spezielle okuläre Risikofaktoren wie z. B. Voroperationen und ¶-erkrankungen, Verletzungen oder Myopie, sowie allgemeine Risikofaktoren (kardiovaskuläre Erkrankungen, Diabetes, etc.) wurden erfaßt. Am Ende der Nachbeobachtungszeit war der Visus gegenüber dem präoperativen Befund bei 7 Patienten schlechter, bei 3 Patienten besser und bei 1 Patienten unverändert. 4 Augen waren amaurotisch, wovon 2 enukleiert wurden. Schlußfolgerung: Auch mit modernen operativen Methoden bleibt die Prognose massiver suprachorioidaler Blutungen ernst. Betroffen sind nahezu ausschließlich Patienten, die eine Vielzahl okulärer und allgemeiner Risikofaktoren auf sich vereinigen.SummaryBackground: The aim of this study was to analyze risk factors, therapeutic strategies, and functional and anatomic results of eyes with severe suprachoroidal hemorrhage. Patients: Eight of 11 bleeding episodes occurred intraoperatively and 3/11 postoperatively. Bleeding was associated with the following surgical procedures: perforating keratoplasty (5 ×), extracapsular cataract extraction (3 ×), pars plana vitrectomy (2 ×), intracapsular cataract extraction (1 ×). Results: Nine operations were performed with general anesthesia, two after retrobulbar injection. Ocular risk factors (e. g., prior operations, ocular diseases) and general risk factors (e. g., cardiovascular diseases, diabetes) were analyzed. At the end of the follow-up time visual acuity had improved in three eyes, and it was unchanged in one eye and worse in seven eyes. Four eyes were amaurotic; two of them had to be enucleated. Conclusions: In spite of using state-of-the-art surgical techniques the prognosis of suprachoroidal bleeding remains serious. Patients who have a combination of several ocular and general risk factors almost exclusively are the ones who afflicted by this complication.

EVALUATION OF LASER SCLEROSTOMY FISTULAS USING ULTRASOUND BIOMICROSCOPY

Background. Laser sclerostomy is a relatively new technique in glaucoma surgery. Clinical examination,particularly of the intrascleral part of laser sclerostomy fistulas, is difficult. We performed ultrasound biomicroscopy (UBM) in order to determine,if it were possible to visualize fistulas. Moreover,it was the aim to investigate whether this imaging technique could provide additional information on fistula morphology. Patients and methods. Ten eyes of eight patients with chronic open angle glaucoma who had undergone erbium-YAG laser sclerostomy ab externo were examined using a UBM-probe with a 20 MHz transducer providing spatial resolution of approximately 80 μm. Results. Radial scanning allowed visualization of the sclerostomy fistula in nine of ten eyes. The different functional state of sclerostomy fistulas correlated well to UBM findings. It was possible to image differences in the morphology of occluded and patent fistulas and to visualize the filtering pathway in functioning blebs. Conclusions. Ultrasound biomicroscopy allows imaging of laser sclerostomy fistulas. UBM and clinical findings correlated well in the majority of the patients we examined. The technique supplements clinical examination and in some cases may provide additional information.