Hans Mittelviefhaus

Systemic mycophenolate mofetil avoids immune reactions in penetrating high-risk keratoplasty: preliminary results of an ongoing prospectively randomized multicentre study*

Recently, in a monocentre study mycophenolate mofetil (MMF) was demonstrated to be efficacious and safe in penetrating high‐risk keratoplasty. Here, preliminary results of a randomized multicentre trial are presented. To date, 86 of 140 scheduled patients undergoing high‐risk penetrating keratoplasty have already been randomized into the two study groups: 48 into the MMF group and 38 into the control group. All 86 patients received fluocortolon 1 mg/kg body weight/day, tapered within 3 weeks, and topical prednisolone acetate 1% tapered within 5 months. MMF was administered at a daily oral dose of 2 × 1000 mg for the first 6 postoperative months. Thereafter, MMF was tapered within 2 weeks. The proportion of grafts with immune reactions and side‐effects were the main outcome measures. Within an average follow up of 9.2 ± 6.6 months two patients developed reversible endothelial immune reactions in the MMF group after cessation of MMF application. In the control group, five reversible and three irreversible immune reactions were observed within an average follow up of 10.1 ± 7.6 months. According to Kaplan and Meier analysis, the ratio of grafts without immune reactions was estimated 89% 1 year postoperatively in the MMF group, in contrast to only 67% in the control group (P = 0.03; log‐rank test). Fifteen patients experienced side‐effects, especially gastroenterotoxicity, tachycardia, arthralgia or systemic infections. All attributable side‐effects were reversible. Systemic MMF may be an effective and safe immune modulating drug in the prophylaxis of immune reactions after penetrating high‐risk keratoplasty.

Transscleral suture fixation of posterior chamber intraocular lenses in children under 3 years

Abstract · Background: Children who have undergone lentectomy for congenital or traumatic cataract do not have adequate capsular support for secondary posterior chamber intraocular lens (PC-IOL) implantation and thus will become severely amblyopic if contact lens intolerance occurs. In order to prevent amblyopia we fixed PC-IOLs by transscleral sutures in three children younger than 3 years. Clinical outcome, visual acuity and course of refraction were studied. · Methods: Four eyes of three children with contact lens intolerance were operated. Posterior chamber lenses (PC-IOL) were sutured in the ciliary sulcus by transscleral sutures. Two children had monocular traumatic cataract and one child underwent surgery on both eyes for congenital cataract. To allow adjustment of refraction in situ without removing the primarily implanted and transsclerally fixed PC-IOL we used the piggyback intraocular lens system for implantation. · Results: Visual acuity improved in all four eyes. The two children with traumatic cataract achieved visual acuity of 0.7 and 1.0, respectively, and stereopsis. No complications related to the technique of transscleral suture fixation of the PC-IOL were observed. Postoperative changes in refractive power were caused by a myopic shift between –1.0 D and –9.0 D. Follow-up was 25–70 months. · Conclusion: Transscleral suture fixation of PC-IOLs did not cause specific complications during follow-up of up to 70 months. This technique offers an important option for the correction of an aphakic refractive error which cannot be corrected otherwise. In future the piggyback intraocular lens system may help to rather atraumatically correct postoperative changes in refractive power.

Cicatricial ectropion in progressive skin diseases

PURPOSE . To report the clinical course, patient care and treatment of cicatricial ectropion in patients with progressive skin diseases. METHOD . Review and photo series of three typical cases, which were followed for up to 10 years. RESULTS . In certain severe progressive skin diseases, tissue shrinkage may progress permanently. The soft lid tissue cannot withstand the forces of vertical lid traction. As a result, recurrent ectropion occurs. Patients with lamellar ichthyosis and with eruptive Grzybowski-type keratoacanthoma were followed for up to 10 years. Free skin grafts of severely involved donor skin were repeatedly transplanted to the lids. The lid margins were fixed by traction sutures in order to spread out the wound and to allow rapid vascular ingrowth and undisturbed healing. In this way, early wound contracture could be prevented. Nevertheless, follow-up revealed progressive shrinkage of the transplanted lid skin. Eversion of the lacrimal punctum was the first sign of progression. Epiphora was the leading complaint of the patients. Bacterial superinfection of the deepened lacrimal lake was more frequent in advanced ectropion. CONCLUSION . Patients should understand the natural history of their disease in order to accept multiple surgical procedures. Ectropion should be re-operated in time in order to reduce epiphora, to prevent corneal complications, and to avoid metaplasia and keratinization of the conjunctiva and thickening of the lid margin. The elasticity of the lid skin should be improved pharmacologically and by increasing the relative humidity of the home environment, especially in winter. Consistent vertical lid massage can delay recurrence.

Severe bleeding eyelid after trivial trauma: conjunctival metastasis of a renal cell carcinoma

Dear Editor, A 70-year-old woman was referred to our clinic with a persistent bleeding of the eye following a minor injury, having slipped and bumped her head against a bedside table that morning. The right upper eyelid contained a subtarsal lesion and a hyposphagma in the temporal superior quadrant of her right eye. There was no evidence of a penetrating eye injury. Due to a permanent conjunctival hemorrhage, inspection of the wound was difficult. As the source of bleeding could not be identified using the slit-lamp, surgical exploration and wound care were planned. The wound exploration and haemostasis were performed as an emergency procedure. Next to the wound, a whitish gelatinous nodule could be identified as the source of the bleeding (Fig. 1a). An excisional biopsy of this nodule was taken and the bleeding was stopped with an electrosurgical cauter. The patient’s medical history revealed a renal cell carcinoma (initial pT3, pNx cM0 G2 R0 L0 V1). A nephrectomy on the left side had been performed in July 2006 as well as consecutive resections of metastases of the diaphragm, the right lung, and the right breast in November 2007. In September 2008, partial resection of the 6th rib was performed, as well as a resection of a second metastasis of the right lung. Since January 2009, a further 20 smaller metastases of the lungs had been removed, and in February 2009 the patient presented with cerebral metastases. These were treated with a radiosurgical procedure in April 2009. The patient is still alive and in moderate condition. Histology of the conjunctival specimen showed a low differentiated malignant epithelial tumor (Fig. 1b). There were only a few small vessels supplying the tumor. Immunohistochemistry was positive for pancytokeratine AE1/AE3 (Fig. 1c) and CD10 (Fig. 1d). Examination of the primary tumor showed identical histological and immunohistochemical findings. In summary, the histopathological findings confirmed the nodule as a conjunctival metastasis of the known renal cell carcinoma. In 2004, Shields and co-worker analyzed a series of 1,643 conjunctival tumors [1]. In this large cohort they found only 13 metastases, i.e., metastases accounted for less than 1% of all conjunctival tumors. Five of these 13 metastases were associated with breast cancer, three with pulmonary cancer, two with a malignant melanoma of the skin, one with a carcinoid, one with a laryngeal carcinoma, and one metastasis of unknown origin. These data illustrate the rarity of conjunctival metastases in comparison to primary conjunctival tumors. However, renal cell carcinomas (RCC) represent approximately only 1–3% of all adult visceral cancers [2]. One of the common characteristics of RCCs is their tendency to metastasize without showing early clinical symptoms. The most common locations of metastases are the lungs (>50%) and the bones (up to 30%), followed by regional lymph nodes, the liver, and the brain [3]. Only in very rare cases do RCCs affect the eye. In a T. Lapp (*) Division of Infection and Immunity, University College London, The Cruciform Building, Gower Street, London WC1E 6BT, UK e-mail: T.Lapp@ucl.ac.uk

Astigmatismus nach transskleraler Hinterkammerlinsenimplantation bei Kleinkindern

ZusammenfassungHintergrund. Ziel der vorliegenden Untersuchung war es, festzustellen, wie hoch der Astigmatismus nach skleraler Nahtfixation einer Hinterkammerlinse bei Kleinkindern ist und wie lange er bestehen bleibt. Darüber hinaus sollte eine Strategie für die postoperative Amblyopieprophylaxe entwickelt werden. Patienten und Methode. Bei 8 lentektomierten Augen, bei denen eine Kontaktlinsenunverträglichkeit bestand, wurden eine Hinterkammerlinse durch transsklerale Nähte fixiert und der postoperative Astigmatismus in den ersten 2 Monaten wöchentlich, danach in monatlichen Intervallen skiaskopisch gemessen. Die Hornhautradien wurden mit einem automatischen Handkeratometer (Alcon) bestimmt. Ergebnisse. Der induzierte Astigmatismus betrug 2,5–8,0 dpt und bildete sich bei 4 der 8 Augen innerhalb von 4 Wochen und bei 5 der 8 Augen innerhalb von 16 Wochen bis auf Werte unter 0,75 dpt zurück. Während der Astigmatismus bei einem Auge in 8 Wochen nur bis auf 2,0 dpt zurück ging, blieb er bei zwei Augen unverändert bei 2,5 dpt bzw. 2,75 dpt. Nach 16 Wochen war der Astigmatismus bei allen Augen konstant bei 0,5–2,75 dpt. Die Sehschärfe betrug 0,016–1,0. Schlussfolgerungen. Die Ergebnisse der Untersuchung zeigen, dass sich der postoperative Astigmatismus in der Regel rasch zurückbildet und die Amblyopiebehandlung nicht gefährdet. Wir empfehlen einen postoperativen Astigmatismus, der größer als 2 dpt ist, bereits unmittelbar nach der Operation zur Hälfte im Brillenglas auszugleichen und das Kind im folgenden Vierteljahr häufig zu skiaskopieren, um das Brillenglas entsprechend nachkorrigieren zu können. Nach 16 Wochen kann die Vollkorrektur des Astigmatismus erfolgen.AbstractBackground. The purpose of this study was to evaluate the postoperative astigmatism after trans-scleral fixation of intraocular lenses in children and to develop a strategy for amblyopia prophylaxis. Patients and methods. In eight eyes with lentectomy, posterior chamber intraocular lenses were fixed in the ciliary sulcus by trans-scleral sutures. The postoperative astigmatism was measured by retinoscopy every 1 to 2 weeks in the first 2 months, followed by monthly intervals thereafter. Keratometry was performed with an automated hand keratometer. Results. Postoperative astigmatism was 2.5 to 8.0 D. The astigmatism regressed to 0.75 D in half the eyes within 4 weeks and in five of the eyes within 16 weeks. In one of the eight eyes, the astigmatism decreased to 2.0 D and in two it remained unchanged. The astigmatism did not change any more after 16 weeks postoperatively. Visual acuity was 0.016 to 1.0. Conclusions. Our study shows that the postoperative astigmatism regresses soon and does not seriously interfere with amblyopia therapy. If greater than 2 D, half of the astigmatism should be corrected with glasses, even in the early postoperative period. After 16 weeks, full correction is recommended.

Neuroendocrine Tumor of the Eyelid: A Clinicopathological Case Report

Published Online: March 13, 2014. doi:10.1001/jamaophthalmol.2014.120. Author Contributions: Dr Margo had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Margo, Friedman. Acquisition of data: Margo. Drafting of the manuscript: Margo. Critical revision of the manuscript for important intellectual content: Margo, Friedman. Administrative, technical, and material support: Margo, Friedman.

[Clarithromycin for monotherapy of B-cell MALT lymphoma?].

Mit Interesse haben wir den Artikel „Clarithromycin-Therapie eines B-ZellMALT-Lymphoms“ der Kollegen Danilko et al. gelesen, worin ein beeindruckender Rückgang eines MALT-Lymphoms der Bindehaut im Stadium I nach Ann-Arbor unter der alleinigen Behandlung mit Clarithromycin gezeigt wird. Der Tumor war nach einer 21-tägigen Behandlung zwar deutlich rückläufig, aber auf dem gezeigten Bild auch 4 Monate nach Therapiebeginn noch vorhanden. In der Annahme, dass das Bild die maximale Tumorregression wiedergibt, möchten wir zu 3 Punkten kommentieren: 1. Eine empirische, alleinige Antibiotikatherapie mit Doxycyclin oder Clarithromycin ohne Nachweis von Chlamydia-psittaci-DNS im Gewebe wird bisher nicht empfohlen [1, 2]. Da dieser auch mit paraffineingebettetem Material möglich ist [4, 5], könnte die Untersuchung in vorliegendem Fall gut nachgeholt werden, falls noch Material vorliegt. 2. Studien an Lymphommaterial asiatischer (Korea; [3]) und kaukasischer (Kuba) Herkunft [4] ergaben in der Tat in bis zu 79% der Fälle einen positiven Nachweis von Chlamydiengenom. Dagegen waren in einer von uns durchgeführten retrospektiven Studie die Biopsate von 40 Patienten aus der süddeutschen Region mit Lymphomen der okulären Adnexe eindeutig Chlamydia-psittaci-negativ bei korrektem Ausgang der Positivkontrolle [5]. 3. Auch wenn eine immunmodulatorische und mögliche direkte antineoplastische Wirkung von Clarithromycin in manchen Regionen positive Effekte bei Lymphomen der okulären Adnexe ohne systemische Beteiligung haben kann [6], so bleibt der therapeutische Goldstandard die Bestrahlung, die in 85–100% zum Tumorrückgang bzw. zur Vollremission führt [2]. Diese wird niedrig dosiert angewandt. Als optimale Dosis werden 30,6–32,4 Gy in täglichen 1,8-Gy-Fraktionen empfohlen mit 81%iger Rezidivfreiheit nach 5 Jahren [7]. Die meistens nicht zu irreversiblen Sehschärfeverlusten führenden Nebenwirkungen treten bei bis zu jedem zweiten behandelten Patienten auf: Keratoconjunctivitis sicca (20– 40%) und/oder Katarakt (30–50%; [8]). Eine Optikusschädigung ist bei sachgemäßer Anwendung der fraktionierten Bestrahlung bei MALT-Lymphomen der Augenoberfläche unwahrscheinlich, insbesondere wenn die Dosis unter 36 Gy liegt [2]. Daher sind wir der Ansicht, dass in Anbetracht des noch deutlichen Resttumors nach Antibiotikatherapie und des recht jungen Alters der Patientin eine Bestrahlung unbedingt angezeigt ist (ggf. nach erneuter Biopsie), um eine eventuelle systemische Ausbreitung des Tumors zu verhindern Literatur

Recurrent conjunctival papilloma progressing into squamous cell carcinoma with change of HPV-finding during the course

A Caucasian woman in her eighties presented at our clinic with a reddish, papillomatous lesion covering the medial and inferior quadrants of the bulbar conjunctiva of the left eye. Duration of this lesion was unknown (fig 1A). As a squamous cell carcinoma was suspected, the tumour was surgically removed, and the resection margins treated by cryotherapy. Histopathological examination showed no signs of malignancy but did reveal a limbal papilloma (fig 1B). Figure 1 (A) Conjunctival papilloma. (B) Conjunctival papilloma (H&E stain, original magnification 200×). One year later, a richly vascularised lesion reoccurred in the nasal and lower circumference and began to grow over the cornea. Histological examination of the tumour, which was excised in toto, again showed a papilloma, just like the specimen of another resection 4 months later. The patient did not keep regular follow-up appointments after these operations. Two years later, she presented with an advanced tumour recurrence of the nasal inferior conjunctiva. Even though parts of the infiltrated medial rectal muscle were sacrificed, and excision margins underwent freeze–thaw therapy, we were unable to excise the tumour in toto. This time, histological examination revealed not a papilloma but a well-differentiated squamous cell …

Improvement of facial asymmetry with eye glasses

The appearance of cosmetic deformities of the orbit can be improved by eye glasses. These optical methods can improve the final outcome after orbital or facial reconstructive surgery. Patients with vertical displacement of one globe, enophthalmos or microphthalmos, and buphthalmos may benefit if the eye is amblyopic or blind.

Cicatricial ectropion with fixation of the lid margin to the bone o

In severe cicatricial ectropion the scarring and shrinkage between tarsus and periosteum can lead to fixation of the lid margin to the underlying bone. This is often the result of radical maxillectomy or tumor excision with consecutive radiation. A series of seven patients with this severe form of cicatricial ectropion is presented. All patients had had several previous operative procedures and two of them inferior orbital rim augmentation using free bone grafts. The extremely low position of the inferiorly frozen lid caused exposure keratitis. One patient lost his eye by perforation of a corneal ulcer. In two patients exposure keratitis was reduced by performing a large free skin graft and a transpositional flap from the upper lid. As free grafts have a high failure rate, tend to contract, and are not able to fill up the tissue deficit, a thick myocutaneous transposition flap from the area immediately above the eyebrow was used in four patients. These flaps provided a better blood supply and did not cont...