Hartmut Wenkel

Posterior scleritis associated with Borrelia burgdorferi (Lyme disease) infection

OBJECTIVE To report on the clinical findings in a patient with posterior scleritis associated with infection with Borrelia burgdorferi. DESIGN Interventional case report. PARTICIPANT A 39-year-old male ranger who experienced posterior scleritis after several tick bites with erythema migrans. TESTING Extensive ophthalmic and systemic workup, including serologic testing and imaging techniques. RESULTS Sonography and contrast-enhanced computed tomography showed a large scleral mass (16 x 12 x 13 mm) in a patient with painful proptosis in the left eye with episcleral vascular dilation, reduction in bulbar motility, and chorioretinal folds in the upper temporal quadrant. Treatment with high-dose corticosteroids resulted in rapid regression of clinical symptoms and of the scleral mass. Intensive workup revealed immunoglobulin M antibodies (enzyme-linked immunoassay, Western immunoblot) and a positive lymphocyte transformation assay against B. burgdorferi. No other cause for posterior scleritis could be identified. CONCLUSIONS Posterior scleritis should be added to the list of ocular manifestations associated with Lyme disease. Because corticosteroids alone resulted in rapid improvement of clinical symptoms, the scleritis might be mediated by autoimmunologic mechanisms.

Long term results after autologous nasal mucosal transplantation in severe mucus deficiency syndromes

AIM Severe mucus deficiency syndromes may require substitution of mucous membrane for re-establishment of the ocular surfaces. The long term results after autologous nasal mucosal transplantation were investigated. METHODS 55 eyes of 50 patients with severe mucus deficiency syndromes were followed retrospectively after free autologous nasal mucosal transplantation—group A: patients after severe lye, acid, heat burns, or radiation (n=38 eyes), group B: patients with systemic mucosal disease (n=17 eyes). The results of routine clinical examination were recorded and patients were followed for a median of 37 months. 17 biopsies of transplanted nasal mucosa were studied by light microscopy and 22 patients by impression cytology before and at several intervals after mucosal transplantation. RESULTS All nasal mucosal grafts healed well and no intraoperative complications occurred. During follow up 107 additional surgical procedures were performed including 16 lamellar and 21 penetrating keratoplasties. Subjective complaints improved in 44/47 patients with preoperative symptoms. Best corrected visual acuity at the end of follow up was increased in 23 eyes, 10 eyes (18.2%) reached a final visual acuity equal to or greater than 20/200. Histopathologically, all (n=17) biopsies showed vital intraepithelial mucin producing goblet cells in the nasal mucosal graft (median 25 cells/field (400× magnification)). The mean density of goblet cells before transplantation was 48/mm2 and after nasal mucosal grafting 432/mm2measured by impression cytology (p<0.0001). CONCLUSIONS Functional goblet cells persist in autologous nasal mucosa for up to 10 years after transplantation. In patients with severe mucus deficiency syndromes of different origin nasal mucosal transplantation can re-establish the ocular surface, substitute the mucus components of the tear film, improve symptoms of the patients, and facilitate a moderate increase in visual acuity.

Detection of varicella zoster virus DNA and viral antigen in human eyes after herpes zoster ophthalmicus

OBJECTIVE The purpose of the study was to identify varicella zoster virus (VZV) DNA and viral antigen in human eyes at various intervals after clinical onset of herpes zoster ophthalmicus (HZO). DESIGN A retrospective case series. PARTICIPANTS There were 9 eyes and 4 corneal buttons surgically obtained from 13 patients with HZO at the University Eye Hospital of Erlangen-Nürnberg between 1984 and 1994. Specimens were examined at different timepoints after clinical onset of HZO (range, 1 day-19 years; median, 36 months). METHODS Histopathologic evaluation was performed on formalin-fixed and paraffin-embedded tissue by routine histology, immunohistochemistry (5-B-7 murine monoclonal antibody to VZV; peroxidase-antiperoxidase method), and DNA-in situ hybridization (35S deoxyadenosine triphosphate-labeled HindIII fragments [A and C] of VZV). RESULTS Typical histopathologic changes associated with HZO were identified: vascularization of the corneal stroma (11 of 13), granulomatous reaction to Descemets membrane (8 of 13), fusiform-shaped ciliary scarring (5 of 9), optic neuritis (4 of 9), and perineuritis (8 of 9) and perivasculitis (8 of 9) of the long posterior ciliary nerves and arteries. VZV antigen was detected in two patients with acute infection 1 and 7 days after onset of HZO, respectively. VZV-DNA was identified in seven patients up to 10 years after onset of HZO in corneal epithelial cells (2 of 13), corneal stroma (5 of 13), inflammatory infiltrate of the anterior chamber (1 of 9), episclera (2 of 9), posterior ciliary nerves (1 of 9) and arteries (5 of 9), optic nerve (5 of 9), and adjacent leptomeninges (2 of 9). CONCLUSION Persistence of viral genomes, most likely accompanied by gene expression or slow viral replication, appears to be responsible for the often smoldering panophthalmitis and the chronic recurrent keratouveitis in patients with HZO. Localization of viral DNA in vascular structures suggests a role for vasculitis in the pathogenesis of some ocular findings associated with HZO.

Autologe Nasenschleimhaut-transplantation frühzeitig nach schwersten okularen Verätzungen

Die Therapie schwerster Verätzungen ist immer noch problematisch. Im Verlauf kommt es häufig zu ausgeprägten Mukusmangelsyndromen, zu deren Therapie an der Augenklinik der Universität Erlangen-Nürnberg seit 1984 die autologe Nasenschleimhautplastik etabliert ist. Wir berichten über erste Erfahrungen beim Einsatz der Nasenschleimhautplastik frühzeitig nach schwersten Verätzungen.Patienten: Prospektiv wurden 9 Patienten (8 Männer, 1 Frau) mit autologer Nasenschleimhautplastik innerhalb von 14 Tagen nach schwerster okularer Verätzung untersucht. Bei allen Patienten lagen ein fast zirkulärer Defekt des kornealen Randschlingennetzes, eine großflächige konjunktivale Nekrosezone sowie eine persistierende Epithelialisierungsstörung vor. Die durchschnittliche Nachbeobachtungszeit betrug 38 Monate.Ergebnisse: Bei allen Patienten besserten sich die subjektiven Beschwerden, und es wurde eine ausreichende okulare Befeuchtung erzielt, die zur raschen Reepithelialisierung führte. Bei 2 Patienten traten im Verlauf leichte Symblephara auf. Fünf Patienten erreichten einen Visus ≥0,1.Schlußfolgerung: Eine frühzeitige Nasenschleimhauttransplantation scheint den Verlauf schwerer okularer Verätzungen günstig zu beeinflussen.The treatment of severe eye burns is still complicated. Since 1984 we have performed autologous nasal mucosa transplantation for the severe mucus deficiency syndromes often occurring during follow-up. Now we report on our initial experience using nasal mucosa transplantation shortly after severe burns.Patients: Prospectively, nine patients (eight male, one female) were examined after autologous nasal mucosa grafting within 14 days after eye burns. In all patients there was an almost complete defect of limbal vascularization, large areas of necrotic conjunctiva and prolonged epithelialization problems. The patients were followed for an average of 38 months.Results: In all patients the subjective complaints lessened and sufficient ocular wetting led to rapid reepithelialization. During the follow-up period two patients showed light symblephara. In five patients visual acuity improved to ≥20/200.Conclusion: Early nasal mucosa transplantation is an additional tool in the treatment of severe ocular burns.

Histopathology of retrocorneal membranes after keratoplasty

BACKGROUND This retrospective study examines the histopathological changes, especially the occurrence of retrocorneal membranes, in irreversible graft failure after penetrating keratoplasty. PATIENTS/MATERIALS AND METHODS 371 corneas of 308 patients were examined. The examination was carried out using a light microscope. RESULTS 45% of the corneas (167/371) showed a retrocorneal membrane with a thickness of 2-520 micrometers. Re-endothelialisation was detected in 75 cases. In 74% (124/167) cellular infiltration into the stroma could be observed. In 32% (119/371) the graft-host border was visible. CONCLUSIONS Retrocorneal membranes are a frequent finding in irreversible graft failure after penetrating keratoplasty. Aetiologically the graft-host border as well as the formation of connective tissue seem to play a key role.

Value of conjunctival biopsy in the diagnosis of sarcoidosis

SummaryPurpose: Retrospective study concerning the value of conjunctival biopsy in the diagnosis of sarcoidosis. Patients and methods: Between 1990 and 1996 we performed conjunctival biopsy in 11 patients (mean age 42.7 ± 16.4 years) with suspect of sarcoidosis. Results: In 8 of the 11 patients the diagnosis of sarcoidosis was established during the clinical course. In four of these eight patients conjunctival biopsy was positive. Five of the eight were under systemic steroids at the time of biopsy. Of the four patients with clinically established sarcoidosis and negative biopsy, three were under systemic steroids at the time of biopsy. In two patients diagnosis of sarcoidosis was established primarily by conjunctival biopsy. Conclusion: Conjunctival biopsy is a simple tool in the diagnostic of sarcoidosis. If possible, biopsy should be undertaken before systemic steroid treatment. We consider conjunctival biopsy to be useful as the first diagnostic tool before other invasive methods.ZusammenfassungHintergrund: Retrospektive Studie zur Wertigkeit der Bindehautbiopsie bei der Diagnosestellung der Sarkoidose (Morbus Boeck). Patienten und Methode: Wir haben bei 11 Patienten (mittleres Alter: 42,7 ± 16,4 Jahre), bei denen wir im Zeitraum 1990–1996 eine Bindehautbiopsie bei Verdacht auf Sarkoidose durchgeführt haben, retrospektiv die Wertigkeit der Biopsie für die Diagnosestellung untersucht. Ergebnisse: Von den 11 Patienten mit Verdacht auf Sarkoidose hatten 8 Patienten eine klinisch gesicherte Sarkoidose im Rahmen der Krankengeschichte. Von diesen 8 Patienten war die Bindehautbiopsie bei 4 Patienten positiv. Von den 8 Patienten mit klinisch gesicherter Sarkoidose standen 5 Patienten unter Steroiden zum Zeitpunkt der Biopsie. Bei den Patienten mit klinisch gesicherter Sarkoidose und negativer Biopsie standen 3 von 4 Patienten unter Sterioden zum Zeitpunkt der Biopsie. Bei zwei Patienten konnte die Diagnose einer Sarkoidose primär durch die Bindehautbiopsie gestellt werden. Schlußfolgerung: Die Bindehautbiopsie ist ein einfaches diagnostisches Mittel zur Diagnosefindung bei Verdacht auf Sarkoidose. Nach Möglichkeit sollte die Bindehautbiopsie vor der Verabreichung systemischer oder lokaler Steroide erfolgen. Die Durchführung einer Bindehautbiopsie vor anderen invasiven Maßnahmen zur Diagnosefindung bei Verdacht auf Sarkoidose halten wir für sinnvoll.

Maculo-papillary branch retinal artery occlusions following the Wada test.

Abstract  Background: The Wada test induces short-term anesthesia of one hemisphere by injection of sodium amytal into an internal carotid artery. It is an important presurgical diagnostic tool in epileptic patients. Patient: A 22-year-old man with idiopathic epilepsy noticed a shadow in the central visual field of his right eye immediately following a Wada test of the right hemisphere. Results: The patient presented with an occlusion of two small branch retinal arteries and corresponding defects in his visual field. Fluorescence angiography revealed small dense hyperfluorescent spots within the occluded retinal vessels. Conclusion: Branch retinal artery occlusions are a possible complication of the Wada test, possibly induced by undissolved contrast medium or sodium amytal.