Ina Sterker

Spheno-orbital meningiomas: outcome after microsurgical treatment: a clinical review of 30 cases

Abstract Objective: Spheno-orbital meningiomas represent a delicate subtype of intracranial meningiomas involving the sphenoid wing, orbit and important neurovascular structures such as cavernous sinus, carotid artery or optic nerve. Insidious and aggressive dural, bone and orbital involvement contains several defiances to adequate resection, which provides high rates of recurrence. Methods: This retrospective case analysis consisted of 30 patients, who were surgically treated for spheno-orbital meningiomas performing a fronto-pterional approach by or under the supervision of the senior author (J. Meixensberger) between May 2001 and February 2006. There were 22 woman and eight men with a mean age of 54·4 years. The follow-up period ranged from 3 to 75 months (mean: 33·7 months). Results: The majority of patients presented with a clinical triad of visual impairment (74%), progressive proptosis (55%) and visual field defects (40%). Total microscopic tumor resection was achieved in ten patients (33%). Visual acuity improved in 65% of the patients, and 40% of these returned to normal vision. Pre-existing cranial nerve deficits remained unchanged in the majority of patients (88%) and improved in 12%. Temporary new cranial nerve deficits occurred in three patients. The rate of permanent non-visual morbidity was 10% (three of 30 patients). Eight patients (27%) received post-operative radiotherapy with an overall tumor growth control rate of 63%. The overall recurrence rate was 27% (eight of 30 patients). Conclusion: Sufficient tumor control can be achieved with minimal morbidity and satisfying functional results.

Therapeutic options for treatment of Merkel cell carcinoma

Merkel cell carcinoma (MCC) is a rare malignant neuroendocrine carcinoma of the skin. Owing to the aggressiveness of this tumor and the bad overall survival, we reviewed the therapeutic strategies, including surgery, radiation, and chemotherapy to find out the potentially best treatment option for one patient treated at our hospital. In addition, we investigated MCC biopsies using the FLAVINO assay to find out if individual chemoresponse testing might be a useful supplement in decision-making for the optimal therapeutic option for our MCC patient. The different results achieved using cisplatin, docetaxel, and cetuximab led to the conclusion that an individual chemoresponse testing in a predictive short-time assay might potentially be a useful diagnostic tool in identifying potentially effective chemotherapy treatments.

Pars plana lentectomy for treatment of congenital cataract.

Abstract.Background: Congenital cataract surgery can be performed using a pars plicata/plana or a limbal approach, if placement of an intraocular lens at the time of cataract removal is not a consideration. Because of the high incidence of secondary cataract formation in children the operation should be combined with capsulotomy and anterior vitrectomy. Methods: The series consisted of 30 eyes from 20 consecutive children who suffered from congenital cataract and underwent cataract surgery between May 1995 and June 2000. The inclusion criterion was congenital cataract affecting the visual axis. We performed the operations as lens aspiration with anterior and posterior capsulotomy and anterior vitrectomy via the pars plana or plicata. We used contact lenses to rehabilitate vision. All patients received intensive orthoptic and pleoptic treatment. Results: This surgical technique provided in all eyes a clear visual axis. During follow-up of 3 months to 4.5 years, secondary cataract developed in five eyes. Retinal detachment, glaucoma and endophthalmitis did not occur. One patient developed contact lens intolerance and a secondary intraocular lens was placed in the ciliary sulcus. Discussion: Lentectomy via a pars plana or pars plicata approach is a suitable and safe method for treating cataract in children. Our chosen method of lentectomy is an alternative to early implantation of an intraocular lens. It is possible to perform uncomplicated secondary implantation of an intraocular lens in the ciliary sulcus.

Periocular hemangiomas in childhood – functional and esthetic results

introduction Hemangiomas are the most common tumors of the eyelids and orbit in childhood. These tumors can produce ptosis, strabismus and anisometropia, resulting in amblyopia. The treatment of hemangiomas is a challenge with respect to the functional results (prevention of amblyopia) and cosmetic outcome. material and methods The history, clinical findings, magnetic resonance imaging (MRI), management and outcome of 15 children (3–9 months old) with hemangiomas of the eyelids and/or orbital involvement are reviewed. results Seven patients with small superficial hemangiomas were merely kept under clinical observation. In seven other patients with threatened or existing occlusion of the visual axis or refractive errors, treatment was indicated. Four children were given local Neodymium: YAG-laser therapy. In patients with large subcutaneous eyelid hemangiomas and involvement of the orbita we decided to treat with interstitial Neodymium: YAG-laser therapy in combination with systemic corticosteroids. One patient with an unknown tumor in the medial canthus was diagnosed by biopsy. During the follow-up period of 12–24 months, all untreated patients and 6 of 7 treated children showed involution of their tumors. One patient with a large eyelid and orbital hemangioma with occlusion of the visual axis did not respond to laser therapy and systemic corticosteroids; excision of the tumor was necessary. All children with eyelid hemangiomas with orbital involvement (n = 3) suffered from anisometropia with astigmatism and were treated for amblyopia. During 24 months of amblyopia treatment, the visual acuity improved in two of three cases to 0.4 and 1.0. conclusion Periorbital hemangiomas must be managed by individual and interdisciplinary diagnostic and therapeutic approaches. Therapy of amblyopia remains mandatory in all cases of large eyelid hemangiomas and/or orbital involvement.

Corneal topography of the fellow eye in unilateral keratoconus

SummaryPurpose: To study the incidence and shape of subclinical keratoconus with corneal topography in the fellow eye in the case of clinically, slit-lamp biomicroscopically and topographically diagnosed unilateral disease. Methods: Eighty patients with keratoconus were fitted with contact lenses. Twelve of them revealed clinical features of unilateral disease. In these patients we performed a computed topographic analysis in the clinically normal fellow eye. We measured quantitative parameters (central corneal power, I-S value) and qualitative parameters (localization and shape of corneal steepening). Results: In all 12 patients we found in the fellow eye no slit-lamp evidence for keratoconus. Nine patients were emmetropic in the fellow eye, three patients myopic between −1.5 and −4.0 D. The myopia in these patients was corrected with contact lenses and the investigation was performed 5 days after discontinuance of contact lenses. The corneal topography showed the typical keratoconus pattern in 11 patients with a steepening of the inferior cornea and in 1 case a superior steepening of the cornea; range of I-S values −1.0 to +5.0 D. All patients revealed a configuration of oval type cone keratoconus in the corneal topography. Conclusion: Keratoconus occurs with a high degree of bilaterality, but with onset of the disease at different times in the two eyes. Corneal topography seems to be a sufficient method to detect early keratoconus.ZusammenfassungFragestellung: Ziel war es, Daten über die Häufigkeit und die Art eines subklinischen Keratokonus des Partnerauges bei Keratokonuspatienten mit klinisch, biomikroskopisch nur einseitiger Erkrankung mittels Hornhauttopographie zu gewinnen. Methode: Derzeit befinden sich 80 Patienten wegen eines Keratokonus in unserer kontaktologischen Behandlung. Davon wiesen 12 lediglich einen einseitigen Keratokonus auf. Bei diesen Patienten erfolgte anläßlich einer Kontrolluntersuchung eine computergestützte korneale Topographie mit Bestimmung quantitativer (K-Wert, I-S-Wert) und qualitativer (Lokalisation, Form der kornealen Versteilung) Parameter des bisher klinisch unauffälligen Partnerauges. Ergebnisse: Bei allen 12 Patienten fanden sich am Partnerauge biomikroskopisch keine Zeichen für einen Keratokonus, die Refraktion war bei 9 Patienten auf diesem Auge emmetrop, bei 3 Patienten myop zwischen −1,5 und −4,0 dpt. Die Myopie war kontaktlinsenkorrigiert. Die Untersuchung der Kontaktlinsenträger erfolgte nach 5 tägiger Kontaktlinsenkarenz. Die korneale Topographie zeigte bei 11 Patienten das Muster der inferioren und in 1 Fall einer superioren Versteilung der Hornhaut mit einem I-S-Wert von −1,0 bis +5,0 dpt. Die Form des Versteilungsareals wurde bei allen Patienten als „ovaler Konustyp“ eingeschätzt. Somit war bei allen Augen eine Keratokonuskonfiguration nachweisbar. Schlußfolgerung: Unsere Ergebnisse unterstützen die These des hohen Grads der Bilateralität des Keratokonus, welcher jedoch die beiden Augen des Patienten zu unterschiedlichen Zeitpunkten befallen kann. Die Hornhauttopographie kann als gut geeignetes Verfahren zur Erfassung früher Keratokonusformen angesehen werden.

Reconstructive and ophthalmologic outcomes following resection of spheno-orbital meningiomas.

Purpose: To assess long-term stability and aesthetic and functional outcomes of orbital reconstruction after resection of spheno-orbital meningiomas using calvarial bone grafts. Methods: A series of 21 patients were retrospectively examined after an average follow-up period of 65.6 months with regard to their personal satisfaction and also proptosis, ocular function, and reconstructive outcome. The sagittal position of the globe was analyzed by CT and MRI. Patients were treated surgically in an interdisciplinary approach between 1997 and 2006. Results: A permanent postoperative decrease in globe protrusion of 2.7 mm on average was achieved. Most patients (76%) reported identical or improved vision, 85% were satisfied with the reconstructive result, and 55% were free of discomfort in daily life. Seven patients suffered from recurrences that were invariably accompanied by globe protrusion. Conclusions: Calvarial bone grafts provide good, stable long-term results in the reconstruction of orbital defects. Globe protrusion is a reliable indicator for the detection of recurrences in spheno-orbital meningiomas. Because of high recurrence rates, it is advisable to continue follow-up for 20 or more years.

23-Gauge-Lentektomie zur operativen Behandlung einer angeborenen Katarakt

BACKGROUND Congenital cataract surgery can be performed using a pars plana/plicata approach if placement of an intraocular lens at the time of cataract removal is not a consideration. To prevent development of secondary cataract, we performed lens aspiration, anterior and posterior capsulotomy, and anterior vitrectomy via pars plana or pars plicata approach. Lentectomy in babies should be performed using a minimally invasive technique to prevent complications. Immediately after surgery, insertion of a contact lens should be possible. METHOD The series consisted of 11 eyes of 8 consecutive children who suffered from congenital cataract and underwent pars plana/plicata lentectomy between April 2007 and September 2008. Age at operation ranged from 6 weeks to 13 months (median age 4 months). The inclusion criterion was congenital cataract affecting the visual axis. Lentectomy was performed via a pars plana or pars plicata approach using a special 23-gauge aspiration and irrigation system and a 23-gauge cutter. We performed lens aspiration, anterior and posterior capsulotomy, and anterior vitrectomy. RESULTS Postoperatively the eyes showed only mild signs of inflammatory reaction. At the end of the operation, all eyes were provided with contact lenses. For all eyes, the surgical technique provided a clear visual axis during the follow-up period of 2-18 months. One eye developed secondary cataract. CONCLUSION The use of 23-gauge instruments has advantages over standard 20-gauge equipment. Pars plana/plicata lentectomy using 23-gauge instruments is a safe, effective, and minimally invasive method for treating cataract in babies.

Strabological results in patients with macular translocation surgery and counterrotation of the globe as a secondary procedure.

INTRODUCTION Age-related macular degeneration is the most common cause of irreversible loss of visual acuity, including the ability to read, in elderly patients. One of the surgical treatment options is macular translocation with 360° retinotomy. The orthoptic results of torsional muscle surgery as a second procedure are demonstrated. MATERIALS AND METHODS Between January 1999 and December 2000, the macula was rotated upward by 12?45° in 10 eyes following complete artificial detachment and a 360°retinotomy. In these patients, torsional surgery was carried out as a second procedure. Depending on the resulting cyclotorsion, we performed surgery on the oblique muscles only in four patients with a cyclotropia of 12?20° and a combination of oblique muscle surgery with surgery of two or four rectus muscles in the remaining six eyes (cyclotropia over 21°). The pre- and postoperative diagnostic techniques included visual acuity, reading vision and the orthoptic status. RESULTS Due to the unilateral ectopia of the macula, all patients presented postoperative strabismus with a vertical deviation of 2?10° and a subjective cyclotropia between 12° and 40°. After surgery on the oblique muscles, the patients showed a residual cyclotropia of 0?6°. In patients in whom surgery on the oblique muscles was accompanied by rectus muscle surgery, the remaining cyclotorsion was 5?13°. Four patients excluded the non-operated fellow eye, six patients experienced double vision under binocular conditions and thus required prescription of additional prism glasses. CONCLUSION Macular translocation causes diplopia under binocular conditions because of the unilateral ectopia of the macular region with cyclotropia and vertical deviation. These problems can be resolved or reduced by oblique muscle surgery or in combination with additional surgery on the rectus muscles, depending on the range of the cyclotorsion. Performing the torsional surgery as a second procedure after macular rotation with an exact preoperative measurement of the subjective cyclodeviation appears to be useful.

Blunt forehead trauma and optic canal involvement: finite element analysis of anterior skull base and orbit on causes of vision impairment

Background Clinical studies report on vision impairment after blunt frontal head trauma. A possible cause is damage to the optic nerve bundle within the optic canal due to microfractures of the anterior skull base leading to indirect traumatic optic neuropathy. Methods A finite element study simulating impact forces on the paramedian forehead in different grades was initiated. The set-up consisted of a high-resolution skull model with about 740 000 elements, a blunt impactor and was solved in a transient time-dependent simulation. Individual bone material parameters were calculated for each volume element to increase realism. Results Results showed stress propagation from the frontal impact towards the optic foramen and the chiasm even at low-force fist-like impacts. Higher impacts produced stress patterns corresponding to typical fracture patterns of the anterior skull base including the optic canal. Transient simulation discerned two stress peaks equalling oscillation. Conclusions It can be concluded that even comparatively low stresses and oscillation in the optic foramen may cause micro damage undiscerned by CT or MRI explaining consecutive vision loss. Higher impacts lead to typical comminuted fractures, which may affect the integrity of the optic canal. Finite element simulation can be effectively used in studying head trauma and its clinical consequences.

[23-gauge-lentectomy for the treatment of congenital cataract].

BACKGROUND Congenital cataract surgery can be performed using a pars plana/plicata approach if placement of an intraocular lens at the time of cataract removal is not a consideration. To prevent development of secondary cataract, we performed lens aspiration, anterior and posterior capsulotomy, and anterior vitrectomy via pars plana or pars plicata approach. Lentectomy in babies should be performed using a minimally invasive technique to prevent complications. Immediately after surgery, insertion of a contact lens should be possible. METHOD The series consisted of 11 eyes of 8 consecutive children who suffered from congenital cataract and underwent pars plana/plicata lentectomy between April 2007 and September 2008. Age at operation ranged from 6 weeks to 13 months (median age 4 months). The inclusion criterion was congenital cataract affecting the visual axis. Lentectomy was performed via a pars plana or pars plicata approach using a special 23-gauge aspiration and irrigation system and a 23-gauge cutter. We performed lens aspiration, anterior and posterior capsulotomy, and anterior vitrectomy. RESULTS Postoperatively the eyes showed only mild signs of inflammatory reaction. At the end of the operation, all eyes were provided with contact lenses. For all eyes, the surgical technique provided a clear visual axis during the follow-up period of 2-18 months. One eye developed secondary cataract. CONCLUSION The use of 23-gauge instruments has advantages over standard 20-gauge equipment. Pars plana/plicata lentectomy using 23-gauge instruments is a safe, effective, and minimally invasive method for treating cataract in babies.