Irene Dejaco-Ruhswurm

Long-term results of implantation of phakic posterior chamber intraocular lenses

Purpose: To study the incidence and progression of lens opacification after implantation of phakic posterior chamber intraocular lenses for myopia and its correlation with vaulting and endothelial cell density (ECD). Setting: Department of Ophthalmology, University of Vienna Medical School, Vienna, Austria. Methods: An implantable contact lens (ICL V4, Staar Surgical Inc.) was inserted in 76 myopic eyes. Patients were prospectively followed preoperatively and at 1, 3, 6, 12, 24, and 36 months. The uncorrected visual acuity and best corrected visual acuity (BCVA) were determined. Vaulting was measured optically with a Jaeger II pachymeter, and the crystalline lens was examined at the slitlamp for the presence and characteristics of opacification. Endothelial cell morphometry was performed by specular microscopy, and the ECD was calculated. Eyes in which lens opacification developed were followed for at least 12 months to determine the degree and course of visual impairment. Results: Lens opacification occurred in 11 eyes (14.5%). Opacification was correlated with intraoperative trauma to the crystalline lens, age older than 50 years, and decreased ECD values throughout the observation period. Vaulting of the ICL did not correlate with the risk for lens opacification. After onset of lens opacification, 6 eyes (55%) had a stable BCVA within ±0.5 lines and 5 eyes had progressive opacification, losing between 3.5 lines and 0.5 lines (mean 1.8 lines ± 1.1 [SD]). Three eyes (3.9%) in the progressive group had a 1‐ to 2‐line loss of BCVA over preoperative values and subsequently had cataract surgery. Conclusions: Risk factors for lens opacification after implantation of the model V4 ICL included intraoperative trauma to the crystalline lens and older age. Decreased ECD in eyes with opacification suggests ongoing inflammation as a cause. Patients younger than 45 years may have a significantly lower incidence of opacification.

Outcome after treatment of ametropia with implantable contact lenses

OBJECTIVE To evaluate long-term results after insertion of implantable contact lenses (ICLs) in phakic eyes. DESIGN Prospective, noncomparative, interventional case series. PARTICIPANTS Seventy-five phakic eyes (65 myopic, 10 hyperopic eyes) of 45 patients aged 21.7 to 60.6 years were included. INTERVENTION STAAR Collamer Implantable Contact Lenses (STAAR Surgical Inc., Nidau, Switzerland) were implanted for correction of high myopia and hyperopia. MAIN OUTCOME MEASURES Uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), and intraocular pressure (IOP) were determined. Presence of lens opacification and the distance between the ICL and the crystalline lens were assessed by slit-lamp examination before surgery and at 1, 3, 6 months, and yearly after lens implantation. RESULTS Preoperative mean spherical equivalent was -16.23+/-5.29 diopters (D) for myopic eyes and +7.88 +/-1.46 D for hyperopic eyes. After ICL implantation, mean residual refractive error was -1.77+/-2.17 D in myopic patients and +0.44+/-0.69 D in hyperopic patients. Preoperative mean UCVA was Snellen 0.03+/-0.03 for myopic patients and Snellen 0.12+/-0.16 for hyperopic patients. Preoperative mean BCVA was Snellen 0.49+/-0.23 for myopic patients and Snellen 0.82+/-0.23 for hyperopic patients. After ICL implantation, mean UCVA up to the end of individual observation time was Snellen 0.36+/-0.36 for myopic patients and Snellen 0.58+/-0.28 for hyperopic patients. Mean BCVA was Snellen 0.73+/-0.26 for myopic and Snellen 0.80+/-0.24 for hyperopic patients. Mean preoperative IOP was 14.2+/-2.7 mmHg, and mean postoperative IOP was 13.46+/-2.1 mmHg over all follow-up investigations. The main complication was the development of subcapsular anterior opacifications of the crystalline lens in 25 eyes (33.3%), 2 of which showed direct contact to the ICL. Eleven eyes (14.7%) were stable in opacification and 14 eyes (18.7%) had progressive opacifications. The median time to opacification was 27.1 months. In 8 patients (10.7%), the subjective visual impairment mandated cataract surgery. CONCLUSIONS The most significant long-term complication after ICL implantation is the formation of opacifications of the crystalline lens with the risk of the necessity of subsequent cataract surgery (10.7%). Old age, female gender, and contralateral opacification are independent significant risk factors for early formation of opacifications in this patient group.

Long-term endothelial changes in phakic eyes with posterior chamber intraocular lenses

Purpose: To evaluate the long‐term endothelial cell changes in phakic eyes after implantation of a posterior chamber phakic intraocular lens to correct high ametropia. Setting: Department of Ophthalmology, University Hospital of Vienna, Vienna, Austria. Methods: Thirty‐four eyes of 21 patients having implantation of an implantable contact lens (ICL, Staar Surgical) for high myopia or hyperopia were prospectively examined. The minimum follow‐up was 2 to 4 years. Preoperative and serial postoperative specular microscopy (Noncon Robo SP 8000, Konan) was performed to evaluate the long‐term endothelial cell changes. Results: The mean preoperative endothelial cell density was 2854 cells/mm2. The mean endothelial cell loss from preoperatively was 1.8% at 3 months, 4.2% at 6 months, 5.5% at 12 months, 7.9% at 2 years (n = 34), 12.9% at 3 years (n = 13), and 12.3% at 4 years (n = 11). All other endothelial cell characteristics remained stable during the 4‐year follow‐up. Conclusions: Continuous endothelial cell loss was observed after ICL implantation during a 4‐year follow‐up. There was rapid cell loss until 1 year postoperatively, after which the rate of loss was no longer statistically significant. The percentage of hexagonal cells (polymorphism) and the coefficient of variation (polymegethism) remained stable during the 4‐year follow‐up.

Gonioscopic changes after implantation of a posterior chamber lens in phakic myopic eyes

Purpose: To evaluate the effects of posterior chamber implantation of phakic intraocular lenses on angle structures and the correlation with intraocular pressure (IOP). Setting: Department of Ophthalmology, University Hospital of Vienna, Vienna, Austria. Methods: A Staar implantable contact lens (ICL) was implanted in 20 white patients (34 eyes) with high myopia. The patients were followed for a mean of 2.3 years (range 0.8 to 6.0 years). Two subgroups were created: One had a follow‐up of 2.4 to 6.0 years and the other, 0.8 to 2.3 years. The mean spherical power of the implanted ICL was −16.8 diopters (D) (range −9.0 to −21.0 D). The angle structures were examined by gonioscopy using the Spaeth technique, and optical pachymetry and IOP were measured in dilated and undilated pupils. Trabecular pigmentation was measured semiquantitatively. The ICL models included a few prototypes (6 eyes), the V2 model (10 eyes), the V3 model (6 eyes), and the V4 model (12 eyes). Results: The anterior chamber angle was between 11 and 20 degrees in 41% of eyes, between 21 and 30 degrees in 21%, larger than 30 degrees in 21%, and 10 degrees or smaller in 17%. An apparent iris root insertion was above Schwalbes line in 6% of eyes, behind Schwalbes line in 12%, at the scleral spur in 67%, and in a deep angle recess behind the scleral spur in 15%. The curvature of the iris was regular in 19 eyes and steep in 15 eyes. The mean pigmentation in all 4 quadrants was 1.3. (Grade 1 was defined as trace pigmentation.) The mean pachymetry from the endothelium to the ICL anterior surface was 2.7 mm and from the endothelium to the anterior surface of the crystalline lens, 3.2 mm. The mean IOP was 14.1 mm Hg in undilated pupils and 12.1 mm Hg in dilated pupils. There was no correlation between angle pigmentation and IOP. Conclusion: Trace pigmentation in the trabecular meshwork was common after ICL implantation. However, there was no direct influence on IOP. Long‐term follow‐up is necessary to evaluate the effect and progress of trabecular pigmentation in eyes with an ICL.

Ocular blood flow in patients infected with human immunodeficiency virus

PURPOSE Alterations of ocular blood flow may play a role in the pathophysiology of human immunodeficiency virus (HIV) related retinal microvasculopathy. In this study ocular blood flow was investigated in patients with HIV infection. DESIGN In a prospective, cross-sectional study ocular blood flow was measured in 37 eyes of consecutive HIV- infected persons and compared with the data of age-matched healthy controls. This sample size was calculated based on an alpha-error of 0.5 and a beta-error of 0.8. METHODS Macular white blood cell flow, fundus pulsation amplitude, and blood flow velocities in the retrobulbar vessels were measured with blue field entoptic technique, laser interferometry, and Doppler sonography, respectively. Immunologic and ophthalmologic status was evaluated from each patient. RESULTS Mean CD4+ cell count of the HIV-infected persons was 206.8 +/- 145.6 cells/mm(3). In five patients HIV-related retinopathy was observed. A significant reduction in leukocyte density was seen in HIV infected persons (82.2 +/- 23.4) as compared with the control group (102.0 +/- 28.4; P =.019). The resistive index in the central retinal artery was higher in HIV infected patients (0.77 +/- 0.05) as compared with the controls (0.74 +/- 0.04; P =.04). The other hemodynamic parameters were not different between groups. No correlation of flow parameters and CD4+ cell count or HIV-related retinopathy was observed. CONCLUSIONS Decreased macular leukocyte density was detected in HIV infected persons. Our study suggests that abnormal retinal hemodynamics in individuals infected with HIV may be involved in the pathogenesis of HIV-related microvasculopathy.

Seven Years of HAART Impact on Ophthalmic Management of HIV-Infected Patients

Purpose: The widespread use of highly active antiretroviral therapy (HAART) has changed the clinical picture of HIV-associated eye disease. We evaluated the incidence of ocular manifestations of HIV infection since the introduction of HAART. Methods: Between January 1996 and December 2002, we examined 539 HIV-infected patients in our hospital. Follow-up of the patients was performed in case of ophthalmologic symptoms, regardless of current immunologic status, or for screening. Results: A total of 217 patients (40.3%) had HIV-associated eye disease. Of these patients, 42.0% had no eye symptoms. Fifty-eight (10.8%) of the 539 patients had cytomegalovirus (CMV) retinitis, most of whom had CMV retinitis before receiving HAART. Four patients developed immune-recovery uveitis. A total of 145 patients (26.9%) had HIV-related microangiopathy and 96 (17.8%) had dry-eye syndrome. Conclusion: The introduction of HAART had a major impact on the medical history of patients with HIV-related eye disease with improved survival time and decreased morbidity.

Changes of axial length and keratometry after keratoplasty for keratoconus using the guided trephine system

PURPOSE The purpose of this study was to examine the cause of increasing myopia after penetrating keratoplasty for keratoconus with the guided trephine system. DESIGN Prospective interventional study cohort. METHODS Thirty eyes (28 patients) after keratoplasty for keratoconus were examined. Preoperatively and 1, 3, 6, 12, and 24 months postoperatively subjective refraction was evaluated. Keratometry was calculated with a computerized videokeratoscope (TMS-1). Axial length was measured using applanation ultrasonography before surgery and 2 years after surgery. Anterior chamber depth, lens thickness, and vitreous length were taken into consideration. RESULTS The mean spherical equivalent was + 2.22 +/- 3.47 diopters 1 month postoperatively and had a continuous myopic shift to -1.02 +/- 2.65 diopters 2 years postoperatively. This was associated with a significant increase in mean keratometric levels from + 41.72 +/- 2.96 diopters 1 month postoperatively to + 43.77 +/- 2.29 diopters 2 years postoperatively (r(s) = -0.36, P =.05). Overall, no significant changes in axial length were observed. However, vitreous length showed a small but statistically significant increase. As expected, mean anterior chamber depth decreased significantly postoperatively (P </=.05). In eyes with a decrease in keratometric values (n = 8) a myopic shift was also observed. In this group a significant elongation of the axial length and the vitreous length was found. CONCLUSIONS A study of eyes after keratoplasty for keratoconus demonstrated continuous myopic shift over time. Increasing myopia was associated with increasing keratometric values. Thus, the major cause of increasing myopia after keratoplasty in keratoconus eyes seems to be continuing keratectasia. However, ongoing bulbus growth may contribute to continuing myopia in some eyes.

Imaging of polarization properties of the human cornea with phase resolved polarization sensitive optical coherence tomography

Polarization sensitive optical coherence tomography (PS-OCT) was used to measure and image retardation and birefringent axis orientation of in vitro human cornea. We used a two-channel PS-OCT system employing a phse sensitive recording of the interferometric signals in two orthogonal polarization channels. Using an algorithm based on a Hilbert transform, it is possible to calculate the retardation and the slow axis orientation of the sample with only one A-scan per transversal measurement location. While the retardation information is encoded in the amplitude ratio of the two interferometric signals, the axis orientation is encoded entirely in their phase difference. We present maps of retardation and slow axis distribution of normal and pathologic human cornea in longitudinal cross sections and en face images, obtained at the back sruface of the cornea. The results can be explained by a birefringence model based on stacked collagen fibril lamellae of different orientations.

Nachweis von Monosomie 3 in uvealen Melanomen — erste Ergebnisse

ZusammenfassungProblemstellungDer Verlust eines Chromosoms 3 in uvealen Melanomen gilt in der Literatur als ein prognostisch ungünstiger Faktor. In der vorliegenden Studie wurden die Veränderungen des Chromosoms 3 bei uvealen Melanomen untersucht.Patienten und MethodeZwischen Juli 2004 und November 2005 wurden 23 Tumoren von Patienten (12 weiblich, 11 männlich, mittleres Alter 65,3 ± 12,2 Jahre) mit uvealem Melanom mittels Fluoreszenz-in-situ-Hybridisierung (FISH) hinsichtlich Veränderungen in der Zytogenetik untersucht. Das Material wurde entweder nach Enukleation (n = 18) oder durch Endoresektion des Tumors (n = 5) gewonnen.ErgebnisseEine Monosomie des Chromosoms 3 wurde bei 12 (52,2%) der 23 Tumoren nachgewiesen. Partielle Veränderungen am Chromosom 3 fanden sich bei 3 Tumoren (13%). Der Zusammenhang der genetischen Ergebnisse mit dem großen Durchmesser der Tumorbasis (15,5 ± 3,3 mm), Beteiligung des Ziliarkörpers (n = 7), histologischem Zelltyp (Spindel B, n = 5; gemischt oder epitheloidzellig, n = 18), und Tod durch Metastasierung wurden untersucht.DiskussionIn unserer Patientengruppe wurde bei 52,2% der uvealen Melanome der Verlust des Chromosoms 3 nachgewiesen. Das uveale Melanom ist eine hoch maligne Erkrankung mit einer Mortalitätsrate von 50% nach 10 bis 15 Jahren. Bei chromosomalen Aberrationen, insbesondere bei Monosomie 3, ist mit einer herabgesetzten Lebenserwartung zu rechnen. Adäquate und rechtzeitige Identifizierung von Patienten mit einer hohen Metastasierungswahrschemlichkeit ist in Hinblick auf das Management mit engmaschigen klinischen Kontrollen wesentlich.SummaryPurposeAccording to the literature, loss of chromosome 3 in uveal melanoma correlates with a decreased survival of a patient. In this study, changes of chromosome 3 in uveal melanoma are analyzed in a patients’ population.Patients and methodFrom July 2004 to November 2005 23 tumors from patients (12 females, 11 males, mean age 65.3 ±12.2 years) with uveal melanoma were analyzed for genetic aberrations by fluorescence-in-situ-hybridization (FISH) after enucleation (n = 18) or endoresection (n = 5) respectively.ResultsMonosomy of chromosome 3 was detected in 12 (52.2%) of the 23 tumors. Partial deletions of chromosome 3 were found in 3 tumors (13%). Results were related to large basal tumor diameter (15.5 ± 3.3 mm), ciliary body involvement (n = 7), histologic cell type (spindle B, n = 5; mixed or epitheloid cell type, n = 23), and death due to metastatic disease.ConclusionIn our cohort 52.2% of uveal melanoma patients were found to have monosomy 3. Uveal melanoma is a highly malignant disease with a mortality rate of 50% at 10 to 15 years. Chromosome aberrations, especially monosomy 3, in uveal melanoma is associated with a decreased survival of the patients. Accurate identification of patients with a high probability of metastatic disease may be important with regard to clinical management, including close surveillance.

Klinische Ergebnisse nach Keratoplastik mit dem geführten Trepansystem (GTS®) bei Keratokonuspatienten

ZusammenfassungEinleitungDie klinischen Ergebnisse nach Keratoplastik mit dem geführten Trepansystem (GTS®) bei Keratokonuspatienten werden präsentiert. Wir erforschten insbesondere die Ursachen für die progrediente postoperative Myopisierung.MethodeIn dieser prospektiven Studie wurden 30 Augen (28 Patienten) nach perforierender Keratoplastik bei Keratokonus untersucht. Präoperativ, sowie 1, 3, 6, 12 und 24 Monate postoperativ, wurden die subjektive Refraktion und Keratometrie (TMS I) evaluiert. Zusätzlich wurde vor und 2 Jahre nach der Operation die axiale Länge mittels Ultrasonographie (Ocuscan) vermessen. Insbesondere wurden hierbei die Vorderkammertiefe, die Linsendicke und die Vitreuslänge berücksichtigt.ErgebnisseEin Monat postoperativ war das mittlere sphärische Äquivalent (sÄ) +2, 22 ± 3,47 Dpt. Bis zur Untersuchung 2 Jahre postoperativ kam es zu einem kontinuierlichen myopen Shift, das sÄ war −1,02 ± 2,65 Dpt. zu diesem Zeitpunkt. Die zunehmende Myopisierung war mit einer signifikanten Zunahme der keratometrischen Werte von +41,72 ± 2,96 Dpt. ein Monat postoperativ zu +43,77 ± 2,29 Dpt. zwei Jahre postoperativ (rs = −0,36, p = 0,05) assoziiert.Bei der axialen Bulbuslänge wurden keine signifikanten Veränderungen beobachtet. Die Vitreuslänge hingegen nahm leicht, aber statistisch signifikant zu. Wie zu erwarten, nahm die Vorderkammertiefe postoperativ signifikant ab (p < 0,05).SchlussfolgerungDie PKP mit dem GTS® resultiert in stabilen Astigmatismus- und guten Visusergebnissen. Es bestätigte sich aber eine zunehmende postoperative Myopisierung nach PKP bei Keratokonuspatienten, welche mit einer signifikanten Zunahme der keratometrischen Werte assoziiert war. Die hauptsächliche Ursache der postoperativen Myopisierung nach PKP scheint eine progrediente Keratektasie zu sein. Ein Bulbuslängenwachstum trägt allerdings in manchen Fällen zur weiteren Zunahme der Myopie bei.SummaryPurposeThe purpose of this study was to evaluate the clinical results after penetrating keratoplasty for keratoconus with the guided trephine system (GTS®) and, further to examine the cause of increasing postoperative myopia.MethodsIn a prospective interventional study cohort 30 eyes (28 patients) after keratoplasty for keratoconus were examined. Preoperatively and 1, 3, 6, 12 and 24 months post-operatively subjective refraction and keratometry (TMS I) were evaluated. Axial length was measured by using applanation ultrasonography before surgery and 2 years after surgery. Anterior chamber depth, lens thickness and vitreous length were taken into consideration.ResultsThe mean spherical equivalent was +2.22 ± 2.47 D one month postoperatively and had a continuous myopic shift to −1.02 ± 2.65 D two years postoperatively. This was associated with a significant increase in mean keratometric levels from +41.72 ± 2.96 D one month postoperatively to +43.77 ± 2.29 D two years postoperatively (rs = −0.36, p = 0.05).Overall, no significant changes of axial length were observed. However, vitreous length showed a small, but statistically significant increase. As expected, mean anterior chamber depth decreased significantly postoperatively (p < 0.05).ConclusionKeratoplasty with the GTS® results in stable corneal astigmatism and good visual results. Study of eyes following keratoplasty for keratoconus demonstrated continuous myopic shift over time. Increasing myopia was associated with increasing keratometric values. Thus, the major cause of increasing myopia after keratoplasty in keratoconus eyes seems to be continuing keratectasia. However, ongoing bulbus growth may contribute to continuing myopia in some eyes.