J. C. Schmidt

Primary vitrectomy in complicated rhegmatogenous retinal detachment--a survey of 205 eyes.

Introduction: In a few types of rhegmatogenous retinal detachment (RRD), scleral buckling (SB) has a lower success, and, here, pars plana vitrectomy (PPV) is a good alternative option. This survey reviews the indications and the surgical outcome of primary PPV with internal tamponade. Patients and Methods: We reviewed 205 eyes operated by primary PPV for RRD at the Department of Ophthalmology of the Philipps University Marburg between the years 1990 and 1997. The indications of PPV were: holes greater than 90°; holes posterior to the equator; proliferative vitreoretinopathy grade C; pseudophakic status. Results: A complete reattachment of the retina after absorption of the gas or after silicone oil removal was achieved by 1 operation in 146 eyes (71.2%) and in 195 eyes (95.2%) by a second intervention. Conclusion: Although SB is the standard procedure for the treatment of RRD, complicated cases can be treated successfully with primary PPV.

Muscarinic receptor functioning and distribution in the eye : molecular basis and implications for clinical diagnosis and therapy

Muscarinic receptor functioning and distribution in the eye: Molecular basis and implications for clinical diagnosis and therapy

A modified technique to stain the internal limiting membrane with indocyanine green.

Purpose: Peeling of the internal limiting membrane (ILM) has improved the outcomes in vitreoretinal surgery of macular diseases. Indocyanine green (ICG) is used to stain and improve the visualization of the ILM. This paper aims to describe a modified approach to stain and peel the ILM avoiding potential adverse side effects. Methods: After a core vitrectomy, 0.05 ml of ICG in a concentration of 5 mg/ml is quickly injected under water around the macular region. The tip of the syringe is positioned about 5 mm from the macular tissue, in a way that about a 3-mm diameter area around the fovea is stained by the ICG. Additional ICG is immediately removed by aspiration. Peeling of the ILM is accomplished with a forceps. Results: Neither residual ICG in the vitreous cavity nor any clinical signs of phototoxicity like retinal edema were detected in any patients operated by this technique. Conclusions: This modified technique to stain the ILM limits the amount and concentration of ICG. The locally limited contact of ICG with the retinal surface seems to be a safe procedure to stain the ILM.

Effect of pars plana vitrectomy for proliferative diabetic vitreoretinopathy on preexisting diabetic maculopathy.

Abstract.Background: Vitrectomy is the treatment of choice for proliferative diabetic vitreoretinopathy with tractions and persistent vitreous hemorrhage. Since vitrectomy has recently been discussed as a possible therapy for diabetic maculopathy as well, we were especially interested in studying the change in diabetic maculopathy following surgery. For that purpose a grading system developed at our clinic was used. Methods: In a retrospective study we evaluated fundus photographs and fluorescein angiograms of 33 eyes of 30 patients who had undergone vitrectomy for proliferative diabetic vitreoretinopathy at our clinic between 1990 and 1997. In all eyes diabetic maculopathy was present at the time of surgery. The grading was performed using preoperative images and images taken a median of 18 months postoperatively. Results: Best corrected visual acuity increased by 3.7 lines on average. Intraretinal dot and spot hemorrhages, hard exudates, microaneurysms on fundus photos, and leakage and cysts on fluorescein angiograms decreased after surgery. The extent of the foveolar avascular zone and the extent of the perifoveolar ischemic area worsened, however. Conclusion: Vitrectomy seems to help diabetic eyes not only by removal of membranes, tractions, and vitreous hemorrhage; it seems to have a positive influence on the course of diabetic maculopathy as well. We suspect that the removal of the posterior vitreous membrane is one of the crucial factors in interrupting the disease process. From these results the indication for vitrectomy in diabetic patients may have to be reconsidered and extended to include diabetic maculopathy prior to the development of ischemia.

Radial Optic Neurotomy for Central Retinal Vein Occlusion: Long-Term Retinal Perfusion Outcome

Background/Aims:To analyze the long-term changes in retinal perfusion and functional improvement induced by radial optic neurotomy (RON) in central retinal vein occlusion (CRVO). Methods: Sixty-three eyes of 63 consecutive patients with CRVO were included. Twenty-eight (44.5%) patients underwent RON and 35 (55.5%) were followed as a control group. Time of arteriovenous transit and visual acuity were determined at baseline and after 1-year follow-up. Results:After 1 year, retinal perfusion status improved in 63.1% of operated eyes and 14.3% of controls (p = 0.048). The improvement in arteriovenous retinal transit was statistically significant (p = 0.023) only in the RON group. The visual improvement in the RON group was significantly better (p = 0.043) than in the control group. Moreover, the development of chorioretinal anastomosis was significantly higher (p = 0.036) after RON than in controls and correlated with better functional results. In operated eyes there was a lower incidence of CRVO-related complications. Conclusion:RON improved retinal perfusion and achieved a better functional outcome. The measurement of perfusion changes as presented here may be useful for monitoring CRVO and assessing other treatment modalities.

Modified transscleral suture for sulcus fixation of posterior chamber lenses

&NA; We describe a modified technique to minimize the risk of hypotony during the placement of transscleral anchoring sutures. An anchor thread is used to transsclerally fixate a posterior chamber intraocular lens (IOL). The IOL is placed precisely and without trauma. The technique was used in 17 patients. Postoperatively, all IOLs were well centered. Visual acuity increased from a preoperative mean of 0.25 to a postoperative mean of 0.40. The mean postoperative refraction was −0.75 diopter (D) (range +0.50 to −4.50 D). Longer phases of hypotony do not occur, and the use of CIF needles can be omitted.

Retropupillare Fixation einer Irisklauenlinse (Artisan™, Verisyse™) bei Aphakie. Ist die skleranahtfixierte Intraokularlinse noch state of the art?

ZusammenfassungProblemstellungZur Korrektur der Aphakie stehen verschiedene Techniken und Intraokularlinsen zur Auswahl. Bis vor einem Jahr erfolgte an unserer Klinik die Korrektur der Aphakie durch eine skleranahtfixierte Hinterkammerlinse. Neuerdings verwenden wir eine Irisklauenlinse, welche ebenfalls hinter der Iris platziert werden kann. Es stellt sich die Frage, welche Methode geeigneter für eine Aphakiekorrektur erscheint.Methoden und/oder PatientenSiebzehn konsekutive Fälle mit skleranahtfixierter Intraokularlinse und zehn Fälle mit retropupillarer Fixation einer Irisklauenlinse konnten in die retrospektive Studie mitaufgenommen werden. Neben der Operationsmethode bezugnehmend auf technische Anforderungen und Komplikationsrate wurden refraktive Ergebnisse, Vorderabschnittsbefund und die Pupillenmotilität untersucht. Besondere Berücksichtigung fand die postoperative Fundus-beurteilbarkeit und somit der Einfluss auf spätere operative Hinterabschnittseingriffe.ErgebnisseIm untersuchten Intervall (skleranahtfixierte IOL bis maximal 24 Monate, Irisklauenlinse bis maximal 14 Monate) zeigte sich in einem Auge mit skleranahtfixierter IOL eine Subluxation zwei Jahre postoperativ nach stumpfem Trauma. Eine Ablatio retinae vier Wochen nach Implantation einer Irisklauenlinse konnte erfolgreich mittels Parsplana-Vitrektomie behandelt werden. Der korrigierte Visus war durchschnittlich von 0,25 auf 0,4 in der skleranahtfixierten Gruppe und von 0,23 auf 0,37 in der irisfixierten Gruppe angestiegen. Die durchschnittlichen refraktiven Änderungen konnten in der skleranahtfixierten Gruppe von + 8,5 dpt präoperativ zu −1,75 dpt postoperativ und in der skleranahtfixierten Gruppe von + 7,1 dpt zu −1,6 dpt gemessen werden. Pupillomotorik und Ausmaß der Mydriasis nach diagnostischer Pupillenerweiterung war in keinem Fall der skleranahtfixierten Linsen vergleichend zum präoperativen Befund verändert. Einzelne Fälle von signifikanter Pupillenentrundung in Richtung der Inkarzeration bei Nativpupille konnte bei der Aphakiekorrektur durch die irisfixierten IOL beobachtet werden. Die Pupillenmotilität und das Ausmaß der medikamentösen Mydriasis zeigte dezente Einschränkungen bei den irisfixierten Linsen. Eine Explantation war in keinem Fall notwendig.SchlussfolgerungDie retropupillare Fixation einer Irisklauenlinse scheint die Vorteile einer echten Hinterkammer-linsenimplantation bei postoperativer guter Verträglichkeit aufzuweisen. Der im Vergleich zur skleranahtfixierten IOL einfachere Implantationsvorgang stellt einen Vorteil dieser Methode dar. Irispathologien und sekundäre Irisveränderungen bei Ischämie-Erkrankungen reduzieren jedoch das Indikationsspektrum. Einfluss auf Pupillenform, Pupillenmotilität und Ausmaß der diagnostischen Mydriasis sowie der geringere Optikdurchmesser sollten dabei aber nicht außer Acht gelassen werden.SummaryIntroductionThere are several surgical options available to correct aphakia. Routinely transscleral suture fixation of the IOL is performed. In the last 1.5 years we also employed the Mohr technique of retropupillary fixation of an iris claw lens. We investigated which method is more suitable to correct aphakia especially from the vitreoretinal point of view.Patients and methodsSeventeen consecutive cases of sclerafixated lenses and ten cases of irisfixated lenses where included in the study. The following parameters have been compared: intraoperative and postoperative complications, pupil movement, optic diameter, visual acuity, refractive changes and the influence on the vitreoretinal surgery.ResultsThe implantation was possible in all cases of sclerafixated and irisfixated lenses. The follow up was with a maximum of 24 months for the sclerafixated and 14 months for the irisfixated group. There was one subluxation of a lens following blund head trauma two years after sclerafixated lens surgery. Retinal detachment followed two months after a irisfixated lens. The mean best-corrected visual acuity improved from 0.25 to 0.4 in the sclerafixated group and from 0.23 to 0.37 in the irisfixated group. Refractive changes revealed a change from + 8.5 dpt preoperative to −1.75 dpt postoperative in the sclerafixated group and from +7.1 to −1.6 in the irisfixated group. Whereas there was no change in pupil diameter and pupillomotoric in the group of sclerafixated lenses a distorsion of the pupil toward the enclavation site was observed in a few cases of irisfixated lenses. An explantation of a lens was not necessary in any of the cases.ConclusionThe retropupillary fixation of an iris claw lens seems to have the advantages of a true posterior chamber implantation with a low intra- and postoperative risk profile. The shorter and easier implantation technique is an advantage in comparison to the sclerafixated technique. However, the influence on pupil form and the reduced diameter of optic zone should be considered especially in view of later fundus examination and eventual vitreoretinal surgery.

Dreidimensionale Optische Kohärenz-Tomographie (3D-OCT) zur Verlaufskontrolle von Makulaödemen nach intravitrealer Triamcinolon-Applikation

ZusammenfassungProblemstellungIntravitreales Triamcinolon acetonid (TA) stellt eine neue Therapieform zur Behandlung verschiedenster Makulaerkrankungen wie u. a. Makulaödeme und altersabhängige Makuladegeneration dar. In der Literatur sind verschiedene Untersuchungsmethoden beschrieben, welche den klinischen Effekt und Therapieverlauf von intravitrealem TA dokumentieren. Sehkraft, Fundusfotografie, Fluoreszenzangiografie (FA), lineare optische Kohärenztomografie (OCT) und dreidimensionales (3D) OCT werden in dieser Studie verglichen und die Vorteile der jeweiligen Untersuchung dargestellt.Methode und PatientenBei 21 Patienten mit Makulaödemen in Fällen von Zentralvenenthrombose (ZVT), Venenastverschluss (VAV) diabetischer Retinopathie und Uveitis wurde Triamcinolon acetonid intravitreal appliziert. Neben den bisher üblichen Untersuchungsmethoden (Visus, FA) erfolgte zusätzlich die Fundusfotografie, lineares OCT und 3D-OCT prä- und postoperativ.ErgebnisseEin Visusanstieg erfolgte bei 15 Patienten. In allen Fällen konnte fluoreszenzangiographisch präoperativ eine deutliche Leckage im Bereich der Makula dargestellt werden. Obwohl in 14 Fällen eine Reduktion der Leckage postoperativ nachweisbar war, konnte in 7 Fällen aufgrund fehlender Quantifizierung keine wesentliche Veränderung der Befunde beschrieben werden. Die Fundusfotografie ermöglichte eine angemessene Darstellung von Makulaveränderungen in nur 4 Fällen. Das lineare OCT zeigte eine Reduktion der Netzhautdicke von 380–620 um zu 168–450 um. In zwei Fällen konnte keine signifikante Differenz dokumentiert werden. Da das 3D-OCT eine Fläche der Makula mit einem Durchmesser von 6.000 μm repräsentiert, war es möglich, Veränderungen der Makulaödeme in allen Fällen nachzuweisen.SchlussfolgerungAuch wenn die Sehkraft nicht in allen Fällen angestiegen ist, so helfen doch andere Untersuchungs-methoden wie lineares OCT und 3D-OCT hocheffizient, Makulaveränderungen nach TA-Applikation zu verifizieren. Das 3D-OCT stellt für uns die derzeit sensitivste Untersuchungsmethode dar, den therapeutischen Effekt von intravitreal appliziertem Triamcinolon nachzuweisen.SummaryIntroductionIntravitreal Triamcinolone acetonide (TA) is a new therapy to treat several macular diseases including macular edema and age-related macular degeneration. There are several examination methods described in the literature to follow the clinical effects of intravitreal TA. Visual acuity (VA), fundus photography, fluorescein angiography (FA), linear optical coherence tomography (OCT) and three-dimensional (3D) OCT are compared in this study and the advantage of each examination is pointed out.Patients and methodsTA was injected intravitreal in 21 patients with macular edema secondary to central retinal vein occlusion (CRVO), branch retinal vein occlusion (BRVO), uveitis and diabetic maculopathy. Routine VA and FA examination were performed in all cases. Additionally, fundus photography, linear OCT and 3D-OCT were conducted pre- and post-operatively.ResultsVA improved in 15 patients. Pre-operative FA examination demonstrated extensive macula leakage in all cases. While in 14 cases a marked leakage reduction was observed postoperative in FA, in seven cases the quantification of leakage was not possible. Fundus photography allowed appropriate visualization of the macular changes in only four cases. Linear OCT showed a reduction of retinal thickness from 380–620 urn to 168–450 urn postoperatively. In two cases no significant differences could be documented. Because 3D-OCT represents a large area of 6000 μm in diameter, macular edema changes could be clearly observed in all cases.ConclusionAlthough in some cases VA did not improve, other examinations such as linear and 3D-OCT demonstrated a high efficacy to detect macular changes after TA injection. 3D-OCT is the most sensitive and precise examination to demonstrate therapeutic effects of intravitreal TA application.

Vitreoretinale Chirurgie bei komplizierten Netzhautablösungen im Kindes- und Jugendalter

ZusammenfassungHintergrund. Ziel dieser Untersuchung war die Evaluation der vitreoretinalen Silikonölchirurgie im Kindes- und Jugendalter bei komplizierten Netzhautablösungen infolge Traumata und hohen Myopien. Methode. Wir führten eine retrospektive Untersuchung der an der Universitäts-Augenklinik Marburg bei Kindern und Jugendlichen bis 17 Jahre vorgenommenen vitreoretinalen Eingriffe mit Silikonölinstillation durch. In den Jahren 1990 bis 1997 wurden insgesamt 30 Augen von 29 Patienten operiert, 24 wegen eines Traumas und 6 mit komplizierten Netzhautablösungen bei hoher Myopie. Der Nachbeobachtungszeitraum betrug im Mittel 1,7 Jahre. Aus 18 der 30 Augen konnte das Silikonöl nach durchschnittlich 4,7 Monaten wieder entfernt werden. Im Durchschnitt wurden 2 Pars-plana-Vitrektomien pro Auge durchgeführt. Ergebnisse. Bei 21 von 30 Augen (70%) konnte die Netzhaut durch einen oder mehrere Eingriffe zur Anlage gebracht werden. Bei 16 dieser 21 Augen (53%) konnte das Silikonöl wieder entfernt werden, was als anatomischer Erfolg definiert wurde. Bei 23 der 29 Augen (79,3%) stieg der Visus an oder blieb unverändert (14 versus 9 Augen; 48,3% versus 31%). Der Visus fiel bei 6 von 29 Augen (20,7%) trotz Operation ab. 2 Augen (6,7%) davon mussten auf Grund einer Phthisis enukleiert werden. 17 Augen erreichten einen postoperativen Visus von mindestens Fingerzählen (FZ bis 0,5). Bei einem Kind konnten auf Grund des geringen Alters keine Visusprüfung erfolgen. Schlussfolgerung. Die Pars-plana-Vitrektomie mit Silikonölendotamponade ist mittlerweile ein Standardverfahren zur Behandlung der oben genannten komplizierten Netzhautpathologien im Kindes- und Jugendalter. Ein Vorteil gegenüber der Gasendotamponade ist die postoperativ nicht zwingend notwendige Gesichtstieflage, wozu Kinder nur schwer anzuhalten sind. Die anatomische Erfolgsquote, d. h. die Rate der wieder angelegten Netzhäute ist ermutigend. In einem Großteil der Fälle zeigen die funktionellen Ergebnisse einen Visus von Fingerzählen oder darüber und ermöglichen zumindest orientierendes Sehen. In einigen Fällen wird nach schwersten Netzhautveränderungen sogar wieder ein Lesevisus erreicht.AbstractBackground. The purpose of this study was to evaluate anatomical and functional results of vitreoretinal silicone oil surgery for complicated retinal detachments due to trauma and myopia in children and juveniles. Methods. We retrospectively reviewed the records of children and juveniles up to 17 years of age who had undergone vitreoretinal surgery with silicone oil instillation for the above causes between 1990 and 1997. A total of 30 eyes of 29 patients were operated on, 24 because of trauma and the remaining 6 because of retinal detachment in high myopia. There was a mean postoperative follow-up period of 1.7 years. Silicone oil could be removed from 18 of the 30 eyes after a mean of 4.7 months. The median number of vitrectomies performed per eye was two (range one to five). Results. In 21 of 30 eyes (70%) the retina could be reattached after one or more surgeries. Silicone oil was removed from 16 of these 21 eyes (53%) which was defined as anatomical success. Visual acuity increased (14 eyes, 48.3%) or remained unchanged (9 eyes, 31%) in 23 of 29 eyes (79.3%). Visual acuity decreased in 6 of 29 eyes (20.7%) despite surgery. Two eyes (6.7%) had to be enucleated due to bulbar phthisis. Seventeen eyes reached a postoperative visual acuity of at least counting fingers. In one child functional tests could not be performed due to young age. Conclusion. Vitreoretinal surgery with silicone oil endotamponade has become a standard procedure in treating complicated retinal pathologies in children and juveniles. In very young patients it is thought that silicone oil instillation has advantages over gas endotamponade since it is very difficult for children to keep the proper face-down positioning after the procedure. The retinal reattachment rate is encouraging. In the majority of cases visual acuity greater than or equal to counting fingers and thus orienting vision was reached postoperatively. In few cases even reading vision was regained.

Vitreous body and retinal vein occlusion

PURPOSE The aim of this study was to evaluate whether the adhesion status of the posterior vitreous cortex (PVC) towards the internal limiting membrane (ILM) has an impact on the development of retinal vein occlusion (RVO). MATERIAL AND METHODS In a retrospective analysis the operation protocols of 238 eyes receiving pars plana vitrectomy (ppV) and radial optic neurotomy (RON) for central retinal vein occlusion (CRVO) or ppV in combination with arteriovenous sheathotomy (AVS) for branch retinal vein occlusion (BRVO) were evaluated with respect to the intraoperative status of posterior vitreous body adhesion. The results were compared with age-matched healthy controls. RESULTS In this study 145 eyes (60.9 %) suffering from CRVO and 93 eyes (39.1 %) diagnosed with BRVO were included. In eyes with CRVO and BRVO the posterior vitreous cortex (PVC) was significantly more often attached (126 eyes, 86.9 % and 89 eyes, 95.7 %, respectively) than completely detached (19 eyes, 13.1 % and 4 eyes, 4.3 %, respectively, in each case p < 0.001). In the age groups between 70 and 79 years as well as between 80 and 89 years the PVC was significantly more often attached in both RVO entities in comparison to age-matched healthy controls (CRVO 70-79 years, p = 0.001 and 80-89 years, p = 0.002 and BRVO 70-79 years, p < 0.001, 80-89 years, p = 0.011). In eyes from the age group between 65 and 69 years (of age) the PVC was not significantly more often attached in comparison to healthy controls (CRVO p = 0.334 and BRVO p = 0.114). CONCLUSION According to these findings posterior vitreous adhesion is an independent risk factor for the development of retinal vein occlusion among patients aged 70 years or older.