J. Nepp

Results of hydrophilic acrylic, hydrophobic acrylic, and silicone intraocular lenses in uveitic eyes with cataract : comparison to a control group

Purpose: To evaluate the uveal and capsular biocompatibility of hydrophilic acrylic, hydrophobic acrylic, and silicone intraocular lenses (IOLs) in eyes with uveitis. Setting: Department of Ophthalmology, University of Vienna, Vienna, Austria. Methods: This prospective study comprised 72 eyes with uveitis and 68 control eyes having phacoemulsification and IOL implantation by 1 surgeon. Patients received 1 of the following IOLs: foldable hydrophilic acrylic (Hydroview®, Bausch & Lomb), hydrophobic acrylic (AcrySof®, Alcon), or silicone (CeeOn® 911, Pharmacia). Postoperative evaluations were at 1, 3, and 7 days and 1, 3, and 6 months. Cell reaction was evaluated by specular microscopy of the anterior IOL surface and the anterior and posterior capsule reaction, by biomicroscopy. Results: Small round cell deposition was observed on all IOLs in the immediate postoperative period, especially in eyes with uveitis. This reaction decreased 3 to 6 months after surgery. Although the CeeOn 911 had a higher mean grade of small cells, there was no statistical difference between the 3 IOL types after 6 months in the uveitis and control groups. Foreign‐body giant cells (FBGCs) increased after 1 week to 1 month. The AcrySof IOLs had the highest number of FBGCs; after 6 months, there was a statistically significant difference between the AcrySof and Hydroview uveitis groups (P = .036) and the AcrySof and CeeOn 911 uveitis groups (P = .003) but there was no difference among the 3 IOL types in the control group. Lens epithelial cell outgrowth persisted on the Hydroview IOLs in control eyes and regressed on all 3 IOL types in uveitic eyes and on the AcrySof and CeeOn 911 IOLs in control eyes (P = .0001). Anterior capsule opacification (ACO) was more severe on all IOL types in uveitic eyes and on the CeeOn 911 IOL in control eyes. Posterior capsule opacification (PCO) was more severe in uveitic eyes. The Hydroview group had more severe PCO than the AcrySof and the CeeOn 911 groups in uveitis and control eyes. Six months postoperatively, the difference was significant (P = .0001). There was no significant difference between the AcrySof and CeeOn 911 IOLs. Conclusions: Intraocular lens biocompatibility is inversely related to inflammation. Hydrophilic acrylic material had good uveal but worse capsular biocompatibility. Hydrophobic acrylic material had lower uveal but better capsular biocompatibility. Silicone showed a higher small cell count (mild) and more severe ACO but achieved PCO results comparable to FBGC results and better than those with the AcrySof lens 6 months after surgery. Despite the differences in IOL biocompatibility, all patients benefited from the surgery.

Influence of operator experience on the performance of ultrasound biometry compared to optical biometry before cataract surgery

Purpose: To compare measurements performed with the IOLMaster (Carl Zeiss, Meditec AG) with those obtained by applanation ultrasound (US) and manual keratometry and to evaluate the effect of operator experience on US biometry. Setting: Department of Ophthalmology, University of Vienna, Vienna, Austria. Methods: The axial length (696 eyes) and anterior chamber depth (ACD) (462 eyes) were measured in 377 patients with cataract using the IOLMaster and applanation US. To assess the effect of operator experience on the biometric results, the operators were divided into 2 groups: experienced and less experienced in performing US biometry. The difference in measurements between the methods and the variability of the difference were compared between the 2 groups. Results: Applanation US measured axial length and ACD shorter than the IOLMaster; the mean numerical difference was 0.13 mm and 0.19 mm, respectively (P<.01). For axial length, the absolute difference was smaller with experienced operators than with less experienced operators (0.15 mm versus 0.22 mm) (P<.01). For ACD, experienced operators obtained a smaller difference between measurement techniques (0.21 mm versus 0.29 mm; P<.05). Conclusions: Experienced US operators had less difference and lower variability in the difference between applanation US and IOLMaster readings for axial length and ACD measurements. The noncontact optical method, which is essentially operator independent, gave significantly more reliable biometry before cataract surgery, especially in the case of less experienced operators.

Treatment of keratoconjunctivitis sicca with topical androgen

OBJECTIVE Androgens have been reported to influence lipid production of sebaceous glands and even many ocular tissues. The effect of topical androgen therapy on a 54-year-old patient with keratoconjunctivitis sicca (KCS) and decreased lipid phase of the tear film is reported. METHODS For assessment of the lipid phase of the tear film, break up time (BUT) and lipid layer thickness (LLT) were monitored during 6 months before treatment as well as 3 months while using a daily topical androgen therapy. RESULTS During the topical androgen therapy the pathological lipid phase of the tear film was completely restored indicated by the normalisation of the values of BUT and LLT. CONCLUSION These findings are consistent with animal experiments indicating that topical administered androgen can restore the decreased lipid phase of the tear film. This may open up new therapeutic strategies for KCS.

The clinical use of viscoelastic artificial tears and sodium chloride in dry-eye syndrome.

This study was performed to test viscoelastic artificial tears (VAT) based on both subjective and clinical parameters in patients with keratoconjunctivitis sicca (KCS). Twenty-eight patients were evaluated in a randomized double-blind study. Sodium hyaluronate was used in two different concentrations (0.4%, 0.25%) and in combination with chondroitin sulfate. Each preparation was used for one week preceded by another weekly cycle using a sodium chloride solution. Before and after each cycle, clinical examinations were performed: tear film break-up time, Schirmers test, lipid-layer thickness and fluorescein staining. Patients kept a record of the drop-frequency, subjective response and side effects. After the study, they were asked to give a rating of the various preparations. The severity of KCS was expressed based on a sicca score and correlated with response to viscoelastic treatment. Both the subjective and the clinical parameters revealed no statistically significant differences between the various viscoelastic agents or between the viscoelastics and the sodium chloride solutions. Severe side effects did not occur. There was a positive correlation of response to viscoelastic treatment with severe KCS (+ 0.36) but not with mild KCS (-0.07). The VAT seems to be indicated in severe cases of dry-eye syndrome. Sodium chloride solutions may be a useful short-term alternative to other tear formulations.

Dry eye treatment with acupuncture

Dry eye is defined as a disorder of the tear film due to tear deficiency or excessive tear evaporation, which causes damage to the interpalpebral ocular surface and is associated with symptoms of ocular discomfort.1 Tear film homeostasis is based on an adequate, proper function and balance of at least three systems that produce the lipid, aqueous, and mucus layers of the tear film. Previous studies give evidence that humoral factors—for instance, vasointestinal active peptide, endocrine factors (estrogen, androgens), and the vegetative nerve system—are part of the complex regulatory mechanism of these systems.2

Die Behandlung der Konjunktivitis sicca mittels Akupunktur

ZusammenfassungHintergrundIn einer vorangegangenen Studie konnte gezeigt werden, daß nach Abschluß der Behandlung Beschwerden aufgrund einer Konjunktivitis sicca durch Akupunkturtherapie in 91% der behandelten Patienten reduziert, in 59% sogar Beschwerdefreiheit ohne Therapie erzielt werden konnte. Diese prospektive Arbeit soll die Objektivierbarkeit und die Dauer der Akupunkturwirkung bei Konjunktivitis sicca aufzeigen.Patienten und MethodeInsgesamt wurden 25 Patienten (22 Frauen/3 Männer) im Alter von 20 bis 71 Jahren (mittleres Alter: 51,5 Jahre) einer Behandlung mit Akupunktur unterzogen. Kriterien für die Aufnahme in die Studie waren: eine mindestens einjährige Dauer der Anamnese, trotz Tropftherapie fehlende Beschwerdefreiheit, wiederholte Schirmertestwerte unter 5 mm sowie Tränenfilmaufreißzeiten unter 5 Sekunden. Die Behandlungsdauer betrug 10 Wochen mit einer mindestens 30 Minuten dauernden Sitzung pro Woche. Zur Beurteilung des Behandlungserfolges wurden ein Beschwerden- und Tropfprotokoll sowie Schirmertest, Tränenfilmaufreißzeit und der Bengalrosatest verwendet. Die Nachuntersuchungen erfolgten eine Woche sowie vierteljährlich bis ein Jahr nach Abschluß der Akupunktur.Ergebnisse1 Woche nach Akupunktur waren 15 (60%) Patienten beschwerdefrei bei einer Tränenfilmaufreißzeit über 10 Sekunden und normaler Bengalrosafärbung, jedoch erniedrigten Schirmertestwerten. 13 (52%) davon benötigen keine Therapie. Bei allen übrigen Patienten wurde eine Reduktion der Beschwerden und Therapienotwendigkeit beobachtet. 12 Monate nach Akupunktur waren 13 (52%) Patienten ohne Therapie beschwerdefrei bei normaler Tränenfilmaufreißzeit und Bengalrosavitalfärbung sowie unveränderten Schirmertestwerten. 5 (20%) Patienten berichteten über gleich starke Beschwerden wie vor Akupunktur. Eine Abnahme des Therapieeffektes wurde erstmals nach 6 Monaten bei 6 (24%) und nach 12 Monaten bei 8 (32%) Patienten beobachtet.SchlußfolgerungenDie subjektive Besserung ist gut mit den Ergebnissen der Therapie sowie Bengalrosafärbung, nicht jedoch mit den Schirmertestwerten in Einklang zu bringen. Bei Patienten mit Konjunktivitis sicca erscheint ein Therapieversuch mit Akupunktur gerechtfertigt, wenngleich über mögliche Wirkmechanismen noch keine Aussagen getroffen werden können.SummaryBackgroundIn a previous study we have shown that complaints due to conjunctivitis sicca were reduced in 91% of patients treated with acupuncture. 59% of these patients had no complaints even without therapy. This prospective study was performed to prove the effect of acupuncture treatment and its duration with objective means.Patients and methodsIn total 25 patients (22 women/ 3 men) with an age ranging from 20 to 71 (mean 51.5) were treated with acupuncture. Inclusion criteria were: an anamnesis of at least one year, complaints despite therapy, repeated Schirmer’s test values below 5 mm and break up time measurements below 5 seconds. Acupuncture treatment was performed 30 minutes once a week for ten weeks. To evaluate the therapy effect a protocol of complaints and therapy frequency as well as Schirmer’s test, break-up time and bengalrose staining were used. Examinations were performed one week and every 3 months up to one year after acupuncture treatment.Results1 week after acupuncture 15 (60%) patients had no complaints. Break-up time exceeded 10 seconds and bengalrose staining was normal, yet the Schirmer’s test were low. 13 (52%) were on no therapy. In all other patients a reduction of complaints and therapy frequency was observed. At 12 months 13 (52%) patients still had no complaints without therapy. Break-up time and bengalrose staining were normal and Schirmer’s test values were unchanged. In 5 (20%) patients the severity of complaints was as severe as before acupuncture. A reduction of the therapy effect was observed at 6 months in 6 (24%) and at 12 months in 8 (32%) patients.ConclusionThere is a good correlation between subjective improvement and break-up time and bengalrose staining, but not with Schirmer’s test results. In patients with conjunctivities sicca a try with acupuncture therapy is justified although the mechanisms remain unclear.

Akupunktur bei Konjunktivitis sicca

ZusammenfassungIn einer prospektiven Studie wurden 22 Patienten (4 Männer, 18 Frauen) mit Konjunktivitis sicca einem Therapieversuch mit Akupunktur unterzogen. Die Indikation für eine Akupunkturbehandlung wurde bei mindestens einjähriger Anamnese, unbefriedigender Tropftherapie sowie bei mehrmaligen Schirmertestwerten unter 5 mm und einer Tränenfilmaufreißzeit von unter 5 Sekunden gestellt. Zur Beurteilung eines Akupunktureffektes wurden die Kriterien Symptomhäufigkeit und -intensität, Tropfhäufigkeit, Schirmertest und Tränenfilmaufreißzeit herangezogen. Die Akupunkturbehandlung erfolgte einmal wöchentlich für über 30 Minuten an fixen und dem aktuellen Beschwerdebild angepaßten Punkten. Das Alter der Patienten schwankte zwischen 20 und 75 Jahren, die Nachbeobachtungszeit betrug 3 Monate. Nach Akupunktur waren bei den unter 50-jährigen Patienten (n = 10) 8/10 völlig beschwerdefrei und benötigten keine Therapie, während die übrigen 2/10 Patienten über eine Reduktion der Symptomatik und Therapie berichteten. Beim Schirmertest beobachteten wir ein Ansteigen der Werte auf über 10 mm in 3/10 Patienten, auf Werte zwischen 5 – 10 mm in 5/10 Patienten. Bei 2/10 blieb der Schirmertest unter 5 mm. Bei der Tränenfilmaufreißzeit wurde in 7/10 Patienten ein Anstieg auf über 10 Sekunden, in 3/10 ein Anstieg auf werte zwischen 5 und 10 Sekunden gemessen. In der Gruppe der über 50-jährigen Patienten (n = 12) kam es dagegen nur in 5/12 zu völliger Symptomfreiheit, und in 5/12 zu einer Reduktion. Die Tropfhäufigkeit wurde von allen Patienten reduziert, wobei 5/12 keine Therapie benötigten. Schirmertestwerte von über 10 mm erreichte 1/12, Werte zwischen 5– 10 mm 6/12 Patienten und 5/12 blieben unter 5 mm. Die Tränenfilmaufreißzeit überschritt 10 Sekunden in 3/12 Patienten. Ein Anstieg auf werte zwischen 5 und 10 Sekunden wurde in 7/12 Patienten beobachtet und 2/12 blieben unverändert. Diese vorläufigen Ergebnisse lassen den Schluß zu, daß bei Patienten mit Konjunktivitis sicca nach unbefriedigender konservativer Therapie ein Therapieversuch mit Akupunktur gerechtfertigt erscheint, wenngleich über mögliche Wirkmechanismen, Langzeitergebnisse und eine nach Ursachen differenzierte Erfolgsrate noch keine sicheren Aussagen getroffen werden können.SummaryIn a prospective study 22 patients (4 men, 18 women) with dry eye’s syndrome were treated with acupuncture. All patients fulfilled the following criteria: anamnesis of at least one year, unsatisfying drop therapy, repeated Schirmer test values below 5 mm and a break-up time of less than 5 seconds. The frequency and intensity of symptoms, the frequency of therapy necessity, Schirmer-test and breakup time were used to evaluate the effect of acupuncture. Acupuncture was performed 10 weeks once a week for more than 30 minutes using fix and variable points, which varied according to the patient’s actual complaints. The patients age ranged from 20 to 75, the follow-up was 3 months. In the group of patients with an age below 50 (n = 10) 8/10 patients had no symptoms and did not use any therapy whereas 2/ 10 reported a decrease in symptoms and therapy necessity. Schirmer-test values increased to 10 mm or more in 3/10 patients and to 5–10 mm in 5/10 patients. In 2/10 the Schirmer-test was still below 5 mm. The break-up time showed an increase in all patients. Values of 10 seconds or more were measured in 7/10 patients and values between 5 and 10 seconds in 3/10.In the group of patients aged 50 or more (n = 12) only 5/12 had no symptoms and 5/12 reported a decrease of symptoms. The therapy frequency was reduced by all patients and 5/12 were without any therapy at all. Schirmer-test results exceeding 10 mm was achieved by 1/12 and values between 5 and 10 mm by 6/12 patients. In 5/12 Schirmer-test results remained below 5 mm. The break-up time exceeded 10 seconds in 3/12 patients. In 7/12 the break-up time of 5 to 10 seconds was found and in 2/12 it remained unchanged. From this preliminary results we propose that acupuncture therapy seem to be justified in patients with dry eye’s syndrome if the conservative therapy is unsatisfying although statements concerning long-term results, possible mechanisms and success rates in the treatment of the different subtypes of dry eye’s syndrome cannot be drawn by now.

Inflammation after phacoemulsification in diabetic retinopathy: Foldable acrylic versus heparin-surface-modified poly(methyl methacrylate) intraocular lenses

Purpose: To evaluate inflammation after cataract surgery in patients with nonproliferative diabetic retinopathy (NPDR) and compare results with 2 intraocular lenses (IOLs): a foldable hydrophobic acrylic and a heparin‐surface‐modified (HSM) poly(methyl methacrylate) (PMMA). Setting: Department of Ophthalmology, University of Vienna, Vienna, Austria. Methods: Patients with NPDR were randomized for implantation of an HSM PMMA IOL (811C®, Pharmacia) through a 6.0 mm sclerocorneal incision (30 patients) or a foldable hydrophobic acrylic IOL (AcrySof®, Alcon) through a 4.0 mm sclerocorneal incision (32 patients). Both IOLs had 6.0 mm optics. All patients were treated according to a standardized protocol. The degree of flare in the anterior chamber was measured with the Kowa 1000 laser flare–cell meter 1 day preoperatively and 1 day, 1 week, and 1 and 3 months postoperatively. Results: In both IOL groups, flare was highest on the first postoperative day and decreased to preoperative levels by 3 months after surgery. There was no statistically significant difference in relative flare values between the 2 groups. Conclusion: There was no difference in postoperative inflammation in eyes with a foldable hydrophobic acrylic IOL implanted through a small incision and those with a rigid HSM PMMA IOL. Postoperative inflammation results indicate that the lenses are equally suitable for the use in patients with diabetic retinopathy.

Inzidenz intra- und postoperativer Komplikationen nach Kapsulorhexis und Hochfrequenz-Kapsulotomie

ZusammenfassungIn dieser prospektiv-randomisierten Studie wurden die Unterschiede bezüglich intra- und postoperativer Komplikationen bei Kapsulorhexis bzw. Hochfrequenz-Kapsulotomie (HF-KT) erarbeitet.Intraoperativ kam es bei der Hochfrequenz-Kapsulotomiegruppe zu einer signifikant höheren Inzidenz radiärer Einrisse der vorderen Linsenkapsel (41%) als in der Kapsulorhexisgruppe (0%). Diese Tatsache weist auf die verminderte Stabilität des Randes des vorderen Kapselblattes nach HF-KT hin.Postoperativ zeigten sich nach 3 Monaten keine signifikanten Unterschiede zwischen beiden Gruppen. Allerdings kam es in der HF-KT-Gruppe in 16% der Fälle, als Folge der radiären Einrisse, zu sekundären Fehlpositionierungen der Linse, in der Rhexisgruppe waren alle Linsen im Kapselsack positioniert.Bei spezieller Indikationsstellung stellt die HF-KT eine gute Alternative dar, die verminderte Reißfestigkeit der Kapselöffnung ist allerdings stets zu berücksichtigen.SummaryIn this prospective randomised study we evaluated the difference between the complications after capsulorhexis and high-frequency-capsulotomy during and after cataract-operation. During the operation a significantly difference of radial tears of the anterior edge of the capsul was observed between the used technique: Rhexis (0% tears) and high-frequency-capsulotomy (41% tears).The radial tears may be caused by less stability of the edge of the anterior capsul in compairment to the edge of the capsul after the rhexis.Three month after the operation, there were only few differences between both groups, except the malposition of the intraocular lens after high frequency capsulotomy (16%) which may be caused by the instability of the anterior capsul by the radial tears.High frequency capsulotomy is a good additional surgery method, if there are special indications. Otherwise it should be considered of those complications.

Psychovegetative Spannung bei Keratoconjunctivitis sicca und Beeinflussung mittels Akupunktur

ZusammenfassungEinleitungDie Keratoconjunctivitis sicca (KCS) ist eine chronische Bindehautentzündung mit Beeinträchtigung des Tränenfilms. Deren Behandlung mit Tränenersatzmittel ist oft unbefriedigend. Vorversuche mit Akupunktur zeigten eine klinische Wirksamkeit auf die KCS, jedoch mit unbekanntem Hintergrund. Da Erb eine erhöhte Spannung bei KCS festgestellt hat, und Akupunktur empirisch einen beruhigenden Effekt hat, sollten nun die Spannungen sichtbar und die Veränderungen nach Akupunktur gemessen werden.MethodeBei vegetativer Dystonie mit Aktivierung des sympathischen Nervensystems kommt es zu vermehrter Schweißbildung und Mydriasis, bei parasympathischer Aktivität zu Abgeschlagenheit und Myosis.Beide Systeme haben Einfluss auf die Tränenbildung. Gemessen wurde der Haut-Kontakt auf der Handfläche mittels Silberchlorid-Elektroden, die Pupillenweite mit TV-Pupillometrie 1050 und die psychische Befindlichkeit mit Fragebogen nach Zerssen.Spaltlampenuntersuchung, Schirmer II, Tränenfilmaufrisszeit(BUT), Lipidinterferenz, Bengalrosa, Impressionszytologie und Tropfprotokoll bestimmten die KCS. Die Tests wurden nach 3 Monaten wiederholt. In der Zwischenzeit erhielt ein Teil der Patienten Akupunkturbehandlungen (10×). Statistisch wurden der Willcoxen Test, t-test und Withney-Mann-Test angewendet.Ergebnisse45 Patienten mit KCS (18 m : 27 w) wurden untersucht, davon 33 mit Akupunktur behandelt. Der Pupillendurchmesser änderte sich im Durchschnitt um 1,3 mm nicht signifikant, gegenüber der 1. Messung und gegenüber der Vergleichsgruppe. Die Schweißbildung verringerte sich, ebenso besserte sich die allgemeine Befindlichkeit (nach Zerssen) signifikant nach Akupunktur gegenüber der Voruntersuchung und gegenüber der Vergleichsgruppe.BUT, Lipidinterferenz und Tropfhäufigkeit verbesserten sich nach Akupunktur mit statistisch signifikantem Unterschied gegenüber der Ausgangslage und gegenüber der Vergleichsgruppe. Impressionszytologie, Bengalrosa-Färbung und Schirmer-Test blieben ohne Signifikaten Unterschied.Die Ergebnisse dieser Beobachtung zeigten einen ersten positiven Einfluss der Akupunktur auf die vegetativen und psychischen Spannungen bei KCS.SummaryIntroductionKeratoconjuctivitis sicca (KCS) treatment with artificial tears is unsatisfying in many cases. Therefore in previous studies acupuncture was used with success on Schirmers test, break up time and drop-frequency. The effect of acupuncture on the tear film is still unknown, but generally patients told of relaxation after the therapy. C. Erb observed elevated psychic tension in patients with KCS. This study was created to observe the influence of acupuncture on this tension.MethodTo observe the tension of the sympathetic system, we measured the skin contact level by attaching agcl electrodes on the tenar and antithenar of the untrained hand. For determination of skin contact level and habituation computer assisted measurement was used. For the computer assisted measurement of the pupillary diameter a TV pupillometer 1050 by whittaker cooperation was used. With a record by Zerssen the psychic condition was observed. For evaluation of mood the self rating well being scale by Zerssen has to be presented by the patients.The teat film was evaluated by slit lamp, Schirmer BUT and Bengal-Rosa staining. These observations were repeated after 3 month. In meantime part of patients was treated by acupuncture for 10 weeks, once weekly. For statistic analyses Wilcoxon matched pair test, withney Mann and t-test were carried out.Results45 patients with KCS (27 women, 18 men) have been observed, 33 of them with acupuncture treatment. After acupuncture the diameter of the pupil reduced 1.3 average and there was no statistical difference (p > 0.05), the habituation and the skin values changed like the emotional persistence (by Zerssen-record) with significant difference. Even the difference after acupuncture was significant more than that of the controll group in the skin reaction and in the psychic reaction.Changes of the BUT, the Lipid-interference and the drop frequency of artifical tears were significant too (p < 0.05). Rosa-Bengal staining, Schirmer test changed without satistical difference.ConclusionAfter this study we could observe a positive influence of acupuncture on the psychic and vegetative tension in patients with KCS. This may be a good usefull additional therapeutical approach in future.