Konrad R. Koch

Artificial iris devices: benefits, limitations, and management of complications.

Purpose To discuss limitations and benefits of a custom‐made foldable artificial iris (Artificialiris) in the management of acquired iris defects. Setting Hochkreuzklinik Eye Hospital, Bonn, and the Department of Ophthalmology, University of Cologne, Germany. Design Case series. Methods We reviewed the clinical course and surgical management in eyes with sight‐compromising complications after phakic anterior chamber implantation of synthetic iris devices between November 2011 and January 2012. Results Three eyes of 2 patients were reviewed. One patient developed cataract and corneal decompensation after anterior chamber artificial iris implantation in the left eye to treat post‐uveitic mydriasis. Further treatment included artificial iris removal, cataract surgery, iridoplasty, and Descemet membrane endothelial keratoplasty (DMEK). By the 6‐month follow‐up, visual acuity had increased from 20/50 to 20/25. The second patient presented with bilateral secondary glaucoma, cataract, corneal edema, and iris atrophy after implantation of Newiris devices for cosmetic reasons. He consecutively had binocular explantation of the cosmetic devices, cataract surgery, artificial iris implantation, and DMEK in both eyes and Ahmed valve implantation in the right eye. During the 6‐month follow‐up, the intraocular pressure remained sufficiently adjusted in both eyes. Photophobia was eliminated, and visual acuity improved to 20/32 in the right eye and 20/20 in the left eye. Conclusions In patients with major iris defects ineligible for pupilloplasties, the artificial iris allows functionally and esthetically satisfactory anterior segment reconstruction. To prevent secondary complications, the artificial iris should only be implanted in aphakic or pseudophakic eyes and placed in the posterior chamber. Financial Disclosure Dr. H.‐R. Koch received travel grants from Humanoptics AG and Dr. Schmidt Intraocularlinsen GmbH. No other author has a financial or proprietary interest in any material or method mentioned.

Descemet membrane endothelial keratoplasty in eyes with glaucoma implants.

Purpose This study aims to analyze the feasibility of Descemet membrane endothelial keratoplasty (DMEK) in the management of corneal endothelial decompensation in eyes with glaucoma implants. Case Report A 62-year-old male with bullous keratopathy after trabeculectomy and Baerveldt shunt implantation for contusion glaucoma of the right eye (case 1) underwent surgical tube trimming with a DMEK procedure. A 54-year-old male with Descemet stripping automated endothelial keratoplasty (DSAEK) failure and dislocation in the presence of an Ahmed glaucoma valve and an artificial iris in the right eye (case 2) was treated by removal of the DSAEK graft and subsequent DMEK procedure. In both eyes, the DMEK graft could be successfully inserted, unfolded, positioned in front of the glaucoma tube, and attached to the host stroma by air injection into the anterior chamber. Postoperatively, both corneas cleared with complete graft attachment and stable glaucoma tube position. After 3 days, peripheral graft detachment occurred in case 1 and was managed successfully with one intracameral air reinjection. Case 2 revealed intraocular pressure (IOP) elevation up to 30 mm Hg in the immediate postoperative period, treated successfully by antiglaucoma medications. Within 1-year follow-up, visual acuity improved from hand movements to 20/63 and 20/32, respectively; endothelial cell density decreased by 36% and 42%, respectively; and the IOP ranged between 7 and 14 mm Hg in both cases without treatment. Conclusions Descemet membrane endothelial keratoplasty seems to be feasible in the management of corneal endothelial decompensation in eyes with glaucoma implants. Graft attachment, IOP, and endothelial cell density should be followed up closely.

Subjective and functional deterioration in recurrences of neovascular AMD are often preceded by morphologic changes in optic coherence tomography

Background Different tests were applied to test the sensitivity of patient self-control; Amsler grid and visual acuity (VA) assessment, as well as fundus examinations to reveal recurrent choroidal neovascularisation (CNV) activity in age-related macular degeneration as detected by spectral domain optical coherence tomography (SD-OCT) in monthly controls. Methods A prospective interventional case series of patients with exudative age-related macular degeneration was examined, which received ranibizumab injections until complete resolution of fluid in SD-OCT. Analysis of changes in subjective perception, Amsler grid, early treatment diabetic retinopathy study (ETDRS) VA, Radner reading VA and fundus examination was conducted in the case of OCT-confirmed CNV recurrences. Results Out of 40 morphological recurrences determined by SD-OCT, six (15%) were noticed by subjective patient perception. Amsler grid testing revealed deterioration in 12 cases (30%); 11 recurrences (28%) were accompanied by loss of ≥5 letters in ETDRS VA and/or ≥1 line in Radner VA; fundus examination showed signs of novel CNV activity in 10 out of 40 recurrences (25%). The combined sensitivity of all diagnostic methods compared to SD-OCT for recurrence detection was 67.5% (27 out of 40 recurrences). Conclusion Subjective patient perception, Amsler grid, VA as well as fundus examination lead to pronounced underestimations of CNV recurrences. Morphologic recurrences can be detected prior to functional deterioration. As any delay of treatment can result in irreversible vision loss, attempts should be made to provide monthly OCT controls to detect recurrences as early as possible.

Ergebnisse nach Cutler-Beard-Plastik zur Rekonstruktion ausgedehnter Oberliddefekte nach Tumorexzision

BACKGROUND The Cutler-Beard bridge flap technique is an established method for reconstruction of large full thickness upper eyelid defects. The purpose of the present study was to report experiences with the surgical technique, complications and results of this cutaneoconjunctival flap procedure following tumor resection. PATIENTS AND METHODS A total of 18 patients with extensive full thickness upper eyelid defects after tumor excision underwent a Cutler-Beard procedure. Of the patients four received an additional eye bank scleral implant and one received an additional free tarsal graft from the fellow upper eyelid to enhance eyelid stability. RESULTS The Cutler-Beard bridge flap technique was surgically feasible in all patients without causing damage to the lower eyelid bridge or resulting in any infections. Out of the 13 reconstructions without additional stabilizing tissue 3 (23%) developed an upper eyelid entropion that was successfully managed using a secondary scleral implant. None of the five reconstructions using additional scleral or tarsal tissue showed an entropion of the upper eyelid. CONCLUSION The Cutler-Beard bridge flap technique, which can be combined with grafting additional stabilization tissue in defects exceeding 75% of the upper eyelid length, is a reliable method for reconstruction of large full thickness upper eyelid defects following tumor excision.

Autocrine Impact of VEGF-A on Uveal Melanoma Cells

PURPOSE Tumor-derived VEGF-A, apart from expediting sufficient vascularization, subsequent tumor growth, and metastatic spread, can act on malignant cells themselves provided that VEGF receptors 1 or 2 (VEGF-R1, -R2) are co-expressed. The study goal was to investigate whether such autocrine VEGF-A signaling exists in uveal melanoma (UM). METHODS Primary (MEL-270, OM-431) and metastatic (OMM-2.3, OMM-2.5) UM cell lines were analyzed for VEGF-A, VEGF-R1, and VEGF-R2 expression by RT-PCR, ELISA (VEGF-A protein), and immunocytochemistry (VEGF receptors). Proliferation of UM cells incubated with neutralizing anti-VEGF-A antibody bevacizumab (≤ 2.5 mg/mL), or VEGF-A (≤ 100 ng/mL) was assessed by bromodeoxyuridine (BrdU) ELISA. It was measured by real-time PCR, whether VEGF-A (100 ng/mL) modulated the expression ratio of VEGF-A itself and its antiangiogenic antagonist pigment epithelium-derived factor (PEDF). RESULTS All UM cells expressed VEGF-A, VEGF-R1, VEGF-R2 mRNA, and protein. In each cell line, the proliferation was stimulated by VEGF-A or inhibited by blocking VEGF-A, or both: bevacizumab significantly decreased the proliferation in MEL-270 (P = 0.005), OMM-2.3 (P = 0.001), and OMM-2.5 (P = 0.011). Increased VEGF-A signaling significantly raised the proliferation in MEL-270, OM-431 (P < 0.001, respectively), and OMM-2.3 (P = 0.043) in a dose-dependent manner but did not significantly change the VEGF-A/PEDF mRNA expression ratio. CONCLUSIONS Autocrine VEGF-A signaling seems to be present in UM, sustaining the proliferation of both primary and metastatic UM cells. Apparently, VEGF-A signaling in UM cells neither acts retroactively on VEGF-A expression, in the sense of a feedback loop, nor contributes to a pro-angiogenic shift of the VEGF-A/PEDF ratio.

Aktuelle Aspekte zur Lid-, Tränenwegs- und Orbitachirurgie im Kindesalter

ZusammenfassungHintergrundLid-, Tränenwegs- und Orbitaerkrankungen im Kindesalter unterscheiden sich in ihrem Spektrum und der notwendigen therapeutischen Versorgung von denen im Erwachsenenalter.FragestellungEs soll ein Überblick über die Klinik und Therapie der häufigsten kindlichen Lid-, Tränenwegs- und Orbitaerkrankungen gegeben werden.MethodenDer Beitrag bietet eine Literaturübersicht aus PUBMED und eigene klinische Ergebnisse.ErgebnisseZu den häufigsten Liderkrankungen des Kindesalters zählen kongenitale Lidfehlstellungen wie Ptosis oder Entropium, die bei Gefahr der Amblyopie eine chirurgische Korrektur benötigen. Bei der konnatalen Tränenwegsstenose sollte eine Stufentherapie erfolgen: 1) konservativ mit Tränensackmassage, adstringierenden Augen- und Nasentropfen, 2) Tränenwegsspülung und 3) Tränenwegsspülung und -schienung in Narkose. Benigne Orbitaprozesse wie Dermoidzysten sind gut im Vorschulalter anzugehen. Die systemische β-Blocker-Therapie stellt eine neue konservative Behandlungsoption für kapilläre Hämangiome dar, die bei Fehlen von Kontraindikationen anstelle operativer Maßnahmen primär indiziert werden sollte.SchlussfolgerungenBei Amblyopiegefahr bedürfen Lid- und Orbitaerkrankungen im Kindesalter der raschen, in der Regel operativen Versorgung. Bei konnatalen Tränenwegsstenosen wie auch kapillären Hämangiomen ist ein initial konservatives Vorgehen indiziert.AbstractBackgroundDuring childhood the spectrum of disorders of the eyelid, the lacrimal drainage system and the orbit as well as the subsequent therapeutic management differ from those in adults.ObjectivesThis review outlines the clinical picture and treatment of the most common eyelid, lacrimal drainage and orbital diseases in childhood.MethodsThe study comprises a PubMed literature review and own clinical results.ResultsThe most common eyelid disorders in childhood include congenital malpositions, such as ptosis or entropium, which may require fast surgical correction in order to prevent amblyopia. For connatal dacryostenosis a step-by-step therapeutic approach is recommended: (1) conservative treatment using lacrimal sac massage, astringent eye and nose drops, (2) irrigation and probing of the nasolacrimal system and (3) irrigation, probing and silastic tube intubation under general anesthesia. Benign orbital lesions such as dermoid cysts can be removed at pre-school age. Using systemic beta blockers is a novel conservative approach in the treatment of capillary hemangioma, which should precede surgical interventions.ConclusionEyelid and orbital diseases during childhood may require fast surgical intervention to prevent amblyopia. Initial conservative treatment is recommended for connatal dacryostenosis and capillary hemangioma.BACKGROUND During childhood the spectrum of disorders of the eyelid, the lacrimal drainage system and the orbit as well as the subsequent therapeutic management differ from those in adults. OBJECTIVES This review outlines the clinical picture and treatment of the most common eyelid, lacrimal drainage and orbital diseases in childhood. METHODS The study comprises a PubMed literature review and own clinical results. RESULTS The most common eyelid disorders in childhood include congenital malpositions, such as ptosis or entropium, which may require fast surgical correction in order to prevent amblyopia. For connatal dacryostenosis a step-by-step therapeutic approach is recommended: (1) conservative treatment using lacrimal sac massage, astringent eye and nose drops, (2) irrigation and probing of the nasolacrimal system and (3) irrigation, probing and silastic tube intubation under general anesthesia. Benign orbital lesions such as dermoid cysts can be removed at pre-school age. Using systemic beta blockers is a novel conservative approach in the treatment of capillary hemangioma, which should precede surgical interventions. CONCLUSION Eyelid and orbital diseases during childhood may require fast surgical intervention to prevent amblyopia. Initial conservative treatment is recommended for connatal dacryostenosis and capillary hemangioma.

[Results of Cutler-Beard procedure for reconstruction of extensive full thickness upper eyelid defects following tumor resection].

BACKGROUND The Cutler-Beard bridge flap technique is an established method for reconstruction of large full thickness upper eyelid defects. The purpose of the present study was to report experiences with the surgical technique, complications and results of this cutaneoconjunctival flap procedure following tumor resection. PATIENTS AND METHODS A total of 18 patients with extensive full thickness upper eyelid defects after tumor excision underwent a Cutler-Beard procedure. Of the patients four received an additional eye bank scleral implant and one received an additional free tarsal graft from the fellow upper eyelid to enhance eyelid stability. RESULTS The Cutler-Beard bridge flap technique was surgically feasible in all patients without causing damage to the lower eyelid bridge or resulting in any infections. Out of the 13 reconstructions without additional stabilizing tissue 3 (23%) developed an upper eyelid entropion that was successfully managed using a secondary scleral implant. None of the five reconstructions using additional scleral or tarsal tissue showed an entropion of the upper eyelid. CONCLUSION The Cutler-Beard bridge flap technique, which can be combined with grafting additional stabilization tissue in defects exceeding 75% of the upper eyelid length, is a reliable method for reconstruction of large full thickness upper eyelid defects following tumor excision.

[Current aspects of eyelid, lacrimal and orbital surgery in childhood].

ZusammenfassungHintergrundLid-, Tränenwegs- und Orbitaerkrankungen im Kindesalter unterscheiden sich in ihrem Spektrum und der notwendigen therapeutischen Versorgung von denen im Erwachsenenalter.FragestellungEs soll ein Überblick über die Klinik und Therapie der häufigsten kindlichen Lid-, Tränenwegs- und Orbitaerkrankungen gegeben werden.MethodenDer Beitrag bietet eine Literaturübersicht aus PUBMED und eigene klinische Ergebnisse.ErgebnisseZu den häufigsten Liderkrankungen des Kindesalters zählen kongenitale Lidfehlstellungen wie Ptosis oder Entropium, die bei Gefahr der Amblyopie eine chirurgische Korrektur benötigen. Bei der konnatalen Tränenwegsstenose sollte eine Stufentherapie erfolgen: 1) konservativ mit Tränensackmassage, adstringierenden Augen- und Nasentropfen, 2) Tränenwegsspülung und 3) Tränenwegsspülung und -schienung in Narkose. Benigne Orbitaprozesse wie Dermoidzysten sind gut im Vorschulalter anzugehen. Die systemische β-Blocker-Therapie stellt eine neue konservative Behandlungsoption für kapilläre Hämangiome dar, die bei Fehlen von Kontraindikationen anstelle operativer Maßnahmen primär indiziert werden sollte.SchlussfolgerungenBei Amblyopiegefahr bedürfen Lid- und Orbitaerkrankungen im Kindesalter der raschen, in der Regel operativen Versorgung. Bei konnatalen Tränenwegsstenosen wie auch kapillären Hämangiomen ist ein initial konservatives Vorgehen indiziert.AbstractBackgroundDuring childhood the spectrum of disorders of the eyelid, the lacrimal drainage system and the orbit as well as the subsequent therapeutic management differ from those in adults.ObjectivesThis review outlines the clinical picture and treatment of the most common eyelid, lacrimal drainage and orbital diseases in childhood.MethodsThe study comprises a PubMed literature review and own clinical results.ResultsThe most common eyelid disorders in childhood include congenital malpositions, such as ptosis or entropium, which may require fast surgical correction in order to prevent amblyopia. For connatal dacryostenosis a step-by-step therapeutic approach is recommended: (1) conservative treatment using lacrimal sac massage, astringent eye and nose drops, (2) irrigation and probing of the nasolacrimal system and (3) irrigation, probing and silastic tube intubation under general anesthesia. Benign orbital lesions such as dermoid cysts can be removed at pre-school age. Using systemic beta blockers is a novel conservative approach in the treatment of capillary hemangioma, which should precede surgical interventions.ConclusionEyelid and orbital diseases during childhood may require fast surgical intervention to prevent amblyopia. Initial conservative treatment is recommended for connatal dacryostenosis and capillary hemangioma.BACKGROUND During childhood the spectrum of disorders of the eyelid, the lacrimal drainage system and the orbit as well as the subsequent therapeutic management differ from those in adults. OBJECTIVES This review outlines the clinical picture and treatment of the most common eyelid, lacrimal drainage and orbital diseases in childhood. METHODS The study comprises a PubMed literature review and own clinical results. RESULTS The most common eyelid disorders in childhood include congenital malpositions, such as ptosis or entropium, which may require fast surgical correction in order to prevent amblyopia. For connatal dacryostenosis a step-by-step therapeutic approach is recommended: (1) conservative treatment using lacrimal sac massage, astringent eye and nose drops, (2) irrigation and probing of the nasolacrimal system and (3) irrigation, probing and silastic tube intubation under general anesthesia. Benign orbital lesions such as dermoid cysts can be removed at pre-school age. Using systemic beta blockers is a novel conservative approach in the treatment of capillary hemangioma, which should precede surgical interventions. CONCLUSION Eyelid and orbital diseases during childhood may require fast surgical intervention to prevent amblyopia. Initial conservative treatment is recommended for connatal dacryostenosis and capillary hemangioma.

Stellenwert der transkanalikulären Laser-Dakryozystorhinostomie in der modernen Tränenwegschirurgie

ZusammenfassungBei der Behandlung postsakkaler Tränenwegsstenosen stellt die transkanalikuläre Laser-Dakryozystorhinostomie (TKL-DCR) eine gering invasive Alternative zur klassischen Toti-Operation dar. Hierbei wird der Faserlichtleiter eines Diodenlasers transkanalikulär in den Tränensack vorgeschoben und durch Laserenergie unter nasal-endoskopischer Sichtkontrolle eine Osteotomie zur Nasenhöhle erzeugt. Die publizierten Erfolgraten von 70–90 % lassen sich durchaus mit den sehr guten Ergebnissen der Toti-Operation messen. Therapieplanung und Operationstechnik werden hier dargestellt sowie Vor- und Nachteile der TKL-DCR diskutiert.AbstractFor the treatment of postsaccal lacrimal drainage obstructions transcanalicular laser dacryocystorhinostomy (TCL-DCR) represents a less invasive alternative to external Toti procedures. Herein, a diode laser optical fiber is inserted into the lacrimal sac via the canaliculi. Under visual control with a nasal endoscope laser energy is applied until a patent osteotomy between the sac and nasal mucosa has been created. Published success rates of 70–90 % get close to the excellent results of Toti procedures. Besides describing therapy planning and surgical technique, pros and cons of TCL-DCR are discussed.For the treatment of postsaccal lacrimal drainage obstructions transcanalicular laser dacryocystorhinostomy (TCL-DCR) represents a less invasive alternative to external Toti procedures. Herein, a diode laser optical fiber is inserted into the lacrimal sac via the canaliculi. Under visual control with a nasal endoscope laser energy is applied until a patent osteotomy between the sac and nasal mucosa has been created. Published success rates of 70-90% get close to the excellent results of Toti procedures. Besides describing therapy planning and surgical technique, pros and cons of TCL-DCR are discussed.

[Ocular prosthetics. Fitting, daily use and complications].

BACKGROUND Ocular prosthetics make a decisive contribution to the functional, esthetic and psychosomatic rehabilitation of patients after ocular extirpation. OBJECTIVES This article provides an overview of the fitting, daily care and complications of ocular prosthetics. METHODS The study comprised a PubMed literature review and own clinical results. RESULTS Ocular prosthetics made from cryolite glass or perspex can be manufactured and fitted 5-8 weeks after removal of the eye. During this period a conformer is placed within the conjunctival sac in order to prevent scar formation and shrinking of the socket. Artificial eyes can be worn continuously, only interrupted by a short but regular cleaning procedure. Artificial tears and lid hygiene improve the comfort of wearing. Glass prostheses have to be renewed every 1-2 years, while perspex prostheses need to be polished once a year. Complications, such as giant papillary conjunctivitis or blepharoconjunctivitis sicca are facilitated by poor fit, increased age and inappropriate care of the prosthetic device. In the case of socket shrinkage or anophthalmic socket syndrome, surgical interventions are needed to re-enable the use of an artificial eye. CONCLUSION Adequate fitting, daily care of ocular prosthetics and therapeutic management of associated complications are mandatory for a durable functional, esthetic and psychosomatic rehabilitation after ocular extirpation.