Lutz L. Hansen

Diameter of the optic nerve in idiopathic optic neuritis and in anterior ischemic optic neuropathy

Purpose: There is considerable overlap in the clinical profile of patients with idiopathic optic neuritis(ON) and anterior ischemic optic neuropathy (AION). We tested the hypothesis that the retrobulbar diameter of the optic nerve may be a criterion for the differential diagnosis between ON and AION. Methods: The diameter of the optic nerve was measured by B-scan ultrasonography with the eye in an abducted position. Only patients with a unilateral optic neuropathy were included, 16 ON patients (mean age 24years, 5 with and 11 without disc swelling) and 9patients with AION (mean age 72 years). As controls for the ON patients 10 young normal subjects (mean age25 years) and as controls for the AION patients 10elderly subjects with eye problems not related to the optic nerve (mean age 76 years) were examined. Results: In the ON patients with disc swelling the diameter of the optic nerve was 5.4 ± 0.5 mm in the affected and 3.0 ± 0.3 mm in the unaffected side. This difference was significant (Wilcoxon-test, p = 0.043). In the ON patients without disc swelling the diameter of the optic nerve was 4.4 ± 0.4 mm in the affected and 3.0 ± 0.3 mm in the unaffected side. This difference was significant (Wilcoxon-test, p = 0.003). In the AION patients the diameter of the optic nerve was 3.0 ± 0.3 mm on the affected and2.8 ± 0.4 mm on the unaffected side. This difference was not significant (Wilcoxon-test, p =0.093). Comparing the optic nerves with ON and AION to those of the controls, the diameter was significantly enlarged in the nerves with ON and normal in the nerves with AION (one factor repeated ANOVA). Conclusion: The diameter of the optic nerve is increased in ON without disc swelling and even more so in ON with disc swelling. The enlargement is probably due to edema of the nerve itself, not the surrounding subarachnoidal space. In AION, the diameter of the optic nerve is normal. Measuring the diameter of the optic nerve by B-scan ultrasonography is particularly useful in the differential diagnosis between ON with disc swelling and AION.

[Intravitreal drug therapy for retinal vein occlusion--pathophysiological mechanisms and routinely used drugs].

The novel therapeutic principle of intravitreal drug therapy for retinal vein occlusion has become an integrated constituent of clinical practice over the last years. The two substance classes that have been evaluated in large randomised clinical trials so far are corticosteroids and inhibitors of vascular endothelial growth factor (VEGF). The reported treatment success of these intravitreally administered substances has lead not only to a paradigm shift in clinical care but has also advanced our understanding of the underlying pathophysiological principles of retinal vein occlusions. In this review the different substances are discussed, their mechanisms of action are analysed and the results of the large clinical trials available to date are critically evaluated. Furthermore, an approach to integrate these novel treatment options into the existing treatment regimes for retinal vein occlusions is suggested.

[Clinical diagnostics and therapy for non-arteritic central retinal artery occlusion].

Central retinal artery occlusion (CRAO) is an ophthalmological emergency situation. Known risk factors are arterial hypertension, cardial arrhythmia, arteriosclerosis, hypercholesterolemia and diabetes. Elderly patients should be examined for an arteritic genesis. Young patients (< 45 years) without typical risk factors may suffer from thrombophilia. There is no uniform recommendation on how to treat non-arteritic CRAO. Many different interventions have been suggested in the literature, i. e., massaging the eye, systemic or local reduction of intraocular pressure, anticoagulation, either systemically administered venous thrombolysis or supraselective intra-arterial thrombolysis. In this review we present the causes of CRAO and diagnostic means to detect causes; we also critically discuss previously described therapeutic options. It is our aim to provide a guide through the necessary interdisciplinary diagnostics in co-operation with internal medicine and neurology and to recommend a multimodal therapy in patients with non-arteritic CRAO.

Retinal hemorrhage in the infant as an indication of shaken baby trauma

BACKGROUND The shaken baby syndrome is a form of child abuse in young children. Typical are intracranial and intraocular bleedings. As external injuries are often missing, the shaken baby syndrome may easily be overlooked. Intraocular bleeding is a major diagnostic sign and can prove the diagnosis, if child abuse is suspected by the paediatrician. Thus critical family situations can be uncovered and long term help can be initiated. PATIENTS Between 1991 and 1997 seven babies (age two to nine months) with intraocular bleedings were examined. Diagnosis, differential diagnosis and prognosis of the shaken baby syndrome are presented with these children. RESULTS In two of the seven children a non-accidental trauma and shaken baby syndrome was obvious. In three cases the diagnosis of a shaken baby syndrome was most probable. In one child intraocular bleeding was possibly caused by a fall three months earlier. One child had retinal bleedings after resuscitation. In two cases a vitrectomy was performed. The follow up was two months to six years. In two children intraocular bleeding resolved completely, three children developed mild to severe amblyopia and two children became blind. Vitrectomy could not prevent loss of sight. CONCLUSIONS Sudden cerebral symptoms or intraocular bleedings in otherwise healthy young children are suspicious for child abuse. A shaken baby syndrome has to be considered. Thus funduscopic examination in mydriasis is obligatory. The prognosis depends on the severeness of ocular hemorrhages and cerebral lesions.

Antiangiogene Therapie am Auge - bewährte und neue Therapieansätze

Originating from therapeutic concepts in oncology, angioinhibitory strategies have changed the way ophthalmological patients are treated for a variety of diseases like age-related macular degeneration, diabetic retinopathy or retinal vein occlusion. It is likely that these therapeutic options will not be limited to retinal disease, but will also prove useful for corneal disorders associated with lymph- or angiogenesis. This review is intended to provide a concise overview of the current options investigated in clinical trials.

Gibt es Risikofaktoren für eine Enukleation bei Patienten mit Endophthalmitis? Ergebnisse einer Übersicht von 13 Jahren Dauer

ZusammenfassungHintergrundBei einer Endophthalmitis müssen immer wieder Augen enukleiert werden. Wir fragten uns, ob sich diese Patienten von denen, bei denen dies nicht notwendig ist, unterscheiden.Patienten und MethodeWir führten eine retrospektive Untersuchung aller Patienten durch, welche zwischen 1988 und 2000 wegen einer Endophthalmitis operiert worden waren. Die Patienten wurden in Gruppe A (keine Enukleation) und Gruppe B (Enukleation) eingeteilt.ErgebnisseGruppe A bestand aus 176 Patienten (41% Frauen, Durchschnittsalter 64,6 Jahre), Gruppe B aus 15 Patienten (40% Frauen, Durchschnittsalter 60,8). Die Patienten nahmen in 47% (40%) Medikamente gegen Herz-Kreislauf-krankheiten ein, 9% (13%) gegen Lungenleiden, 10% (27%) gegen Diabetes, 10% (20%) gegen bakterielle/virale Krankheiten, 44% (53%) gegen sonstige Leiden. Sie stellten sich 32 (5,8) Tage nach ersten Symptomen in der Klinik vor, der Unterschied war statisitisch signifikant. Es handelte sich in 70% (33%) um Fälle postoperativer, 16% (40%) endogener und 14% (27%) posttraumatischer Endophthalmitis. Endogene Fälle waren in Gruppe B statistisch signifikant häufiger. Es wurden 42% (40%) grampositive, 15% (13%) gramnegative Bakterien, 6% (13%) Pilze und 2% (0%) Viren isoliert. Colibakterien und Pneumokokken wurden in Gruppe B statistisch signifikant häufiger nachgewiesen. Zur Behandlung der Endophthalmitis wurde in 81% (73%) vitrektomiert, in 10% (20%) die eigene, in 17% (0%) die Kunstlinse entfernt, in 40% (33%) die Vorderkammer gespült und in 6% (0%) die Hinterkapsel eröffnet (Mehrfachnennungen waren möglich). Ein Zweiteingriff wurde in 63% (93%) wegen persisitierender Entzündung, 14% (7%) wegen Netzhautablösung oder 27% (7%) aus sonstigen Gründen notwendig. Die Unterschiede waren nicht signifikant. Die durchschnittliche Sehschärfe betrag bei Aufnahme 0,1 (0,02), bei Entlassung aus der Klinik 0,17 (0,03). Die Unterschiede waren statistisch signifikant. Der Augendruck betrug bei Aufnahme 17,8 (25,4) mm Hg, bei Entlassung 15,4 (16,3) mm Hg. Der Unterschied im Aufnahmedruck war signifikant.SchlussfolgerungPatienten, bei denen eine Enukleation vorgenommen werden musste, unterschieden sich in ihrem Allgemeinzustand nicht signifikant von denjenigen, bei denen keine Enukleation nötig war, wenn auch ein Trend zu mehr Diabetikern und Patienten mit antibakterieller/antiviraler Therapie erkennbar war. Als Risikofaktor für eine Enukleation erwiesen sich: Infektion mit Pneumokokken oder Colibakterien, kurzes Zeitintervall zwischen ersten Symptomen und Aufnahme in der Klinik, mehr Nachoperationen.SummaryBackgroundSometimes an endophthalmitis still necessitates an enucleation. We wondered how patients who had to be enucleated differed from those who had not.Patients and methodsA retrospective analysis of all patients who were operated upon because of an endophthalmitis between 1988 and 2000 was performed. There were two groups: those with enucleation (group A) and those without (group B).ResultsGroup A consisted of 176 patients (41% female, mean age 64.6y), group B of 15 (40% female, mean age 60.8y). They were on medication for: heart disease or blood pressure 47% (40%), lung disease 9% (13%), diabetes 10% (27%), bacterial/viral disease 10% (20%), other 44% (53%). They presented 32 (5,8) days after initial symptoms in the clinic, the difference was statistically significant. 70% (33%) were postoperative cases, 16% (40%; difference statistically significant) endogenous, and 14% (27%) posttraumatic. Gram-positive bacteria could be found in 42% (40%), gram-negative in 15% (13%), fungi in 6% (13%), and vira in 2% (0%). In group B Coli and Pneumococci were statistically significantly more often. As an initial treatment 81% (73%) received a vitrectomy, the pseudophacos was removed in 17% (0%), the cristalline lens was removed in 10% (20%), an anterior chamber irrigation was performed (as a sole procedure or in combination) in 40% (33%), and the posterior capsule was opened in 6% (0%). A second procedure was necessary because of persistant inflammation in 63% (93%), because of retinal detachment in 14% (7%), because of other reasons in 27% (7%). The differences were not statistically significant. The mean visual acuity was 0.1 (0.02) at initial presentation, and 0.17 (0.03) after immediately having left the clinic. The differences were statistically significant. The mean intraocular pressure was 17.8 (25.4) mm Hg at initial presentation (statistically significant), and 15.4 (16.3) mm Hg at discharge from the hospital.ConclusionAlthough there were more patients with diabetes or patients with antibacterial/antiviral therapy in group B the difference was not statistically significant. Risk factors for enucleation in endophthalmitis were: infection with Pneumococci or Coli, short time interval between initial symptoms and presentation in the clinic, number of secondary procedures.