Martin Eckhardt

Intraocular pressure difference in Goldmann applanation tonometry versus Perkins hand-held applanation tonometry in overweight patients

OBJECTIVE To analyze the increase in intraocular pressure (IOP) caused by anatomic and physiologic factors in overweight patients when using Goldmann applanation tonometry. DESIGN A prospective cohort study. PARTICIPANTS Seventy average-weight individuals who had no difficulties with IOP measurements at the slit lamp and 12 obese patients with suspected glaucoma who could position the head at the slit lamp only with great effort participated. INTERVENTION The authors compared IOP values between slit-lamp-mounted Goldmann applanation tonometry and Perkins hand-held tonometry. MAIN OUTCOME MEASURE The difference in Goldmann and Perkins IOP measurements was examined. RESULTS In the group of obese patients, the mean IOP was 20.9+/-2.28 mmHg (mean +/- standard deviation; range, 18-26 mmHg) for the right eye and 21.4+/-3.16 mmHg (range, 16-28 mmHg) for the left eye when determined by Goldmann tonometry and 16.3+/-2.39 mmHg (range, 13-20 mmHg) for the right eye and 16.3+/-2.42 (range, 11-19 mmHg) for the left eye when determined by Perkins tonometry. The mean decrease was 4.5+/-1.3 mmHg (range, 3-7 mmHg) for the right eye and 4.9+/-1.9 mmHg (range, 2-9 mmHg) for the left eye. In the control group, the mean difference between the two types of tonometers for the right eye was 0.34+/-0.69 mmHg and for the left eye was 0.33+/-0.82 mmHg. Patients who had a falsely elevated IOP on Goldmann tonometry had an average body mass index of 34+/-3.82 (range, 28.5-41.9); most were female (5:1 ratio). CONCLUSION The authors believe simultaneous breath-holding and thorax compression, with subsequent increase in venous pressure, may be a causative factor for transitory elevations of IOP. Perkins tonometry in obese patients may help avoid a false diagnosis of glaucoma caused by transitory elevations in IOP.

Synthesis pattern of matrix metalloproteinases (MMPs) and inhibitors (TIMPs) in human explant organ cultures after treatment with latanoprost and dexamethasone.

Purpose: To determine changes in production of matrix metalloproteinases (MMPs) and tissue inhibitors of matrix metalloproteinases (TIMPs) in the ciliary body, the trabecular meshwork and the retinal pigment epithelium induced by both prostaglandins and corticosteroids.Methods: Explant organ cultures were removed by a scleral incision 3 mm posterior to the limbus. Retinal pigment epithelium was grown to confluence. Organ and cell cultures were treated with latanoprost and/or dexamethasone for 72 h. The activity of MMP- 2, -3 and -9 was assessed using zymography. The synthesis pattern of MMPs and TIMP-1 and -2 was identified using immunostaining.Results: Treatment of explant organ cultures with 10 μg/ml of latanoprost induced a mean upregulation of MMP-2 by 36%, MMP-3 by 112% and MMP-9 by 156% as seen by zymography. Dexamethasone 500 nm reduced the amounts of secreted MMP-2 by 13%, MMP-3 by 69%. MMP-9 was not detectable in the media of corticosteroid-treated explant organ cultures. The addition of 10 fLg/ml of latanoprost to dexamethasone-treated cultures increased MMP-2 by 14%, MMP-3 by 43% and MMP-9 by 49%. Using immunohistochemistry we found staining with antibodies against MMP-2, -3, -9 and TIMP-1 and -2 within the ciliary body, and only to a lesser degree in the trabecular meshwork. Latanoprost treatment caused an increase of 29% in MMP-2 (p < 0.0001), 98% in MMP-3 (p < 0.0001) and 108% in MMP-9 (p < 0.0001). Dexamethasone reduced the staining for MMP-2 by 32% (p < 0.0001), for MMP-3 by 33% (p < 0.0001) and for MMP-9 by 83% (p < 0.0001). Almost nochange in staining for MMPs was detectable in the trabecular meshwork. Neither latanoprost treatment nor dexamethasone induced significant changes (p < 0.93) in the secretion of TIMPs. In the media of non-treated retinal pigment epithelium (RPE) cells the only MMP detected was MMP-2. RPE cells in culture did not respond to either treatment with a change in their MMP secretion. Conclusion We detected a profound upregulation of both MMP-3 and MMP-9 and a mild induction of MMP-2 through latanoprost in the ciliary body, but not the trabecular meshwork or RPE cells. Corticosteroids, on the other hand, downregulated MMP expression in both tissues. This inhibiting effect of corticosteroids on MMP production was reversed by latanoprost.

Complete capsulorhexis opening occlusion despite capsular tension ring implantation.

An 89-year-old woman and an 86-year-old woman had continuous curvilinear capsulorhexis, phacoemulsification, and implantation of a silicone plate-haptic intraocular lens. Because of presumed weak zonules (high age, pseudoexfoliation), a poly(methyl methacrylate) capsular tension ring was also implanted. Despite this, both patients reported deterioration in visual acuity that was the result of complete occlusion of the anterior capsule opening by fibrotic tissue 4 and 3 months postoperatively, respectively.

Das maligne Melanom des Ziliarkörpers : Ein diagnostisches Problem

ZusammenfassungHintergrund. Das Melanom des Ziliarkörpers hat wegen seiner meist späten Entdeckung eine schlechte Prognose. Die zirkuläre Infiltration der Kammerwinkelstrukturen durch Melanomzellen führt zum Sekundärglaukom. Diese Veränderung kann im Anfangsstadium als Pigmentglaukom fehlinterpretiert werden. Patienten und Methoden. Im Fall 1 wurde die Diagnose “atypisches Pigmentdispersionsglaukom” gestellt. Im 2. Fall wurde im unteren Anteil des Kammerwinkels eine starke Pigmentierung gefunden. Das Auge wurde aufgrund der Verdachtsdiagnose “Ziliarkörpermelanom” enukleiert. Ergebnis. Im 1. Fall kam es 4 Jahre nach der Erstmanifestation zu massiven Iris- und Kammerwinkelveränderungen, sodass eine Enukleation aufgrund der Verdachtsdiagnose “Ziliarkörpermelanom” durchgeführt wurde. Der histologische Befund zeigte ein Ringmelanom des Ziliarkörpers mit diffuser Aussaat in die Vorderkammer. Im 2. Fall zeigte der mikroskopische Befund eine totale Amotio mit intraokulärer Blutung. Ein Melanom war nicht vorhanden. Die Pigmentierung im unteren Bereich des Kammerwinkels war auf Siderophagen zurückzuführen. Schlussfolgerung. Die Diagnose eines Ziliarkörpermelanoms kann im Anfangsstadium schwierig sein. Deshalb sollte bei einseitigem Pigmentdispersionsglaukom immer auch an ein malignes Melanom des Ziliarkörpers gedacht werden.AbstractBackground. Ciliary body melanoma is often diagnosed too late and therefore has a poor prognosis. The circular infiltration of the iridocorneal angle by malignant cells can lead to secondary glaucoma, often misdiagnosed as pigmentary glaucoma. Material and methods. In a 40-year-old patient the diagnosis “atypical pigmentary glaucoma” was made due to elevated intraocular pressure and pigmentation of the iridocorneal angle; no changes were present in the iris. In a second case pronounced pigmentation of the chamber angle and secondary glaucoma led to the clinical diagnosis of a ring melanoma and resulted in enucleation of the globe. Results. In the first case, increasing pigmentation of the chamber angle over 4 weeks led to the presumed diagnosis of a ring melanoma. Histopathological evaluation confirmed the diagnosis of a ring melanoma of the ciliary body. In the second case histology revealed retinal detachment with intraocular bleeding without intraocular melanoma. The pigmentation in the lower part of the chamber angle was due to hemosiderosis. Conclusion. Diagnosis of ciliary body melanomas may be difficult in some cases due to its similarity to other eye diseases. The differential diagnosis of malignant melanoma of the ciliary body should be considered in cases of unilateral pigmentary glaucoma.

Influence of a Single HELP Application on Hemorheology and Retinal Hemodynamics

The heparin-induced extracorporeal low-density lipoprotein precipitation (HELP) eliminates selectively fibrinogen, total cholesterol, low-density lipoproteins (LDL) and triglycerides and improves hemorheology. We investigated the hemodynamic changes in 10 patients without ocular diseases performing a video fluorescein angiography after a single HELP procedure measuring the arm-retina time (ART) and the arteriovenous passage time (AVP). Laboratory parameters such as fibrinogen, cholesterol, LDL, triglycerides, red cell transit time, plasma and whole-blood viscosity were determined and retinal circulation was measured immediately before and after the HELP application. All of the laboratory parameters were lowered significantly. The ART was unaffected by the HELP procedure; however, there was a significant AVP reduction from 2.41 +/- 0.49 to 1.97 +/- 0.47 (p < 0.005). These results support the hemorheological and hemodynamic efficiency of the HELP system in microcirculatory diseases.

Frequenzverdoppelungs-Perimetrie als Screeningmethode?

ZusammenfassungDas Frequenzverdoppelungstechnologie-Perimeter (FDT-Perimeter) beruht auf dem Prinzip der Frequenzverdoppelung, einem psychophysischen Effekt, der vorwiegend das magnozelluläre System betrifft und vom Hersteller als einfach zu handhabende Screeningmethode von Gesichtsfelddefekten empfohlen wird. Wir erprobten die Fähigkeiten dieses Gerätes als Screeningtest im Vergleich zur herkömmlichen Weiß-auf-Weiß-Perimetrie (W/W-Perimetrie).Patienten und MethodikWir untersuchten insgesamt 214 Augen, davon 170 Augen von 85 Patienten mit unterschiedlichen Augenerkrankungen und 44 Augen von Augengesunden mit dem Screeningtest des FDT-Perimeters. Die W/W-Perimetrie (Octopus, Programme 32, G2, M2, 07) diente uns als Referenz insofern, als wir übereinstimmende Befunde als gleiche Ergebnisse, normale FDT-Perimetrie bei pathologischer W/W-Perimetrie als bessere und pathologische FDT-Perimetrie bei normaler W/W-Perimetrie als schlechtere Ergebnisse bewerteten.ErgebnisseIn 65% der Patienten fanden wir eine Übereinstimmung, 35% jedoch ergaben bessere Befunde in der FDT-Perimetrie. Bei den Augengesunden zeigte sich in 77% ein gleiches Ergebnis, in 23% bessere FDT-Perimeter-Befunde.SchlussfolgerungBei 35% besseren („falsch positiven“) Ergebnissen scheint uns die Spezifität des FDT-Perimeters zu gering, um es als Screeningmethode einzusetzen.SummaryFrequency-Doubling-Perimetry (FDP) is based on the frequency-doubling effect, which is a psychophysiological phenomenon. This effect mainly concerns the magnocellular system and is recommended by the manufacturer as a simple and user-friendly screening instrument for visual field defects. We studied visual field results of FDP and compared them to conventional white on white perimetry (W/W perimetry).Patients and methodsWe investigated a total of 214 eyes. 170 eyes of 85 patients had various eye diseases and 44 eyes of 22 were normal. W/W perimetry was performed with the Octopus-perimeter using different programs (32, G2, M2, 07) depending on the cause of the disease. Normal FDP with pathological W/W was rated as better and pathological FDP with normal W/W was valued as a worse result.Results35% of the patients showed better results in FDP than in W/W perimetry, whereas 65% had the same results in both investigations. 21% of the normal patients presented better results in FDP than in W/W perimetry, whereas 73% had the same results in both investigations.ConclusionConsidering that 35% of the patients had better result („false positive“) in FDP-perimetry it appears to us that the specifity is too low for using FDP as a screening method.

Passport Injektor: Ein neues Faltlinsen-Implantationssystem zur Kleinschnittchirurgie

ZusammenfassungDas „passport foldable lens placement system“ ist ein neuartiges System zur Implantation faltbarer Silikonlinsen in den Kapselsack, wobei die im Verhältnis zu bisherigen Faltlinsen-Implantationssystemen neuerlich reduzierten Außendurchmesser des Injektors gewährleisten, die Linse bei einer Inzision von 2,65 mm Breite in den Kapselsack zu implantieren und die Operation ohne Nahtverschluß zu beenden.Die Überlegenheit des neuentwickelten Injektors zeigt sich insbesondere bei der erleichterten Plazierung der Silikonlinse in das Injektionsinstrument. Durch die konische Form des Injektionszylinders wird die Linse im Zuge des Vortriebs kontinuierlich eingerollt und kann somit während des Implantationsvorganges kaum beschädigt werden. Das System kann während der Implantation einhändig bedient werden.Um spätere Schrumpfungen des vorderen Kapselblattes mit den damit verbundenen Komplikationen zu vermeiden, bevorzugten wir eine eher große Rhexis (5–6 mm).Um das Gleiten der Faltlinse im ausgesprochen dünnen Injektionszylinder zu erleichtern, empfehlen wir unseren Erfahrungen folgend dünner visköse Substanzen wie Methylcellulose gegenüber höher viskösen Substanzen.Wir konnten weiters anhand der Ergebnisse der ersten 50 operierten Augen zeigen, daß bei Anwendung eines limbokornealen Tunnelschnittes sowie von „no stitch“-Technik bei der überwiegenden Mehrzahl der Fälle kein postoperativer Astigmatismus nachweisbar war. Bei Anwendung oben erwähnter Schnittführung sowie Abschluß der Operation ohne Nahtverschluß („no stitch“) kam es ausnahmslos zu komplikationsfreier Wundheilung ohne Wunddehiszenz.Bis zum Zeitpunkt der Fahnenkorrektur (Ende September 1996) wurden an unserer Klinik 1100 Augen mit dem „passport foldable lens placement system“ operiert, und die Ergebnisse sind derart vielversprechend, daß wir dieses „Passport System“ nunmehr routinemäßig in der Katarakt-Chirurgie einsetzen.Summary“Passport foldable lens placement system” is a newly developed injector system for implantation of foldable silicon lenses into the capsular bag. Compared with earlier implant system, the advantage of this new system consists in an even more reduced outside diameter of the injector allowing the implantation of the lens using an incision of 2.65 mm width and the termination of operation with “no stitch”.The superiority of this newly developed injector clearly shows in its easy handling when inserting the silicon lens into the injector. Due to the conic shape of the injector cylinder, the lens folds continuously during injection, thereby avoiding damage to the lens during procedure.To avoid postoperative shrinkage of the anterior capsule, we preferred a rather wide capsulorhexis (5–6 mm).To enable easier gliding of the folded lens inside the narrow injector cylinder, we recommend viscoelastic material of low viscosity (e.g. methylcellulose) as compared to highly viscous material.Furthermore, considering the outcome of the first 50 operated eyes, we were able to show no occurrence of postoperative astigmatism in most cases when using limbocorneal tunnel incision and “no stitch”-technique. Additionally, no complications in wound healing were observed when using this technique.Up to date of this report (September 1996), 1100 eyes were operated at our clinic using the “passport foldable lens placement system”. The results are so encouraging, that we now use this “passport system” as a routine in cataract surgery.