Noemi Maar

Angiogenic and inflammatory markers in the intraocular fluid of eyes with diabetic macular edema and influence of therapy with bevacizumab.

Purpose: The purpose of this study was to determine the concentrations of angiogenic and inflammatory markers in human eyes with diffuse diabetic macular edema before and during therapy with intravitreal bevacizumab and their association with disease activity. Methods: In a prospective clinical trial, 10 eyes of 10 consecutive patients with vision loss because of diabetic macular edema were compared with 10 eyes of 10 age-matched controls. Bevacizumab was administered at baseline; retreatments were given monthly according to disease activity. During a follow-up of 6 months, aqueous humor samples were taken each time intravitreal therapy was administered. A multiplex assay was used for measurement of 12 different growth factors and cytokines. Results: Aqueous humor of eyes with diabetic macular edema demonstrated a significantly increased expression of monocyte chemoattractant protein-1 and interleukin-8 and higher, but not significant, levels of interleukin-6 and vascular endothelial growth factor. Intravitreal therapy with bevacizumab resulted in a significant decrease of vascular endothelial growth factor below physiologic levels. This change was not associated with clinical disease activity as measured by visual acuity and central retinal thickness. Conclusion: Eyes with diabetic macular edema showed a different profile of monocyte chemoattractant protein-1 and interleukin-8 as compared with controls. The intraocular vascular endothelial growth factor expression decreased significantly after the first intravitreal injection of bevacizumab; this reduction was prolonged by consecutive monthly retreatment.

Choroidal blood flow and progression of age-related macular degeneration in the fellow eye in patients with unilateral choroidal neovascularization.

PURPOSE Cardiovascular risk factors such as smoking, hypertension, and atherosclerosis seem to play an important role in the development of choroidal neovascularization (CNV). Recent studies have also provided evidence suggesting that choroidal and retinal blood flow is decreased in patients with AMD. On the basis of these results, the hypothesis for this study was that lower choroidal blood flow is associated with an increased risk of CNV in patients with AMD. METHODS Forty-one patients with unilateral choroidal neovascular AMD were included in this observational longitudinal study. The fellow eyes of the patients served as study eyes. Subfoveal choroidal blood flow (FLOW) and fundus pulsation amplitude (FPA) were assessed with laser Doppler flowmetry and laser interferometry, respectively. A multivariate COX-regression model was used to test the hypothesis that low choroidal perfusion parameters are associated with the development of CNV. RESULTS Of the 37 patients that were followed up until the end of the study, 17 developed CNV and 20 did not. The univariate COX-regression analysis shows that lower FLOW, systolic blood pressure, intraocular pressure, and FPA are risk factors for development of CNV. Moreover, the more advanced the AMD in the study eye, the higher the risk for CNV to develop in the fellow eye. Multivariate COX regression analysis indicated that only FLOW (P = 0.0071), FPA (P = 0.0068), and staging (P = 0.031) had statistically significant influences on the progression to CNV. CONCLUSIONS The present study indicates that lower choroidal perfusion is a risk factor for the development of CNV in the fellow eye of patients with unilateral CNV.

Influence of viscoelastic substances used in cataract surgery on corneal metabolism and endothelial morphology: Comparison of Healon and Viscoat

Purpose: To evaluate the influence of cohesive and dispersive ophthalmic viscosurgical devices (OVDs) on endothelial morphology and corneal metabolism during cataract surgery. Setting: Department of Ophthalmology, University of Vienna Medical School, Vienna, Austria. Methods: In this prospective randomized blind study, 50 eyes of 43 patients were randomized into 2 groups before surgery. Phacoemulsification with implantation of a posterior chamber intraocular lens was performed in all patients. In half the patients, sodium hyaluronate 1% (Healon®) was used as the OVD and in the other half, sodium hyaluronate 3%‐chondroitin sulfate 4% (Viscoat®). Corneal metabolism was evaluated by fluorophotometric measurement of corneal autofluorescence. The corneal fluorescence values were corrected for interference by fluorescence of the ocular lens. Specular microscopy (Noncon Robo SP800, Canon) was used to evaluate the endothelial cell density, coefficient of variation, and percentage of hexagonal cells. Examinations were performed preoperatively and 3 days, 1 and 4 weeks, and 3 months postoperatively. Results: There were no significant changes between preoperative and postoperative endothelial cell density measurements in either group (P = .1717). The percentage of hexagonal cells was similar (P = .3489); however, there was a slightly increasing tendency toward polymorphism in both groups. Corneal autofluorescence decreased 3 days after surgery, increased after 1 week, and decreased again subsequently in both groups. There was no significant difference in the influence on corneal metabolism between the 2 OVDs (P = .9899). Conclusions: There was no significant difference between Healon and Viscoat. Thus, this study did not confirm an advantage of either for endothelial protection of healthy corneas.

Ocular surface changes and tear film alterations associated with sun gazing during a solar eclipse

ZusammenfassungZiel der Studie war die Beobachtung der Patienten mit ophthalmologischen Beschwerden durch Betrachtung der Sonne während der Sonnenfinsternis über Mitteleuropa am 11. August 1999, wobei das Hauptaugenmerk der Netzhaut und Veränderungen der Augenoberfläche galt.Methode43 Patienten wurden innerhalb einer Woche nach der Sonnenfinsternis primär beobachtet. 33 von ihnen wurden nach einem Jahr nachuntersucht. Untersuchungsparameter waren die Sehschärfe, das zentrale Gesichtsfeld sowie eine Spaltlampenuntersuchung von der Augenoberfläche und vom Fundus. Der Tränenfilm wurde untersucht mittels Schirmer-Test und Tränenfilmaufrisszeit. Die Lipidphase wurde mittels Interferenzmessung an der Spaltlampe sowie mittels Tearoskope® beurteilt.Ergebnisse19 Patienten hatten bei der ersten Beobachtung unspezifische Sehbeschwerden.Bezüglich des Tränenfilms fanden wir in allen 3 Schichten pathologische Veränderungen, im Bereich der wässrigen Phase (Schirmer-Test) in 87%, Tränenfilmaufrisszeit in 85%, der Lipidfilm in 67 bzw 87% im Tearoskope.Nach einem Jahr gab es bei keinem Patienten visuelle Beschwerden, der Tränenfilm erholte sich in allen drei Phasen: am Geringsten im Schirmer-Test, der in 51% noch pathologische Werte anzeigte. Die Tränenfilmaufrisszeit war in 24% und bei der Lipidphase 9% noch pathologisch.ZusammenfassungWir beobachteten Veränderungen an der Augenoberfläche, insbesondere des Tränenfilms nach Sonnenfinsternis. Die Veränderungen wurden verursacht durch eine starke Lichtreizung wie bei der Keratitis photoelectrica und erholten sich innerhalb eines Jahres. Während die wässrige Phase bei vielen Patienten pathologisch blieb, erholten sich Schleim und Lipid fast gänzlich.SummaryPurposeA solar eclipse occurred in central Europe on August 11th, 1999. Following the eclipse, patients with ocular symptoms were investigated. Gazing at the sun without protection is liable to damage the retina. Our attention was focused on changes of the ocular surface and the tear film.MethodsForty-three patients were investigated within one week after the solar eclipse as baseline. 33 of them were followed up one year later. Visual acuity and the central visual-field were measured, and the ocular surface and the fundus were examined using a slit lamp. The quality of the lacrimal tear film was examined using Schirmer’s test for the aqueous layer, break-up time for the mucous layer and interference observation for the lipid layer, measured by a slit lamp and a tearoscope.ResultsAt the baseline 19 patients had non-specific visual problems. Pathological alterations of the tear film were seen in all three tear-film layers: Schirmer’s test was pathological in 87%, break-up time decreased in 85%, the interference pattern of the lipid layer changed in 67% and there were changes in 87% using the tearoscope.One year later the non specific visual disorders had disappeared. Schirmer’s test did not reveal much change from the baseline: 51% pathological. 24% remained pathological in break-up-time and the lipid layer was normalized except in 9%. Using the tearoscope, lipids were better than grade 3 in all patients.ConclusionAfter gazing at a solar eclipse the ocular surface and tear film changed. While the aqueous layer remained pathological in many patients, the lipid layer and the mucous layer recovered spontanously.

Langzeiteffekt und Sicherheit der fokalen Laserkoagulation bilateraler Drusen bei altersbedingter Makuladegeneration

ZusammenfassungDie fokale Laserkoagulation bilateraler Drusen zur Prophylaxe einer schweren Sehbehinderung durch fortgeschrittene altersbedingte Makuladegeneration ist ein neues therapeutisches Konzept, das auf seine Wirksamkeit und Sicherheit im Langzeitverlauf überprüft werden muss. Zu diesem Zweck wurde in einer Pilotstudie ein homogenes Kollektiv von zehn konsekutiven Patienten an einem Auge standardisiert behandelt. Die Partneraugen fungierten als Kontrollgruppe. Nach einer medianen Nachbeobachtungsdauer von 3,9 Jahren wies die Behandlungsgruppe im Bezug zur Kontrollgruppe eine um 0,6 Zeilen geringere Visusreduktion (p = 0,2) und eine signifikante Reduktion der Drusenfläche (p = 0,04) auf. 77,8% der behandelten Augen hatten sichtbare Zeichen einer Drusenresorption. In der Behandlungsgruppe entwickelte kein Auge eine Komplikation im Sinne einer atrophen oder neovaskulären Makulopathie. Im Gegensatz dazu entstand in einem (11,1%) von 9 Augen der Kontrollgruppe eine choroidale Neovaskularisation. Die hier vorliegenden Ergebnisse belegen die potentielle Wirksamkeit und nachhaltende Sicherheit der fokalen Laserkoagulation von bilateralen Drusen in Rahmen der altersbedingten Makuladegeneration.SummaryThe prophylactic laser treatment of bilateral early age-related macular degeneration induces accelerated regression of macular drusen. To assess the therapeutic effect on retinal morphology and visual function, we conducted a pilot study with 20 eyes of 10 consecutive patients. The median time of follow-up was 3,9 years. In comparison to the untreated partner-eyes, the treated eyes showed a, although insignificant, minor loss of visual acuity of 1,4 versus 0,8 lines on the ETDRS-chart. Regression of drusen area was significantly greater in the treatment group (p = 0,04). 77,8% of the treated eyes demonstrated at least some resorption of Drusen. Drusen that did not respond, showed either massive confluence or pronounced flattening. None of the treated eyes developed either choroidal neovascularization (CNV) or atrophy. On the contrary, one eye (11,1%) in the control group developed CNV. The results of this pilot trial suggest the beneficial effect and a long-term safety of the focal laser treatment of bilateral drusen in age-related macular degeneration.

Membranotomie prämakulärer Sublimitansblutungen durch Neodym : YAG Photodisruption

ZusammenfassungPrämakuläre Sublimitansblutungen können in vielen Fällen eine akute Sehverschlechterung verursachen. Kleine Blutungen resorbieren ausreichend rasch. Größere Hämorrhagien zeigen eine verzögerte Resorption und können zu einer dauerhaften Visusbeeinträchtigung führen. Wir haben den therapeutischen Effekt und die Sicherheit der Nd : YAG-Membranotomie untersucht.Es wurden die Krankengeschichten jener Patienten analysiert, bei denen in den letzten 5 Jahren eine prämakuläre Hämorrhagie aufgetreten war. In 10 Fällen wurde eine Perforation der Membrana limitans interna mit dem Q-switched Nd : AG Laser (Zeiss) durchgeführt. Bei 5 Patienten wurde ein natürlicher Verlauf beobachtet.In 6 Fällen war die Sublimitansblutung nach einem Valsalva-Manöver aufgetreten. Ebensoviele Patienten hatten ein arterielles Makroaneurysma. Bei 3 Individuen lag eine diabetische Retinopathie vor. Durch die Membranotomie kam es bei allen zu einer raschen Verlagerung des Blutes in den retrooder intravitrealen Raum. In der Therapiegruppe war schon nach einer Woche ein rund 4,7fach höherer Visusanstieg (3,98 Zeilen auf 0,49 ± 0,40) als in der Kontrollgruppe (0,84 Zeilen auf 0,31 ± 0,40) festzustellen. Nach Ende der Beobachtungszeit lag der mittlere Fernvisus in der Behandlungsgruppe bei 0,93 ± 0,20 (Anstieg um 8,32 Zeilen) und bei 0,88 ± 0,38 (Anstieg um 6,56 Zeilen) in der unbehandelten Gruppe. Bei einem Patienten mit einer kleinen, flachen Blutung kam es durch die Behandlung zu einer lokalen Aderhautblutung. Aufgrund des für die Netzhaut bestehenden Risikos ist die Nd : YAG Laserbehandlung nur bei hinreichend dicken Sublimitansblutungen indiziert, bei denen einer raschen Spontanresorption nicht gerechnet werden kann.SummaryAcute premacular hemorrhages may severely decrease visual acuity. Small hemorrhages resolve in a reasonable time but sometimes large hematomas cause an irreversible vision loss. Our major objective was to investigate the therapeutic effect of Neodymium : YAG membranotomy and whether we can state this method as a safe one. We analysed all patient records of the last five years where a subinternal limiting membrane hemorrhage occurred. 10 cases were treated with laser and in 5 patients we observed the natural course.In 6 cases preretinal hemorrhage was caused by valsalva retinopathy and the same number of cases had an arterial macroaneurysm. 3 individuals had some stage of diabetic retinopathy. With the membranotomy we forced a fast relocation of the hemorrhage into the retro- or intravitreal space. One week after the event we found in the treatment group a 4.7-fold improvement of Snellen visual acuity (nearly 4 lines to 0.49 ± 0.40) versus the control group where Snellen visual acuity increased only 0.84 lines to 0.31 ± 0.40. At the end of follow-up period the mean visual acuity in the treatment group was 0.93 ± 0.20 (improvement of 8.32 lines) and 0.88 ± 0.38 (6.56 lines) in the control group. In one case with a small, flat hemorrhage we experienced a localised choroidal hemorrhage due to laser treatment. We suggested that Nd : YAG Laser-membranotomie harbours a risk for retinal damage, if the hemorrhage is not thick enough for safe disruption and a spontaneous resorption cannot be expected with in a reasonable time.