P. Ruokonen

Adverse effects and short-term results after selective laser trabeculoplasty.

Purpose:To evaluate the risk of adverse effects and to demonstrate short-term results after selective laser trabeculoplasty (SLT) in glaucoma patients. Methods:Sixty-four eyes of 64 patients with primary open-angle glaucoma, not sufficiently treated with local antiglaucomatous therapy, were included in this prospective study. Intraocular pressure (IOP), anterior chamber cells, anterior chamber flare, and vitreous haze (according to the Standardization of Uveitis Nomenclature Working Group) were examined before SLT, for 24 hours, 14 days, 6 weeks, and 3 months after laser. Furthermore, macular thickness measurements in 9 Early Treatment Diabetic Retinopathy Study subfields, including central subfield, measured by Spectralis OCT were performed. The differences between prelaser and postlaser values were obtained. Results:The average of mean preoperative IOP measurement was 19.1±3.972 mm Hg compared with 12.9±2.513 (P<0.001), 13.2±3.331 (P<0.001), 14.1±2.731 (P<0.001), and 13.9±2.922 mm Hg (P<0.001) 24 hours, 14 days, 6 weeks, and 3 months post-SLT, respectively. The central subfield preoperatively was 278.14±74.355 µm compared with 277.14±71.461 (P=0.177), 277.14±71.461 (P=0.354), 287.34±74.363 (P=0.414), and 257.45±68.431 µm (P=0.214) 24 hours, 14 days, 6 weeks, and 3 months after treatment. Anterior chamber cells, anterior chamber flare, and vitreous haze were not denoted at any time of examination. Conclusions:In this study, no significant increase in macular thickness and no other adverse effects were present. Furthermore, SLT was found to significantly lower IOP in glaucoma patients in addition to local therapy. In conclusion, SLT has a good ability to reduce IOP with a minor risk of adverse effects.

Thermography: a new option to monitor filtering bleb function?

Purpose:To evaluate the filtering bleb function after trabeculectomy using a new ocular surface thermography device. Methods:Thirty-five eyes of 35 patients after trabeculectomy were included in this prospective study. The filtering bleb function was tested with a new ocular surface-oriented, infrared radiation thermographic device in a noncontact manner (TG 1000). The eyes were classified into poorly controlled and well-controlled intraocular pressure (IOP) groups according to the patients’ postoperative IOP. According to Kawasaki and colleagues, the mean temperature decrease in the filtering bleb (TDB) for evaluating bleb function was used, where TDB=(mean temperature of the temporal and nasal bulbar conjunctiva)−(mean temperature of the filtering bleb). Furthermore, the filtering bleb was evaluated during 10 seconds of eye opening and a new parameter was introduced, the TB10sec. TDB and TB10sec were analyzed statistically. Results:The TDB was 0.911°C (±0.467) and the TB10sec was −1.027°C (±0.312) in the well-controlled IOP group. The TDB was 0.599°C (±0.499), and the TB10sec was −0.623°C (±0.265) in the poorly controlled IOP group, respectively. The difference in TDB (P=0.045), as well as that of TB10sec (P<0.001), between the well-controlled and poorly controlled IOP groups was significant. Conclusions:Temperature decrease in the filtering bleb provides information about its function. Because of the easy handling and reproducible measurements, thermography using Tomey TG 1000 may be a useful tool in the evaluation of filtering bleb function.

Komplikationen nach kosmetischer Irisimplantation@@@Complications after cosmetic iris implantation

We report the case of a 37-year-old patient with ocular complications associated with the implantation of cosmetic iris implants. Implantation of silicone iris implants for the purpose of changing iris colour has been performed since 2004. Diaphragms are implanted in the anterior chamber. Up to now only little information exists about side effects of this method. In the literature severe ocular complications shortly after cosmetic iris implantation are reported in single cases. In our case 5 months after surgery optic nerve damage caused by elevated intraocular pressure (IOP) was diagnosed. Nuclear opacity of both lenses and a decreased number of corneal endothelial cells were observed at the first visit. Because of recurrent IOP elevation despite maximum antiglaucoma therapy, explantation of the iris implants was required. Damage to the trabecular meshwork, opacity of the lenses as well as the reduced number of endothelial cells are permanent and will probably lead to further complications like corneal decompensation and progressing glaucoma.

Complications after cosmetic iris implantation

We report the case of a 37-year-old patient with ocular complications associated with the implantation of cosmetic iris implants. Implantation of silicone iris implants for the purpose of changing iris colour has been performed since 2004. Diaphragms are implanted in the anterior chamber. Up to now only little information exists about side effects of this method. In the literature severe ocular complications shortly after cosmetic iris implantation are reported in single cases. In our case 5 months after surgery optic nerve damage caused by elevated intraocular pressure (IOP) was diagnosed. Nuclear opacity of both lenses and a decreased number of corneal endothelial cells were observed at the first visit. Because of recurrent IOP elevation despite maximum antiglaucoma therapy, explantation of the iris implants was required. Damage to the trabecular meshwork, opacity of the lenses as well as the reduced number of endothelial cells are permanent and will probably lead to further complications like corneal decompensation and progressing glaucoma.

Diagnostic pitfalls: a case of neurosarcoidosis mimicking tuberculous meningitis

We report on a 44-year-old Caucasian male patient who developed recurrent unilateral vitreous hemorrhages in February 2008. Ophthalmologists assumed a diagnosis of Eales disease (Fig. 1a). In July 2008, he complained of exhaustion, general weakness and gait unsteadiness. In November 2008, he suffered from acute vestibular dysfunction, which responded to intravenous corticosteroid treatment. On admission to our hospital in December 2008, he showed a spinal syndrome with paraspasticity and gait ataxia. His past medical history was unremarkable, but his mother had been treated for tuberculosis in the 1950. Cranial and spinal MRI showed no intraparenchymal abnormalities in the CNS, but widespread nodular, contrast-enhancing meningeal lesions around the cervicothoracic spinal cord (Fig. 1b) and brain stem (Fig. 1c) extending to the cerebellar surface, cervical spinal roots and right trigeminal and vestibular nerve. External MRI 1 week before found only a minor contrast enhancement on the brain stem surface. Chest computer tomography revealed bihilar lymphadenopathy. Blood tests (CRP, erythrocyte sedimentation rate, calcium, ACE, sIL2-R, auto-antibody screening) were normal, except for lymphopenia (0.44/nl, normal CD4/ CD8 ratio). Cerebrospinal fluid (CSF) showed lymphocytic pleocytosis (99 cells/ll) (immune phenotyping in Fig. 1d), increased protein (464 mg/dl) and lactate levels (54.1 mg/dl), decreased glucose (30.8 mg/dl), intrathecal IgA synthesis (16%), oligoclonal bands and increased sIL2-R (1,303 IU/ml). Bronchoalveolar lavage demonstrated inflammation with lymphocytosis (normal CD4/CD8 ratio). Non-caseating epithelioid cell granulomata were discovered in biopsies of an infracarinal lymph node and lung tissue (Fig. 1e). Microbiological tests ruled out a broad spectrum of bacterial, viral and fungal infections. Cytopathological examination of CSF and BAL found no malignant cells. Tuberculin skin test (PPD5), analysis of blood and CSF by T-SPOT.TB and QuantiFERON-TB Gold In-Tube test (QFT-G-IT), microscopy (Ziehl-Neelson staining for acidfast bacteria) and PCR for tuberculous mycobacteria showed no evidence of latent or active mycobacterial infection (5 9 CSF, 3 9 sputum, 3 9 urine, 2 9 BAL, 2 9 lymph node biopsy). After exclusion of malignancies and other infectious or systemic autoimmune diseases, the imperfect sensitivity of mycobacterial diagnostic tests prevented definitive distinction of the remaining differential diagnoses: CNS tuberculosis and neurosarcoidosis. The diagnostic dilemma led to a pragmatic treatment decision including F. Scheibe (&) O. Wengert L. Harms K. Ruprecht Department of Neurology, Charite–Universitatsmedizin Berlin, Chariteplatz 1, 10117 Berlin, Germany e-mail: franziska.scheibe@charite.de

Influence of prostaglandin analogue on outcome after combined cataract surgery and trabecular aspiration in pseudoexfoliative glaucoma

Purpose The aim of this study was to analyze the postoperative outcome and risk profile after combined clear cornea phacoemulsification and trabecular aspiration in the treatment of pseudoexfoliative glaucoma (PEX) associated with cataract. Methods In this retrospective study, 69 eyes of 60 patients with visually significant cataract and PEX were treated with small-incision cataract surgery combined with trabecular aspiration. The intraocular pressure (IOP), number of antiglaucoma eyedrops before and after surgery, as well as complications were measured at all postoperative visits (1 day, 7 days, 6 weeks, 6 months, 12 months). Results There was a statistically significant decrease in postoperative IOP during the follow-up period. There was no significant difference in the number of medications being used after 6 weeks follow-up. Six months and 12 months after surgery, the number of antiglaucoma eyedrops decreased significantly. Complications were fibrinotic iritis in 4 eyes (5.9%), cystoid macular edema in 3 eyes (4.4%), and hyphema in 1 eye (1.4%). Fibrinotic iritis and macular edema were present in only 37 of 69 eyes that were treated with prostaglandin analogues. Conclusions Small-incision cataract surgery combined with trabecular aspiration in cases of PEX associated with cataract is effective in IOP reduction over a 1-year follow-up. Prostaglandin analogues may increase the risk of postoperative macular edema and fibrinotic iritis. Preoperative medication exchange may be considered.

Zentrale toxische Keratopathie nach photorefraktiver Keratektomie

ZusammenfassungDie zentrale toxische Keratopathie stellt eine seltene, jedoch visus- und refraktionsändernde Erkrankung nach Laser-in-situ-Keratomileusis oder photoablativer Keratektomie dar. Aufgrund der weltweit zunehmenden Anzahl refraktiver Eingriffe ist mit einer erhöhten Inzidenz dieses Krankheitsbildes zu rechnen. Eine sorgfältige differenzialdiagnostische Abgrenzung zu inflammatorischen oder infektiösen Krankheitsbildern ist für die Einleitung einer spezifischen Therapie erforderlich.AbstractCentral toxic keratopathy is a rare complication following laser-assisted in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) and may unfavorably influence best-corrected visual acuity and refraction. Because of the growing number of refractive surgical procedures worldwide there may be an increasing incidence of this disorder. A differentiation from an inflammatory or infectious etiology is necessary for the appropriate treatment.

Central toxic keratopathy after photorefractive keratectomy

ZusammenfassungDie zentrale toxische Keratopathie stellt eine seltene, jedoch visus- und refraktionsändernde Erkrankung nach Laser-in-situ-Keratomileusis oder photoablativer Keratektomie dar. Aufgrund der weltweit zunehmenden Anzahl refraktiver Eingriffe ist mit einer erhöhten Inzidenz dieses Krankheitsbildes zu rechnen. Eine sorgfältige differenzialdiagnostische Abgrenzung zu inflammatorischen oder infektiösen Krankheitsbildern ist für die Einleitung einer spezifischen Therapie erforderlich.AbstractCentral toxic keratopathy is a rare complication following laser-assisted in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) and may unfavorably influence best-corrected visual acuity and refraction. Because of the growing number of refractive surgical procedures worldwide there may be an increasing incidence of this disorder. A differentiation from an inflammatory or infectious etiology is necessary for the appropriate treatment.

Zentrale toxische Keratopathie nach photorefraktiver Keratektomie@@@Central toxic keratopathy after photorefractive keratectomy

ZusammenfassungDie zentrale toxische Keratopathie stellt eine seltene, jedoch visus- und refraktionsändernde Erkrankung nach Laser-in-situ-Keratomileusis oder photoablativer Keratektomie dar. Aufgrund der weltweit zunehmenden Anzahl refraktiver Eingriffe ist mit einer erhöhten Inzidenz dieses Krankheitsbildes zu rechnen. Eine sorgfältige differenzialdiagnostische Abgrenzung zu inflammatorischen oder infektiösen Krankheitsbildern ist für die Einleitung einer spezifischen Therapie erforderlich.AbstractCentral toxic keratopathy is a rare complication following laser-assisted in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) and may unfavorably influence best-corrected visual acuity and refraction. Because of the growing number of refractive surgical procedures worldwide there may be an increasing incidence of this disorder. A differentiation from an inflammatory or infectious etiology is necessary for the appropriate treatment.

Birdshot-Retinochoroidopathie: Verlauf, Komplikationen und Behandlungsoptionen

Hintergrund: Die Birdshot-Retinochoroidopathie ist eine seltene, posteriore Uveitis mit vermutlich autoimmunologischer Genese. Die Behandlung mit Kortikosteroiden wird oft als unzureichend betrachtet und durch die bekannten unerwunschten Wirkungen limitiert. Ziel der vorliegenden Untersuchung ist es, den klinischen Verlauf unserer Patienten unter immunomodulativer Therapie zu verfolgen. Methoden: Retrospektive Auswertung von 13 Patienten mit bilateraler Retinochoroidopathie. Alle Patienten waren positiv auf die Expression von HLA-A29 getestet worden. Als Verlaufsparameter wurden bestkorrigierter Visus, Fundoskopie, Fluoreszenzangiografie, optische Koharenztomografie und bei einzelnen Patienten Elektroretinogramme ausgewertet. Ergebnisse: Bei allen Patienten war nach initialer Steroidtherapie eine langerfristige steroidsparende immunmodulatorische Therapie notwendig, um langerfristig eine Stabilisierung des Befunds zu ermoglichen. Insgesamt ergibt sich eine eingeschrankte Visusprognose, die vorwiegend durch das Auftreten eines Makulaodems bestimmt wurde. Schlussfolgerungen: Die Birdshot-Chorioretinopathie ist dank der Moglichkeiten einer steroidsparenden immunmodulativen Therapie bei vielen Patienten stabilisierbar. Die Problematik eines Off-label-Gebrauchs einiger immunmodulatorischer Medikamente erschwert aktuell eine adaquate Therapie.