Richard Brunner

Influence of membrane differential filtration on the natural course of age-related macular degeneration: a randomized trial.

Purpose: Membrane differential filtration is able to optimize rheologic parameters by eliminating high molecular weight proteins and lipoproteins from the blood. Following the hypothesis that these changes result in an improvement of the microcirculation, the authors tested the efficacy of membrane differential filtration in improving visual function in patients with age‐related macular degeneration (ARMD). Methods: Forty patients (40 eyes) were randomized into two groups. The treatment group was treated five times over a period of 21 weeks. In both groups, 9/20 of the eyes showed subfoveolar subretinal neovascularization. The main parameter of the study was visual acuity (VA). Electroretinogram (ERG), electrooculogram, and macular visual evoked potentials were also recorded. Plasma and whole blood viscosity and erythrocyte aggregation were measured. Results: The 20 patients treated repeatedly over a period of 21 weeks showed a mean improvement of 0.63 lines (SD 1.8) of VA on Early Treatment Diabetic Retinopathy Study charts. The control group showed a deterioration of 0.94 lines (SD 1.7) compared to VA at baseline examination. The amplitude of the ERG photopic a‐wave and the flicker ERG was significantly increased. The rheologic parameters were lowered in all treated patients. Conclusion: Repetitive treatment with membrane differential filtration is able to improve visual acuity of patients with ARMD and the natural course of this disease. Several questions arise from the results of this study. Further research will show if it is possible to optimize the selection of patients for subgroups with predictive responses through morphologic and functional tests and how to create an optimized and individual treatment strategy determined by the quality, intensity, and frequency of treatment sessions.

Electrophysiological abnormalities in age-related macular degeneration

Abstract · Background. Results from psychophysical tests indicate that in age-related macular degeneration (ARMD) retinal function is globally impaired. Observations in single ARMD cases showing abnormalities of the electrooculogram (EOG) and electroretinogram (ERG) encouraged us to systematically examine ARMD patients by means of electrophysiological tests to confirm a global retinal dysfunction in ARMD. · Methods. Sixty-six patients with ARMD were examined clinically and by means of EOG, ERG, triple scotopic ERG, and fluorescein angiography (FA). · Results. EOG data were considerably reduced in ARMD. Scotopic a- and b-waves of the ERG were mildly affected. The bright flash response showed reduced b-waves with normal implicit times. The amplitude of the oscillatory potential OP2 was significantly reduced and photopic responses were also pathologic compared with an age-matched control group. Geographic atrophy and pigment epithelium detachment showed specific abnormalities in the ERG, whereas in soft drusen EOG changes were more conspicuous. · Conclusions. In addition to data from psychophysical tests the results from electrophysiological examinations indicated a global reduction of retinal function in ARMD which seemed to be present not only in the macula but also elsewhere in the retina.

Histopathology of an Avascular Filtering Bleb After Trabeculectomy With Mitomycin-c

SummaryThe development of an avascular filtering bleb following trabeculectomy with mitomycin-C is a frequently encountered clinical phenomenon. We studied a small portion of conjunctiva from such a filtering bleb with light and electron microscopy. Examination revealed markedly irregular epithelium. The substantia propria contained only a few cells and no vessels. The basement membrane of the basal layer of the conjunctival epithelial cells was irregular with areas of variable thickness, breaks, and complete absence. These factors may contribute to the long-standing hypotony following trabeculectomy with mitomycin-C seen in a considerable number of patients.

Change in Hemorrheological and Biochemical Parameters following Membrane Differential Filtration

Introduction: The elimination of high molecular weight proteins may have a positive influence on disorders of the microcirculation due to an improvement in rheological parameters. We therefore attempted to evaluate the rheological efficacy of membrane differential filtration (MDF). Patients and methods: Ten patients suffering from macular disease underwent MDF. Rheological and biochemical parameters as well as visual acuity were determined one day before and after therapy: The study aimed at a reduction in plasma viscosity, standardized whole blood viscosity at hematocrit 0.45 and erythrocyte aggregation at hematocrit 0.3. Results: Severe side-effects were not observed. The rheological parameters were significantly reduced. In detail the posttreatment values were reduced as compared to the pretreatment values as follows: plasma viscosity 85%, standardised whole blood viscosity 86% (hematocrit 0.45), erythrocyte aggregation 59% (hematocrit 0.3), total protein 81%, IgG 66%, IgA 59%, IgM 33%, alpha-2-macroglobulin 30%, triglycerides 102%, total cholesterol 47%, VLDL cholesterol 94%, LDL cholesterol 33%, HDL cholesterol 62%. Visual acuity was improved in 7/10 patients. Conclusions: MDF is a safe and highly effective method for lowering biochemical and improving rheological parameters which led to improvement in visual acuity. We have already replaced plasma exchange with MDF in our clinical practice of hemorrheological therapy.

Clinical efficacy of haemorheological treatment using plasma exchange, selective adsorption and membrane differential filtration in maculopathy, retinal vein occlusion and uveal effusion syndrome

The aim of the study was to test the clinical efficacy of haemorheological treatment with extracorporeal techniques in ocular diseases. We treated patients suffering from maculopathies of different origin: age-related (AMD, n = 17), uveitis-associated (n = 14) and myopia-associated maculopathy (n = 5). We also treated patients with uveal effusion syndrome (n = 3) and central retinal vein occlusion (n = 4) resistant to haemodilution or steroid therapy. The treatment consisted of plasma exchange, selective adsorption with a tryptophan-polyvinylalcohol adsorber and membrane differential filtration. Maculopathy patients underwent two treatments while the other patients received between 1 and 7 treatments. Pulsatile ocular blood flow was measured in 10 patients before and after therapy. The main parameter for evaluating clinical outcome was the change in visual acuity. Severe side-effects did not occur. The rheological parameters including plasma viscosity, whole blood viscosity and erythrocyte aggregation were statistically significantly lowered. Of 36 patients suffering from maculopathy, 25 showed an improvement of at least 1 line of visual acuity after therapy, 7/17 patients in AMD, 6/14 in uveitis and 0/5 in myopia improved 3 lines or more. All patients suffering from retinal vein occlusion improved at least 1 line and two showed an improvement of 3 lines or more. In uveal effusion syndrome, an improvement of 3 lines or more was reached in all patients. Plasma exchange, selective adsorption and membrane differential filtration are effective rheological treatment approaches to improving visual acuity in patients suffering from maculopathy except myopia-associated maculopathy. Efficacy in patients suffering from central retinal vein occlusion and uveal effusion syndrome was proven, even when the patients were resistant to previous haemodilution or steroid therapy. We conclude that a rheological approach should be considered before invasive methods such as laser coagulation, radiation therapy or surgery are applied.

Intermediate uveitis in childhood preceding the diagnosis of multiple sclerosis: a 13-year follow-up.

PURPOSE An association between multiple sclerosis during childhood and uveitis is exceptionally rare. This is a report of a female patient who presented at the age of 8 years with bilateral intermediate uveitis and whose final diagnosis of multiple sclerosis was made at age 21 years. DESIGN Case report. METHOD Retrospective chart review of a 13-year follow-up history. RESULTS Over 10 years our patient was treated systemically and underwent bilateral vitrectomy to reduce permanent side effects. Owing to good visual function and low inflammatory signs, systemic therapy was stopped. Multiple sclerosis was diagnosed at the age of 21, after a 13-year history of uveitis and after 3 years without medication. CONCLUSIONS In the constellation of uveitis in childhood and later diagnosis of multiple sclerosis, the outlined therapy provided good functional results. Moreover, it may have delayed the manifestation of the underlying disease for 13 years.

Improvement of visual acuity in patients suffering from diabetic retinopathy after membrane differential filtration: a pilot study

BACKGROUND Membrane differential filtration is an extracorporeal treatment procedure which eliminates high molecular weight proteins and lipids from the blood. This pilot study was initiated to investigate the short-term effects on blood rheology and visual function in patients suffering from diabetic retinopathy. METHODS Six patients with non-proliferative diabetic retinopathy, clinically significant macular edema (five patients, nine eyes) and inactive proliferative diabetic retinopathy (one patient, one eye) underwent a single treatment with a hollow fiber secondary plasma filter. The main parameter measured was visual acuity prior to and after treatment. Biochemical and rheological parameters (whole blood and plasma viscosity, and erythrocyte aggregation) were also measured. The mean follow-up was 25 (range 4-90) days after treatment. RESULTS The mean improvement of visual acuity was 1.4 lines (SD 0.8 lines, p = 0.002) 24 h after therapy. This remained stable during the follow-up period. The rheological measures were significantly lowered. A significant reduction of total protein, fibrinogen, IgG, IgM, IgA, alpha-2-macroglobulin, total cholesterol, LDL and HDL was found. CONCLUSION This study demonstrates the rheological impact of membrane differential filtration. It was shown that rheological changes correlated with clinical improvement in patients suffering from diabetic retinopathy with clinically significant macular edema.

Late onset of Leber’s hereditary optic neuropathy in HIV infection

Editor,—We report a case of late onset of Leber’s hereditary optic neuropathy (LHON) in a 59 year old patient with HIV infection being treated long term since 1991 with zidovudine. The onset and course of the patient’s eye disease as well as the diagnostic process were analysed. Molecular genetic testing revealed the mitochondrial DNA (mtDNA) mutation in nucleotide position 11778 confirming the diagnosis of LHON. In our patient late disease expression may be interpreted as a result of the rare combination of the 11778 mutation with HIV infection and long term zidovudine treatment. This is the first report on a patient with LHON suffering from additional HIV infection. ### CASE REPORT A 59 year old white man was admitted to our outpatient department in July 1997 with acute onset of vision loss in his left eye within the previous 2 weeks. The …

The suitability of the ultrasound biomicroscope for establishing texture in giant cell arteritis

AIM To establish whether ultrasound biomicroscope (UBM) is a helpful tool in locating the arterial segment responsible in patients with segmental attacks in giant cell arteritis METHODS The superficial temporal arteries of 19 patients with suspected giant cell arteritis were examined with the UBM before biopsy. RESULTS 20 specimens provided the histological proof of giant cell arteritis in five patients. Side differences, a dark perivascular halo, and high reflexivity of the intra-arterial space were found. CONCLUSION it is assumed that there are two types of arteritic inflammation: (1) the occlusion of intra-arterial space due to intimal fibrosis (UBM: high reflexive “filling”), and (2) inflammation of the perivascular zone with oedematous thickening and infiltration of the media (UBM: dark halo) and its combination. UBM is helpful in obtaining an indication of the side and segment for biopsy.

Vogt-Koyanagi-Harada syndrome associated with cutaneous malignant melanoma: an 11-year follow-up.

PurposeTo report a case of Vogt–Koyanagi–Harada (VKH) syndrome associated with cutaneous pigmented malignant melanoma (MM) and non-pigmented nodular metastasis after a 10-year recurrence-free interval.MethodsCase report with long-term follow-up of 11 years. Ocular examinations included best-corrected visual acuity (ETDRS charts), fundus photography, fluorescein angiography, and computer-assisted perimetry. In addition, human leukocyte antigen (HLA) typing was performed.ResultsA 48-year-old white female patient developed VKH disease 5 years after she had undergone surgical treatment of a superficial spreading melanoma on her back in 1991. The first symptoms were diffuse alopecia followed by growth of non-pigmented hair after 8 months. In our clinic, she presented 18 months later with cells and opacification in the vitreous, a macular and optic disc edema and atrophy of the retinal pigment epithelium (RPE). The anterior segment showed endothelial precipitates of the cornea, and a progressive secondary cataract. Fluorescein angiography detected a bilateral edema of the macula and the optic disc, and focal leakage in the RPE level. During follow-up the patient developed more cutaneous signs, such as vitiligo-like depigmentation and poliosis. A non-pigmented lymph node MM metastasis was diagnosed after a 10-year disease-free interval. HLA typing was positive for HLA-A*01, HLA-A*24, HLA-B*08, HLA-B*39, HLA-DRB1*03, and HLADRB1*11.ConclusionOur findings suggest that the described ocular findings of VKH disease may represent a component of a syndrome consisting also of melanoma-associated hypopigmentation. Within the framework of current concepts of immunity in patients with MM and VKH , the long recurrence-free interval might support the hypothesis of an autoimmune or hypersensitivity process against melanocytes. The use of immunosuppressive therapy in the treatment of VKH and its potential influence on the development of metastatic disease should be carefully reconsidered.