W. Behrens-Baumann

Prophylactic use of topical anti-infectives in ophthalmology

The prophylactic use of topical anti-infectives is indicated on the eye (1) prior to any surgery on the eye, by periorbital and conjunctival administration and, if required, intraoperatively as well; (2) in the form of the Credé prophylaxis against ophthalmia neonatorum; (3) with accidental pathogenic contamination of the eye; (4) to prevent conjunctivitis by intensive care surgical patients; (5) for the antiseptic irrigation of donor bulbi prior to keratoplasty, and (6) if required, to prevent ocular infection in a given epidemiological situation. The drug of first choice is polyvinylpyrrolidone-iodine at a concentration ranging from 1.5 to 5%. Another topical anti-infective is a 0.02 or 0.01% solution of polyhexanide, a promising medication, currently in the process of being approved.

Ophthalmodynamometry: a reliable method for measuring intracranial pressure.

Under physiological conditions, the pressure in the central retinal vein is equal to or higher than the intracranial pressure (ICP) because the cerebrospinal fluid (CSF) passes the sheath of the optic nerve before draining into the cavernous sinus. The optic nerve sheath is where the ICP affects the retinal venous pressure. Ophthalmodynamometry (ODM) is a useful method for determining the central retinal artery pressure. While papilledema and a lack of venous pulsations are commonly used as a vague indication of the ICP, ODM may be advantageous for determining the pressure in the central retinal vein. Until now, however, the venous pressure has never been compared with the intracranial pressure. In the present study, the pressure in the central retinal vein was recorded in 31 patients while the ICP was simultaneously being recorded for various reasons. The results demonstrate a linear correlation (r = 0.968) between the pressure in the central retinal vein and the ICP. This correlation is of great practical value since until now, reliable intracranial pressure monitoring has only been possible by invasive means, by placing a probe either in the brain parenchyma or the ventricle. Ophthalmodynamometry is useful for momentary assessment of the ICP, can easily be repeated, and may be used whenever an elevated ICP is suspected in hydrocephalus, brain tumors and after head injury. However, it is not suitable for continuous ICP monitoring.

Laser iridocystotomy for bilateral acute angle-closure glaucoma secondary to iris cysts

PURPOSE To report laser iridocystotomy for bilateral acute angle-closure glaucoma secondary to peripheral iris cysts. METHOD Case report. RESULTS In a 55-year-old man with increased bilateral intraocular pressure, gonioscopy revealed varied angle narrowing. Bilateral angle-closure glaucoma secondary to peripheral iris cysts was diagnosed by ultrasound biomicroscopy. The peripheral iris cysts could not be seen in mydriasis by gonioscopy. Therefore, we decided to perform laser iridocystotomy with argon and Nd:YAG laser. Collapse of the cysts after laser treatment was demonstrated by ultrasound biomicroscopy. At follow-up, 9 months after laser treatment, intraocular pressure had dropped below 20 mm Hg in both eyes without further therapy. The iris cysts did not recur, which was demonstrated by ultrasound biomicroscopy. CONCLUSIONS Peripheral iris cysts may produce angle closure and may cause secondary angle-closure glaucoma. If transpupillary laser cystotomy is not possible, laser iridocystotomy may produce collapse of the iris cysts and correction of secondary angle closure.

Retinal vein occlusion and low-dose fibrinolytic therapy (R.O.L.F.): a prospective, randomized, controlled multicenter study of low-dose recombinant tissue plasminogen activator versus hemodilution in retinal vein occlusion.

Purpose: To investigate the efficacy of intravenous thrombolysis with low-dose recombinant tissue plasminogen activator (rt-PA) in recent-onset central retinal vein occlusion (CRVO) or branch retinal vein occlusion. Methods: This was a prospective, randomized, controlled multicenter trial in patients with CRVO or branch retinal vein occlusion, best-corrected visual acuity ≤20/50, and onset of symptoms within 11 days before treatment. In each group, patients were randomized to either hemodilution or thrombolysis with 50 mg of rt-PA with concomitant intravenous heparinization. The primary clinical outcome measure was improvement in best-corrected visual acuity from baseline at 1 year. Results: Fifty-two subjects were enrolled in the study. Patients with CRVO (n = 41) who were treated with rt-PA exhibited a significant improvement in best-corrected visual acuity compared with those who received hemodilution (P < 0.0001). At 1-year follow-up, the proportion of eyes with CRVO achieving an improvement in visual acuity of three or more lines was 45% after treatment with rt-PA and 21% after hemodilution therapy. The median final best-corrected visual acuity among CRVO patients given rt-PA was 20/60 (light perception, 20/15) compared with 20/400 (light perception, 20/20) in the hemodilution group. There were no significant differences among patients with branch retinal vein occlusion (n = 11). We observed no serious adverse events. No significant differences were found regarding the development of ocular neovascularization. Conclusion: Treatment with intravenous low-dose rt-PA improved visual outcome in CRVO. Thrombolysis was not associated with a lower risk of ocular neovascularization, indicating that the mechanisms involved in this process occur at an early stage.

Use of internet technologies for data acquisition in large clinical trials.

Data acquisition for automated processing is a central aspect of clinical trials with large numbers of cases because of their extensive demand for manpower. Scientific data can be collected using data forms, which are created in Hypertext Markup Language and published on the Internet. The completed data form can be returned via E-mail or Common Gateway Interface-Script and forwarded into a study database. For the Internet-based data acquisition of a prospective multicenter trial (e.g., on endophthalmitis incidence after cataract extraction), we developed two special HTML forms that can be opened in the ophthalmology departments homepage. A large number of acquired anonymous data has been collected via Internet and automatically transferred into the trial database. The Internet provides a fast and easy avenue for the acquisition of scientific data. This method of data acquisition and data processing will become more common place in multicenter clinical trials.

Immunsuppression durch Kombinationstherapie mit Basiliximab und Ciclosporin bei Hochrisikokeratoplastik Eine Pilotstudie

ZusammenfassungZielsetzung. Ziel der vorliegenden Studie war die Untersuchung der Wirksamkeit einer komplementären Immunsuppression mit dem IL-2-Synthesehemmer Ciclosporin und dem IL-2-Rezeptor-Antagonisten Basiliximab bei Hochrisikokeratoplastiken hinsichtlich des Risikos einer Transplantatabstoßung nach perforierender Keratoplastik. Patienten und Methodik. In einer offenen Pilotstudie erhielten 7 Patienten mit Hochrisikokeratoplastik eine Kombinationstherapie mit Basiliximab perioperativ und Ciclosporin postoperativ. Alle Patienten erhielten eine perforierende Keratoplastik mit einem nicht HLA-typisierten Transplantat. Ergebnisse. Während der Nachbeobachtungszeit von bisher 14–25 Monaten beobachteten wir keine Immunreaktion, alle Transplantate sind klar. Der Visus stieg im Mittel von 0,04 auf 0,41 postoperativ. Schlussfolgerung. Die vorläufigen Ergebnisse mit Basiliximab in Kombination mit Ciclosporin sind viel versprechend. Zur weiteren Bewertung ist eine multizentrische prospektive Studie in Vorbereitung.AbstractBackground. The risk of postoperative immune reaction/transplant rejection is increased in the presence of distinct risk factors. In these situations, the use of established immunosuppressive agents (steroids, cyclosporin) is indicated. However, immune reactions can occur despite this therapy. Basiliximab is a monoclonal antibody with a high specific binding affinity to the IL-2 receptor of activated T-cells. After renal transplantation, the combination therapy with basiliximab and cyclosporin reduces the risk of acute rejection by 30% against placebo. The aim of this study was to investigate the effect of complementary immune suppression with the IL-2 synthesis inhibitor cyclosporin and the IL-2 receptor antagonist basiliximab on the incidence of transplant rejection after high-risk keratoplasty. Patients and methods. In an open pilot study, seven patients with high-risk keratoplasty were treated with basiliximab perioperatively and cyclosporin postoperatively. All patients had penetrating keratoplasty with a non-HLA-matched corneal graft. Results. Seven patients were operated on from 12/98 through 12/99 with a corneal transplant diameter between 7.1 and 9.5 mm. Risk factors included extensive corneal neovascularization in all patients (indications for surgery: 4 cases with corneal scars after herpetic disease, 2 cases with conditions after alkali burns, 1 case with corneal ulceration after thermal burn). During the follow-up of 14–25 months, no immune reaction has occurred, and all transplants are clear. The mean visual acuity increased from 0.04 to 0.41 postoperatively. Discussion. The preliminary data on a combination therapy with basiliximab and cyclosporin are promising. For further evaluation a prospective multicenter study is planned.

Topical Antimycotics in Ophthalmology

This article surveys the current treatment of fungal eye diseases with topical antimycotics. Their various pharmacokinetic characteristics and antimycotic activities are presented and, in addition, the clinical symptoms of fungal eye diseases which can be topically treated are described, so that a correct diagnosis can be achieved rapidly to avoid delaying proper therapy. Finally, guidelines for treatment of keratomycosis are recommended.

Noninvasive assessment of intracranial pressure with venous ophthalmodynamometry. Clinical article.

OBJECT Venous ophthalmodynamometry is a technique used to register the pressure within the central retinal vein. Because the outflow of the central retinal vein is exposed to the intracranial pressure (ICP), the pressure of the central retinal vein may be correlated with the ICP. In the absence of adequate statistical evidence, the authors compared the pressure of the central retinal vein with results of simultaneous invasive monitoring of ICP in neurosurgical patients. METHODS The pressure within the central retinal vein was recorded in 102 patients, in whom invasive continuous monitoring of ICP had become necessary for various reasons, mostly because of suspected hydrocephalus and intracranial hemorrhage. RESULTS A highly significant correlation of the pressure in the central retinal vein and the intracranial cavity was confirmed statistically. An increased pressure of the central retinal vein indicated an elevated ICP, with a probability of 84.2%, whereas a normal pressure of the central retinal vein indicated a normal ICP in 92.8% of patients. Conclusions Venous ophthalmodynamometry is a valuable technique for the noninvasive assessment of ICP.

Absorption of topically administered ciprofloxacin, ofloxacin and gentamicin in the inflamed rabbit eye.

The authors evaluated the ocular absorption of ciprofloxacin, ofloxacin and gentamicin as a reference drug in a novel model of ocular inflammation. The ocular absorption of ciprofloxacin and ofloxacin was shown to be increased two- to threefold in the inflamed eye. The absorption of gentamicin was undetectable in the normal eye and very poor in the inflamed eye.

Aniridie-Intraokularlinsen bei Augen mit traumatischen Irisdefekten

BACKGROUND Globe injuries frequently are the cause of permanent loss of visual function. Especially ruptures of the globe have a 50 times lower chance of achieving a final visual acuity better than 20/200 as compared to contusions of the globe. Besides injury to the retina and choroids, injury of the iris-lens diaphragm plays an important role for visual rehabilitation (10% iris defects and 1% aniridia after blunt trauma). Against this background the surgical results after implantation of aniridia intraocular lenses were investigated. PATIENTS AND METHODS Eleven patients (41.9+/-19.6 years of age) after globe injury (three ruptures of the globe, eight penetrating injuries with trauma of the iris) were implanted with an aniridia IOL. RESULTS The implantation of an aniridia IOL was performed on average 1.0+/-0.6 years (range: 0.4-2.3 years) after the primary injury. In ten eyes an aniridia IOL model HMK ANI 2 (Ophtec/Polytech) was implanted and in one eye an aniridia IOL model 67 (Morcher). Most patients were very satisfied with the results achieved (average corrected visual acuity 0.48; 0.05-1.0). Of the operated eyes, 63% reached a visual acuity > or = 0.4. All patients noticed a significant reduction in glare disability as compared to the preoperative condition. The incidence of secondary glaucoma remained unchanged after the secondary implantation. One patient demonstrated retinal detachment 3 months after receiving the secondary implant, which was successfully treated with vitrectomy and gas tamponade. CONCLUSIONS The implantation of aniridia IOLs seems to be a beneficial therapeutic option in post-traumatic eyes with partial or complete aniridia and aphakia with good visual recovery. During the postoperative follow-up special attention must be paid to sufficient regulation of intraocular pressure and to the retinal situation.