Wido M. Budde

Immunologic graft reactions after allogenic penetrating keratoplasty

PURPOSE To evaluate frequency and risk factors of immunologic graft reactions after allogenic penetrating keratoplasty. DESIGN Interventional comparative nonrandomized clinical trial. METHODS The setting took place in a university eye hospital. The retrospective study included 338 patients (338 eyes). The patients underwent penetrating keratoplasty performed by a single surgeon in the study period from 1989 to 1997. Follow-up period had to be longer than 12 months (mean +/- SD, 31.4 +/- 18.8 months). Frequency of immunologic graft reactions characterized by relatively few small monomorph whitish cells in the anterior chamber, almost no flare, and retrocorneal cellular precipitates. RESULTS Immunologic graft reactions were detected in 46 patients (46/338 = 13.6%). Statistically significant risk factors for the development of graft reactions were loosening of sutures (P =.046), and preoperative and postoperative corneal vascularization (P =.04). Frequency of an immunologic graft reaction was statistically independent (P >.05) of the graft diameters used in the present study, age, and gender of the patients, HLA-typing, donor age, and preservation data of the donor material. Seventy-four percent (34/46) of all graft reactions were detected within the first 2.5 years after surgery. Thirteen percent (6/46) of all graft reactions were observed more than 4 years after keratoplasty. With intensive corticosteroid treatment, graft transparency could be regained in 44 (95.6%) of the 46 patients with an immunologic graft reaction. CONCLUSIONS Most important risk factors for immunologic graft reactions occurring in approximately 14% of patients after allogenic penetrating keratoplasty are suture loosening and preoperative and postoperative corneal vascularization. Graft diameters as used in the present study, HLA-typing, age of the donor, and preservation data of the donor material may not play a major role. More than 10% of graft reaction episodes can occur more than 4 years postgrafting. With intensive corticosteroid treatment, graft transparency can be regained in the majority of patients after an immunologic graft reaction when detected early.

Optic nerve head appearance in juvenile-onset chronic high-pressure glaucoma and normal-pressure glaucoma.

OBJECTIVE To evaluate the appearance of the optic nerve head in chronic high-pressure glaucoma and normal-pressure glaucoma. DESIGN Clinic-based cross-sectional study. PARTICIPANTS The study included 52 eyes with normal-pressure glaucoma and 28 eyes with juvenile-onset primary open-angle glaucoma that served as models for chronic high-pressure glaucoma. METHODS Color stereo optic disc photographs and wide-angle retinal nerve fiber layer photographs were morphometrically examined. MAIN OUTCOME MEASURES Localized retinal nerve fiber layer defects; parapapillary chorioretinal atrophy; disc hemorrhages; optic cup shape; retinal arteriole narrowing. RESULTS Both study groups did not vary significantly in count of localized retinal nerve fiber layer defects, size of parapapillary atrophy, optic cup depth, steepness of disc cupping, rim/disc area ratio, diameter of retinal arterioles, and frequency and degree of focal retinal arteriole narrowing. In normal-pressure glaucoma versus juvenile open-angle glaucoma, localized retinal nerve fiber layer defects were significantly broader, disc hemorrhages were found significantly more often and were larger, and neuroretinal rim notches were present more frequently and were deeper. CONCLUSIONS Chronic high-pressure glaucoma and normal-pressure glaucoma show morphologic similarities in the appearance of the optic nerve head. The lower frequencies of detected disc hemorrhages and rim notches in high-pressure glaucoma may be due to a smaller size of hemorrhages and localized retinal nerve fiber layer defects in high-pressure glaucoma. Both glaucoma types have morphologic features in common, suggesting that they may possibly belong to a spectrum of the same pathologic process.

Central retinal vessel trunk exit and location of glaucomatous parapapillary atrophy in glaucoma1

OBJECTIVE To evaluate whether the position of the central retinal vessel trunk exit on the lamina cribrosa spatially correlates with the location of parapapillary atrophy in glaucoma. DESIGN Clinic-based, observational, cross-sectional study. PATIENTS Color stereo optic disc photographs of 95 patients with primary or secondary open-angle glaucoma and 65 healthy persons were morphometrically evaluated. The intrapapillary and parapapillary region was divided into four quadrants. We determined the position of the central retinal vessel trunk exit on the lamina cribrosa surface and measured the area of parapapillary atrophy and neuroretinal rim in the four quadrants. MAIN OUTCOME MEASURES The area of neuroretinal rim and parapapillary atrophy and the position of the central retinal vessel trunk exit. RESULTS Comparing measurements between opposite disc quadrants showed that beta zone of parapapillary atrophy was significantly (P < 0.05) larger and that the neuroretinal rim was significantly smaller when beta zone and neuroretinal rim were measured in the disc quadrant most distant to the central retinal vessel trunk exit, than if the beta zone and neuroretinal rim were measured in the quadrant containing the vessel trunk exit. Comparing measurements in the disc quadrants between eyes with different positions of the central retinal vessel trunk exit revealed that, in the respective disc quadrant, the beta zone was significantly larger and the neuroretinal rim was smaller in eyes with the vessel trunk exiting in the opposite disc quadrant than in eyes with the vessel trunk exit located in the respective disc quadrant where the measurements were obtained. CONCLUSIONS Position of the central retinal vessel trunk exit on the lamina cribrosa influences the location of parapapillary atrophy in glaucoma. The longer the distance to the central retinal vessel trunk exit, the more enlarged is parapapillary atrophy and the smaller is the neuroretinal rim. This relationship agrees with the spatial relationship between glaucomatous neuroretinal rim loss and enlarged parapapillary atrophy in glaucoma. Diagnostically, it may indicate that, in eyes with an abnormal configuration of parapapillary atrophy or with an abnormal position of the central retinal vessel trunk exit, early glaucomatous rim changes should be looked for in the disc sector that is most distant to the central retinal vessel trunk exit and where parapapillary atrophy may be relatively large.

Visual outcome after allogenic penetrating keratoplasty

Abstract.Purpose: To evaluate visual outcome after allogenic penetrating keratoplasty. Methods: The clinical non-randomized retrospective comparative interventional study included 245 patients undergoing allogenic penetrating keratoplasty for keratoconus (n=77), herpetic corneal scars (n=29), non-herpetic corneal scars (n=46), Fuchs endothelial dystrophy (n=24), and pseudophakic/aphakic bullous keratopathy (n=69). All patients were consecutively operated on by the same surgeon. The duration of follow-up had to exceed 1 year. Results: Increase in visual acuity and the best-corrected postoperative visual acuity were significantly (P<0.01) highest for the patients with keratoconus (visual acuity increase from 0.16 to 0.69), followed by those with herpetic corneal scars (from 0.18 to 0.58), Fuchs corneal endothelial dystrophy (from 0.13 to 0.48), non-herpetic corneal scars (from 0.13 to 0.36), and finally patients with pseudophakic/aphakic bullous keratopathy (from 0.05 to 0.28). The increase in visual acuity expressed in lines did not vary significantly (P>0.05) among the study groups. Visual acuity increased significantly after suture removal, with no significant (P>0.20) difference between the study groups. Visual acuity was significantly (P<0.001) and positively correlated with the diameter of the corneal graft. Multiple linear regression analysis revealed that graft size, keratometric astigmatism and reason for keratoplasty were the major factors significantly (P<0.05) influencing postoperative visual acuity. Conclusions: The main predictive factors for visual outcome after allogenic penetrating keratoplasty are reason for keratoplasty and graft size. Postoperative visual acuity is significantly the highest in keratoconus and significantly the lowest in pseudophakic/aphakic bullous keratopathy. Expressed in lines, increase in visual acuity does not differ significantly among groups of patients with different reasons for keratoplasty.

Tectonic sclerokeratoplasty and tectonic penetrating keratoplasty as treatment for perforated or predescemetal corneal ulcers.

PURPOSE To report the clinical outcome of patients with perforated or predescemetal corneal ulcers treated by tectonic, centric or eccentric penetrating keratoplasty or by tectonic sclerokeratoplasty. DESIGN Nonrandomized clinical trial. METHODS The study included 60 patients (60 eyes) with perforated or predescemetal corneal ulcers who were consecutively operated on by the same surgeon. Fifty-two patients underwent tectonic penetrating centric or eccentric keratoplasty. Eight patients with paralimbal corneal ulcers underwent tectonic sclerokeratoplasty. A control group consisted of 76 patients (76 eyes) electively undergoing central penetrating keratoplasty for treatment of inactive central corneal scars. RESULTS In the study group with perforated or predescemetal corneal ulcers, best-corrected postoperative visual acuity ranged from perception of light to 0.80 (median, 0.10), with 54 of 60 eyes (90%) attaining an improvement of best visual acuity. In 10 of 60 patients (16.7%), tectonic penetrating keratoplasty had to be re-performed because of a recurring corneal ulcer. Patients with sclerokeratoplasty and patients with eccentric keratoplasty did not differ in clinical outcome, despite larger trephine and corneal lesion size in the sclerokeratoplasty group. Among study patients compared with control patients, postoperative visual acuity was significantly lower (P =.01), postoperative refractive and keratometric astigmatism were significantly higher (P <.05), and immunologic graft reactions (P =.02) and suture loosening (P <.001) occurred significantly more often. CONCLUSIONS Eyes with perforated corneal ulcers or predescemetal corneal ulcers can usually be saved by tectonic keratoplasty or sclerokeratoplasty, with a moderate to considerable amount of remaining useful vision. In case of doubt, one may prefer conservative treatment of corneal ulcers and to electively perform central keratoplasty when the ulcers have healed. For selected clinical situations, sclerokeratoplasty is an alternative to keratoplasty for surgical treatment of paralimbal corneal defects.

Postoperative analgesia by reinjections of local anesthetic through an indwelling retrobulbar catheter

PURPOSE To evaluate an indwelling retrobulbar catheter for repeatable postoperative retrobulbar injections of local anesthetics for titratable analgesia after intraocular surgery. METHODS The prospective study included all 124 patients (124 eyes) who consecutively underwent retinal or cyclocryocoagulation (n = 22), pars plana vitrectomy, or retinal detachment surgery (n = 102), and who were operated on by the same surgeon with local anesthesia within a period of 12 months. Using commercially available retrobulbar needles with a diameter of 0.60 mm or 0.80 mm and a length of 38 mm, 5 ml of mepivacaine 2% with hyaluronidase were injected. Through the same needle, a 28-gauge commercially available flexible catheter was introduced into the retrobulbar space, the needle was withdrawn, and the catheter was fixed in place. When the patients started to feel pain after surgery, 2 ml of mepivacaine 2% or 2 ml of bupivacaine 0.75% were reinjected through the catheter. The catheter was removed 24 to 72 hours after surgery. RESULTS Because of increasing pain in the postoperative period, 93 patients (93 of 124, or 75%) received a reinjection 4.2+/-2.0 hours after the preoperative injection. Seventy patients received a second reinjection after an additional 2.7+/-1.9 hours, and 42 patients received a third reinjection 3.1+/-2.0 hours later. After each reinjection, the patients became pain free. Removal of the catheter after surgery was unremarkable. CONCLUSIONS An indwelling retrobulbar catheter for repeatable postoperative injection of short-acting local anesthetics is useful and effective for titratable postoperative analgesia after intraocular surgery, and it allows patients to avoid the side effects of systemic analgesics and sedatives.

Autologous ipsilateral rotating penetrating keratoplasty

PURPOSE To evaluate visual outcome after autologous ipsilateral rotating penetrating keratoplasty. METHODS The study included nine patients who consecutively underwent autologous ipsilateral rotating penetrating keratoplasty for treatment of traumatic central corneal avascular scars. These patients were compared with 105 patients who consecutively underwent homologous central penetrating keratoplasty in the same study period for treatment of avascular corneal scars extending to the corneal periphery. All operations were performed by the same surgeon. Mean follow-up time for both study groups was 31.27 +/- 21.54 and 32.0 +/- 19.4 months, respectively. RESULTS In the autologous rotating keratoplasty group, visual acuity increased significantly (P = 0.03; Wilcoxon test) from 0.13 +/- 0.11 preoperatively to 0.29 +/- 0.16 postoperatively. Refractive astigmatism and keratometric astigmatism, respectively, increased (P = 0.02) from 3.19 +/- 2.53 diopters and 3.20 +/- 2.24 diopters, respectively, preoperatively to 6.9 +/- 1.82 diopters and 9.55 +/- 4.32 diopters, respectively, postoperatively. Comparing the study groups, postoperative visual acuity was significantly lower (P = 0.01), and keratometric astigmatism (P = 0.003) and refractive astigmatism (P = 0.01) were significantly higher in the autologous rotating keratoplasty group than in the control group. CONCLUSIONS Autologous ipsilateral rotating penetrating keratoplasty compared with homologous central penetrating keratoplasty is associated with a high postoperative refractive and keratometric astigmatism leading to a relatively low postoperative visual acuity. It suggests that, in normal clinical conditions when donor material is available and postoperative follow-up examinations can be performed, homologous central penetrating keratoplasty may be superior to autologous ipsilateral rotating keratoplasty.

Family history of glaucoma in the primary and secondary open-angle glaucomas.

Abstract · Background: A study was carried out to evaluate the frequency of a positive family history in the primary and secondary open-angle glaucomas. · Patients and methods: The study included 1176 patients with chronic open-angle glaucoma who were differentiated into secondary open-angle glaucoma [pseudoexfoliative glaucoma (n=144) and pigmentary glaucoma (n=61)], and primary open-angle glaucoma (POAG; n=971). The POAG group was divided into non-highly-myopic patients without (“non-highly-myopic POAG”; n=662) or with circular parapapillary atrophy (”age-related atrophic POAG“; n=168), highly myopic POAG (n=35), and focal normal-pressure glaucoma (n=106). All patients were asked whether family members had glaucoma. · Results: In the POAG group, frequency of a positive family history of glaucoma (overall frequency 24.5%) decreased significantly with age from 35.8% in patients (n=240) younger than 50 years, to 25% in patients (n=501) aged between 51 and 70 years and to 11.7% in patients (n=230) older than 70 years. The overall frequencies of a positive family history of glaucoma did not vary significantly between age-related atrophic POAG, focal normal-pressure glaucoma, pseudoexfoliative glaucoma, and pigmentary glaucoma, compared with age-matched groups of non-highly-myopic POAG. Highly myopic POAG had a lower, but not significantly lower, frequency of a positive family history of glaucoma (17.1% vs 26.9%). · Conclusions: In POAG, frequency of a known positive family history of glaucoma decreases with increasing age. Apart from juvenile-onset POAG with a relatively high, and highly myopic POAG with a relatively low frequency of known heredity, other primary and secondary open-angle glaucomas do not show pronounced differences in this variable when adjusted for age.

Color axis evaluation of the Farnsworth Munsell 100-hue test in primary open-angle glaucoma and normal-pressure glaucoma

Abstract• Background: It was the aim of the present study to analyze a separate color-axis evaluation of the Farnsworth Munsell 100-hue test (FM100) in primary open-angle glaucoma (POAG) and normal pressure glaucoma (NPG). • Patients and methods: One eye of each of 112 individuals (age 35–65 years, visual acuity >20/28, myopia <−7.5 D) was included. The groups consisted of 62 normal subjects and 50 glaucoma patients (33 POAG and 17 NPG). We evaluated the FM 100 overall error score and the error scores of the protan, deutan and tritan axes. The results were compared with perimetric (Octopus G1 mean defect) and morphometric data of the optic disc. • Results: All error scores were significantly higher in the glaucoma group than in the normal group. In an age-related evaluation, differences were significant in age groups above 45 years. No significant differences were found between the POAG and NPG groups. The sensitivity of the overall score to identify glaucoma was 62% (specificity 80%). In the glaucoma group the overall score and the protan score increased significantly with the mean defect (r>0.3,P<0.01). Several scores increased slightly with decreasing neuroretinal rim area, but not on a significant level. Separate color-axis evaluations did not show any stronger correlations and did not reveal any differences between POAG eyes and NPG eyes. This was true even for the tritan axis error. • Conclusions: Although FM100 error scores are higher in glaucoma eyes and increase with glaucomatous damage, they do not separate well. In the sample of this study, separate color-axis evaluation did not improve the diagnostic value. With the FM100 a different pattern of color vision defects in POAG and NPG eyes could not be detected.

Age-related macular degeneration and optic disk morphology.

PURPOSE To assess the relationship between age-related macular degeneration and appearance of the optic disk. METHOD By morphometric evaluation of wide-angle color fundus photographs, 143 patients with age-related macular degeneration were compared with 33 normal subjects and with 83 diabetic patients. RESULTS Size and shape of the optic disk and size of parapapillary atrophy did not vary significantly (P > .12) between the study groups. CONCLUSIONS Age-related macular degeneration is not associated with special features in the appearance of the optic disk. Parapapillary atrophy, large or small optic disk, and abnormal disk shape are neither risk factors nor protective factors of age-related macular degeneration.