[show abstract][hide abstract] ABSTRACT: To evaluate the success rate and adverse effects of Gold Micro Shunt Plus (GMS+) implantation into the supraciliary space.
This retrospective study included 31 eyes of 31 patients diagnosed with severe glaucoma and uncontrolled intraocular pressure (IOP) with implantation of a GMS+ by means of a full-thickness scleral flap. The main outcome measures were surgical failure or success, based on the intraocular pressure and adverse effects. Clinical examination data are reported up to 4 years postoperatively.
Thirty eyes (97%) met one of our criteria for failure. Within a mean of 7.3 +/- 7.7 months another surgery was performed because of elevated IOP in 24 of 31 eyes (77%) and because of adverse effects in 2 (6%). The remaining 4 eyes, that met one of our criteria for failure, had an IOP reduction of less than 20% with comparable medication. Six GMS+'s were explanted; because of IOP elevation, 2; rubeosis iridis, 2; and low grade inflammation, 2.
GMS+ implantation is not an effective method to control IOP in patients with glaucoma, when using our surgical technique. The reason for the found signs of chronic low grade inflammation or rubeosis iridis in 4 eyes (13%) remains unknown and has to be further investigated.
[show abstract][hide abstract] ABSTRACT: Warburg Micro syndrome and Martsolf syndrome are clinically overlapping autosomal recessive conditions characterized by congenital cataracts, microphthalmia, postnatal microcephaly, and developmental delay. The neurodevelopmental and ophthalmological phenotype is more severe in Warburg Micro syndrome in which cerebral malformations and severe motor and mental retardation are common. While biallelic loss-of-function mutations in RAB3GAP1 are present in the majority of patients with Warburg Micro syndrome; a hypomorphic homozygous splicing mutation of RAB3GAP2 has been reported in a single family with Martsolf syndrome. Here, we report a novel homozygous RAB3GAP2 small in-frame deletion, c.499_507delTTCTACACT (p.Phe167_Thr169del) that causes Warburg Micro syndrome in a girl from a consanguineous Turkish family presenting with congenital cataracts, microphthalmia, absent visually evoked potentials, microcephaly, polymicrogyria, hypoplasia of the corpus callosum, and severe developmental delay. No RAB3GAP2 mutations were detected in ten additional unrelated patients with RAB3GAP1-negative Warburg Micro syndrome, consistent with further genetic heterogeneity. In conclusion, we provide evidence that RAB3GAP2 mutations are not specific to Martsolf syndrome. Rather, our findings suggest that loss-of-function mutations of RAB3GAP1 as well as functionally severe RAB3GAP2 mutations cause Warburg Micro syndrome while hypomorphic RAB3GAP2 mutations can result in the milder Martsolf phenotype. Thus, a phenotypic severity gradient may exist in the RAB3GAP-associated disease continuum (the "Warburg-Martsolf syndrome") which is presumably determined by the mutant gene and the nature of the mutation.
Human Genetics 10/2010; 129(1):45-50. · 4.63 Impact Factor
[show abstract][hide abstract] ABSTRACT: PURPOSE: To report an unusual case of fulminant anterior uveitis, confirmed as endogenous Listeria monocytogenes infection. SUBJECT: A 67-year-old man with multiple comorbidities acutely developed a severe endogenous anterior uveitis. RESULTS: L. monocytogenes, a ubiquitous Gram-positive bacillus, was directly indicated by culture and PCR. Early and aggressive treatment with intravenous antibiotics likely prevented the endophthalmitis which most cases on record experienced. Our patient regained satisfactory visual acuity. CONCLUSIONS: Prompt antimicrobial therapy is paramount when severe endogenous uveitis develops in a patient with comorbidities, especially with systemic immunosuppression. Treatment solely with corticosteroids should be avoided.
Case reports in ophthalmology. 01/2010; 1(2):63-65.
[show abstract][hide abstract] ABSTRACT: Despite the adjuvant use of mitomycin C during trabeculectomy, failures still occur. We investigated whether cultured human Tenon fibroblasts exposed to low-dose mitomycin C developed a multidrug resistance phenotype in vitro, and whether mitomycin C treatment during previous filtration surgery induces P-glycoprotein expression in vivo.
Cultured human Tenon fibroblasts treated with low-dose 0.01 nM mitomycin C for 2 weeks were subsequently treated with 0.1 to 100 microM mitomycin C in the absence or presence of 4 microM verapamil, and allowed to recover for 24 hours. Low-dose mitomycin C-treated fibroblasts were analysed for P-glycoprotein expression using flow cytometry, immunoblotting, and RT-PCR for mdr-1 mRNA. In addition, fibroblasts were treated with low dose 0.1 nM 5-fluorouracil for 2 weeks and analysed for P-glycoprotein expression using flow cytometry. Expression of P-glycoprotein was analysed in surgically removed Tenon tissue (n = 30) using immunohistochemistry. Of the 30 patients, 20 had a previous trabeculectomy, of which nine had previous adjuvant therapy with mitomycin C during trabeculectomy.
Partial resistance to mitomycin C after low-dose mitomycin C pre-treatment was significantly neutralised by the addition of verapamil. Low-dose mitomycin C up-regulated P-glycoprotein expression, but not mdr-1 mRNA expression. 5-Fluorouracil did not induce P-glycoprotein expression. P-glycoprotein expression was detected in all nine patients exposed to mitomycin C during previous trabeculectomies. Only six of 21 specimens from patients not previously exposed to mitomycin C showed faint P-glycoprotein expression.
The induction of P-glycoprotein by mitomycin C could explain some failures that occur after repeated use of mitomycin C during trabeculectomy. The concomitant use of verapamil or the use of 5-fluorouracil alone could increase the success rate of repeat trabeculectomies.
Albrecht von Graæes Archiv für Ophthalmologie 03/2008; 246(2):297-304. · 1.93 Impact Factor
[show abstract][hide abstract] ABSTRACT: To evaluate the long-term outcome of pars plana vitrectomy and primary silicone oil tamponade in patients with severe intraocular foreign body (IOFB) injuries and high risk of proliferative vitreoretinopathy (PVR).
This retrospective consecutive study included 23 patients with severe IOFB injuries who had extensive lacerations including sclera, choroid, and retina, and were complicated by predictive factors for elevated proliferative activity and an unfavorable outcome. All patients underwent pars plana vitrectomy, removal of the IOFB, and primary silicone oil tamponade and were followed up for a mean 8.9 years. Main functional outcome was assessed as final best-corrected visual acuity. Anatomic success was defined as permanent retinal attachment.
PVR occurred in 70% of all eyes and required 16 revisions. Silicone oil was removed in 78% of the eyes after a mean tamponade duration of 9.1 months. Complete retinal attachment was achieved in 83% of the eyes. Three eyes developed a persisting hypotony that was stabilized under permanent silicone oil. Functional stabilization was observed in the third year resulting in a final visual acuity of 20/630. Useful vision of better than 20/400 could be preserved in 55% of the patients. Only one eye underwent a late enucleation after 6.8 years.
Primary silicone oil stabilizes the retina during the critical period of active PVR and may limit the visual loss in selected high-risk eyes in the long term.
[show abstract][hide abstract] ABSTRACT: Artificial retinal detachment is increasingly used in submacular surgery. However, overcoming physiological retinal adhesiveness by subretinal fluid injection is suspected to cause cellular damage and thus to limit visual rehabilitation. This experimental study was designed to examine the ultrastructural changes induced by retinal detachment under vitrectomy conditions and to evaluate factors that reduce adhesiveness and minimize cellular damage.
Twenty-one pigmented rabbits underwent vitrectomy, and the vitreous cavity was perfused for 10 minutes with various solutions. These included variations in osmolarity (314 and 500 mOsM), Ca(2+) ion concentration (Ca(2+)-supplemented, low Ca(2+), active Ca(2+) deprivation via 1 mM EDTA), temperature (19 degrees C and 34 degrees C), and ischemia (5 minutes). Nonvitrectomized eyes served as the control. Consecutively, an artificial bleb detachment was created underneath the visual streak by injecting 1 mL of buffered saline solution subretinally. Eyes were enucleated within 3 minutes, fixed with 2% glutaraldehyde/0.1 M cacodylate buffer (pH 7.4) containing 100 mM sucrose and processed for transmission electron microscopy and scanning electron microscopy.
If a Ca(2+)-containing standard solution was used during vitrectomy, retinal adhesiveness was strong, and a forced bleb detachment caused substantial cellular damage characterized by swollen and fragmented photoreceptor outer segments and disruption of retinal pigment epithelial cells. Use of a Ca(2+)-free solution moderately reduced the adhesive strength with consequently less ultrastructural damage. Active Ca(2+)-deprivation further reduced the retinal adhesion, but may have induced damage as suggested by intracellular vacuolization. Hyperosmolarity and ischemic conditions had toxic effects on both the photoreceptors and RPE cells. In contrast, the use of a preheated Ca(2+)-free solution (34 degrees C) substantially reduced retinal adhesiveness under vitrectomy conditions and hence ultrastructural damage.
Artificial retinal detachment causes substantial ultrastructural damage in eyes with physiological retinal adhesiveness if performed under vitrectomy conditions similar to surgery in humans. The use of a preheated Ca(2+)-free physiologic saline solution seems to be suitable to reduce retinal adhesion sufficiently, without causing significant cellular damage.
[show abstract][hide abstract] ABSTRACT: In glaucoma surgery, scarring of the artificial fistula is the limiting factor for long-term control of intraocular pressure (IOP). Several devices and surgical techniques have been developed for artificial aqueous humor drainage in intractable glaucoma. The authors describe a novel surgical technique that uses a silicone tube as a shunt for aqueous flow from the anterior chamber to the suprachoroidal space.
Thirty-one eyes of 31 patients with uncontrollable refractory glaucoma were included in this prospective consecutive case-control study. Each eye had undergone an average of 3.5+/-1.9 previous interventions for glaucoma. The baseline IOP was 44.25+/-8.7 mm Hg despite maximum therapy. As in trabeculectomy, a limbus-based scleral flap was prepared. The suprachoroidal space was accessed via a deep posterior scleral flap. The silicone tube was inserted as an intrascleral connection from the anterior chamber to the suprachoroidal space. Cyclodialysis was avoided by this surgical approach. Success was defined as a lowering of IOP to below 21 mm Hg without the need for further medication or intervention.
The mean functional shunt survival was 55.9+/-45.6 weeks. IOP was reduced to 12.9+/-5.2 mm Hg in 70% of all eyes after 30 weeks postoperatively. After 52 weeks, 60% of the eyes could be classified as representing success, and 76 weeks after surgery, 40% of the eyes still showed controlled IOP. In none of the eyes were severe postoperative hypotony or suprachoroidal bleeding observed. No localized or general inflammation or infection was seen in connection with the silicon tube. Two patients needed anterior chamber lavage because of bleeding. In 2 patients the tube had to be removed because of corneal endothelial contact. Shunt failure of the tube was caused in some cases by connective tissue formation at the posterior lumen of the tube.
This novel surgical approach and the placement of the silicone tube described here have several advantages. Its intrascleral course minimizes the risk of conjunctival erosion and associated infections. No cyclodialysis is performed. Connection to the suprachoroidal space exploits the resorptive capability of the choroid. It guarantees drainage but also provides a natural counterpressure, avoiding severe postoperative hypotony. The suprachoroidal shunt presented here achieves good follow-up results in terms of IOP control. No serious complications have been observed. This new method promises to be an effective surgical technique and presents a new therapeutic option in intractable glaucoma. Fibroblast reaction obstructing the posterior lumen, seemed to be the only factor limiting drainage. Further studies and experiments will be needed to elucidate the exact physiologic mechanisms underlying the draining, the capacity and duration of the draining effect, and the histologic background of suprachoroidal scarring.
Journal of Glaucoma 07/2006; 15(3):200-5. · 1.87 Impact Factor
[show abstract][hide abstract] ABSTRACT: Amniotic membrane transplantation has become an important treatment option for corneal surface reconstruction. However, suture fixation of the transplant has various disadvantages like corneal irritation, scarring, graft loss due to membrane shrinkage, and the need for subsequent suture removal. Replacement of sutures by bioadhesives might be an advantageous alternative. This controlled study was designed to evaluate a new sutureless technique for amniotic membrane fixation onto the corneal surface by using fibrin glue.
Standardized disks of cryopreserved amniotic membranes were transplanted onto the deepithelialized cornea of 12 rabbits using either conventional suture fixation or a new fibrin glue technique. The rabbits were followed-up with slit-lamp examination and fluorescein staining until epithelialization was completed. Consecutively, the rabbits were killed and the eyes processed for histology and immunohistochemistry for cytokeratin-3.
All membranes of both groups stayed in place throughout the follow-up time and showed a progressive graft epithelialization that was completed after 12 days. Whereas suture-fixated membranes showed progressive tissue shrinkage, fibrin-glued sheets remained unaltered. In the bioadhesive group, histology revealed a smooth fibrin layer in the graft-host interface and a continuous, stratified layer of cytokeratin-3 expressing corneal epithelial cells on the membrane surface. In contrast, suture-fixated membranes showed contracted and prominent membrane edges with epithelial ingrowth into the submembrane interface.
Our results demonstrate the general feasibility of reproducible and reliable sutureless amniotic membrane fixation onto the corneal surface in rabbits. Stable adherence is maintained until epithelialization is completed. The sutureless technique gives sufficient manipulation time for the sheet before the final cross-linking process is completed. Furthermore, several advantageous characteristics could be demonstrated as increased biocompatibility, better epithelialization pattern and the lack of membrane shrinkage.
[show abstract][hide abstract] ABSTRACT: The routine use of mitomycin C to enhance glaucomatous filtering surgery has found wide acceptance. Complications of the application of mitomycin C have been repeatedly noticed. We now report a previously undescribed complication showing a toxic effect of mitomycin C to the corneal endothelium.
Patients underwent routine trabeculectomy with mitomycin C. Following surgery, the eyes were examined by biomicroscopy and specular microscopy of the corneal endothelium.
In two cases, we observed a partial decompensation of the corneal endothelium resulting in a well-demarcated clear zone of the cornea and a second zone with thickening of the cornea and a bullous keratopathy adjacent to the filtering bleb. The specular microscopy showed marked irregularities of the endothelial cells and areas of necrosis in those parts of the cornea close to the filtering bleb.
The two cases described here demonstrate that if the corneal endothelium is already compromised before surgery, the application of mitomycin C may have an additional toxic effect on the endothelium and may result in a partial bullous keratopathy. Surgeons should be aware of this complication.
Albrecht von Graæes Archiv für Ophthalmologie 01/2006; 243(12):1284-7. · 1.93 Impact Factor
[show abstract][hide abstract] ABSTRACT: To develop an intraocular vision aid to provide artificial vision in severely traumatized eyes, where neuroretinal function could be preserved but irreversible anterior segment opacification resulted in blindness.
The basis of an intraocular vision aid is in principle a telemetric circuit to bridge the opaque cornea and to allow for artificial light stimulation of the retina. The visual prosthesis comprises an external high-dynamic range complementary metal oxide semiconductor camera and digital signal processing unit and an intraocular miniaturized light-emitting diode array to project the image onto the retina. For in vivo testing of long-term function and biocompatibility, silicone-encapsulated active photodiodes were implanted in 13 pigmented rabbits and were followed up for up to 21 months.
Lens extraction and stable fixation of the device in the ciliary sulcus were successful in all cases. For up to 21 months inductive energy transmission and wireless stimulation of the implants could be maintained. Electrophysiologic data and histology demonstrated a good tissue biocompatibility in the long-term follow-up.
The results demonstrate the general feasibility and biocompatibility to implant and fixate an intraocular light-emitting diode prosthesis. Inductive energy transmission to the intraocular device and wireless light stimulation are assured in the long term but depend on meticulous water-impermeable encapsulation of the delicate microelectronic components. Clinical Relevance An intraocular vision aid compound system with a high-resolution light-emitting diode matrix might be a future treatment option to restore vision in blind eyes with severe anterior segment disorders.
Archives of Ophthalmology 08/2005; 123(7):964-9. · 3.83 Impact Factor
[show abstract][hide abstract] ABSTRACT: To assess the practical feasibility and signal quality of axial length measurements by partial coherence laser interferometry in silicone oil-filled eyes with previous complicated vitreoretinal surgery.
Department of Ophthalmology, University Cologne, Cologne, Germany.
Using a Zeiss IOLMaster, axial length measurements and signal-to-noise ratios of optical biometry in silicone oil-filled eyes (n=45) and contralateral eyes without tamponade (n=41) were analyzed.
Axial length measurements with signal-to-noise ratio > or =2 were feasible in 41 of 45 silicone oil-filled eyes (91%) and 37 of 41 eyes without tamponade (90%). Cataract, central retinal detachment, vitreous hemorrhage, and emulsified oil droplets attached to the intraocular lens were reasons for failure of partial coherence laser interferometry. The signal-to-noise ratio of the first 2 measurements was significantly smaller (P=.04) in silicone-filled eyes (4.4 +/- 2.0) than in eyes without tamponade (5.5 +/- 3.0). Axial lengths of the oil-filled eye and the contralateral eye showed a significant intraindividual correlation (P<.0001, Spearman r=0.84).
Partial coherence laser interferometry shows good clinical practicability in silicone oil-filled eyes with previous complicated vitreoretinal surgery. Further studies are needed to assess the reliability of these measurements with regard to postoperative refraction after combined oil removal and cataract surgery.
Journal of Cataract [?] Refractive Surgery 06/2005; 31(5):1006-10. · 2.53 Impact Factor
[show abstract][hide abstract] ABSTRACT: Lately, the application of intrascleral implants has been increasingly discussed to improve success rates of nonpenetrating surgery for the treatment of open-angle glaucoma.
A 36-year-old male patient with medically uncontrolled pigmentary glaucoma underwent viscocanalostomy with intrascleral implantation of reticulated hyaluronic acid (SK-GEL) in his right eye.
The immediate postoperative course was unremarkable with control of intraocular pressure without additional glaucoma medications. At first follow-up, 2 weeks post surgery, conjunctival dehiscence with partial extrusion and exposure of the reticulated hyaluronic acid implant was observed. Under topical tobramycin ointment a gradual limbal readaptation of the conjunctiva over the surface of the exposed parts of the implant with formation of a filtration bleb was noted. Therefore, surgical revision remained unnecessary.
Implant exposure following nonpenetrating antiglaucomatous surgery is a specific complication, which can appear whenever intrascleral implants are used. Depending on the local situation nonsurgical treatment may be successful.
Der Ophthalmologe 01/2005; 101(12):1220-3. · 0.53 Impact Factor
[show abstract][hide abstract] ABSTRACT: HintergrundFr die chirurgische Therapie der chronischen Offenwinkelglaukome wird in jngerer Zeit verstrkt die Anwendung intraskleraler Implantate zur Verbesserung der Erfolgsraten nichtpenetrierender Operationsverfahren diskutiert.Patienten und MethodikBei einem 36Jahre alten mnnlichen Patienten mit dysreguliertem Pigmentdispersionsglaukom fhrten wir komplikationslos am rechten Auge eine Viskokanalostomie mit intraskleraler Implantation von hochvernetzter Hyaluronsure (SK-GEL) durch.ErgebnisseNach zunchst unaufflligem postoperativem Verlauf mit regulierten Intraokulardruckwerten zeigte sich im Rahmen der Nachuntersuchung, die 2Wochen nach der Operation erfolgte, eine partielle Luxation des Hyaluronsureimplantats mit Exposition des prolabierten Implantatanteils und deutlicher Bindehautdehiszenz. Unter einer lokalen Infektprophylaxe mit Tobramycinhaltiger Augensalbe zeigte sich ein schrittweiser spontaner Verschluss der Bindehaut mit konsekutiver Ausbildung eines Filterkissens. Eine operative Revision des Befunds war nicht erforderlich.SchlussfolgerungDie Implantatexposition nach nichtpenetrierender Glaukomchirurgie ist eine spezifische Komplikation, die bei der Anwendung intraskleraler Implantate in Einzelfllen auftreten kann. In Abhngigkeit vom Lokalbefund erscheint eine konservative Therapie mglich.BackgroundLately, the application of intrascleral implants has been increasingly discussed to improve success rates of nonpenetrating surgery for the treatment of open-angle glaucoma.Patients and methodsA 36-year-old male patient with medically uncontrolled pigmentary glaucoma underwent viscocanalostomy with intrascleral implantation of reticulated hyaluronic acid (SK-GEL) in his right eye.ResultsThe immediate postoperative course was unremarkable with control of intraocular pressure without additional glaucoma medications. At first follow-up, 2weeks post surgery, conjunctival dehiscence with partial extrusion and exposure of the reticulated hyaluronic acid implant was observed. Under topical tobramycin ointment a gradual limbal readaptation of the conjunctiva over the surface of the exposed parts of the implant with formation of a filtration bleb was noted. Therefore, surgical revision remained unnecessary.ConclusionsImplant exposure following nonpenetrating antiglaucomatous surgery is a specific complication, which can appear whenever intrascleral implants are used. Depending on the local situation nonsurgical treatment may be successful.
Der Ophthalmologe 11/2004; 101(12):1220-1223. · 0.53 Impact Factor
[show abstract][hide abstract] ABSTRACT: We report a long-term hypotony syndrome after deep sclerectomy, associated with intermittent rise in intraocular pressure (IOP) due to steroid response.
A 55-year-old woman with high myopia (RE -9.25, LE -10.50) suffering from uncontrolled pigment open-angle glaucoma, despite laser trabeculoplasty and a cyclodestructive procedure, underwent an uneventful viscocanalostomy.
Intraocular pressure was between 9 and 17 mm Hg with local steroid medication 5 times a day, but became unstable with steroid reduction to 3 times a day and the patient developed hypotonous IOP (3-5 mm Hg) in the fourth postoperative month. With intensification of local steroid therapy, IOP rose to 49 mm Hg, and a reduction in medication was followed by hypotony. The instability of IOP with steroid medication could not be controlled and the IOP response due to steroids diminished with time; a long-term hypotony syndrome with maculopathy developed. Surgical inspection 10 months later with repeated preparation of the scleral flap showed (like ultrasound biomicroscope examination) a normal status after viscocanalostomy, without signs of leakage.
Late hypotony syndrome should be considered as a potential complication of viscocanalostomy, perhaps especially in cases of myopia and former cyclodestructive procedures. In our case, despite nonpenetrating glaucoma surgery, the steroid response at first observed indicated additional outflow via the trabecular meshwork. After some months it could not be provoked any longer, leaving us to consider whether a gradual change in the trabecular meshwork hinders steroid medication changing aqueous outflow facility.
Journal of Glaucoma 09/2004; 13(4):263-7. · 1.87 Impact Factor
[show abstract][hide abstract] ABSTRACT: We report on a 62-year-old healthy woman who suffered from bilateral predescemetic opacities, where the underlying disorder could not be identified. She had bilateral keratopathy with corneal edema, a diffuse predescemetic avascular haze and deszemetic folds. Because of high hyperopia (right +7.50/left +7.75) she weared soft contact lenses for years.
Removal of contact lenses. Treatment with local steroids and tear substitutes.
One year after cessation of contact lenses VA recovered from RE 0.3/LE 0.1 to 0.8/0.63, the deep stromal opacity cleared up, the corneal edema recessed slightly.
The differential diagnosis concludes either a pure contact lens change that is not completely reversible or a possible posterior polymorphous dystrophy that worsens with long-term contact lens wear and improves on cessation.
[show abstract][hide abstract] ABSTRACT: Introduction: We report on a 62-year-old healthy woman who suffered from bilateral predescemetic opacities, where the underlying disorder could not be identified. She had bilateral keratopathy with corneal edema, a diffuse predescemetic avascular haze and deszemetic folds. Because of high hyperopia (right +7.50/left +7.75) she weared soft contact lenses for years. Methods: Removal of contact lenses. Treatment with local steroids and tear substitutes.Results: One year after cessation of contact lenses VA recovered from RE 0.3/LE 0.1 to 0.8/0.63, the deep stromal opacity cleared up, the corneal edema recessed slightly. Discussion: The differential diagnosis concludes either a pure contact lens change that is not completely reversible or a possible posterior polymorphous dystrophy that worsens with long-term contact lens wear and improves on cessation.
[show abstract][hide abstract] ABSTRACT: To prevent recurrence of granular dystrophy by treatment with soft contact lenses.
After penetrating keratoplasty, a soft contact lens was fitted in a 61-year-old woman patient with granular corneal dystrophy. The lens was worn continuously for 53 months.
No recurrence was observed. However, the other eye, which was operated on first and not treated with a contact lens, showed severe recurrence of the underlying disease, with granular deposits in the stroma.
Fitting of a soft contact lens should be considered in this disease after penetrating keratoplasty.