[show abstract][hide abstract] ABSTRACT: In most forms of open angle glaucoma, the trabecular meshwork is the main barrier for aqueous humor outflow, causing elevated intraocular pressure (IOP). The Trabectome is a minimal invasive device for the surgical treatment of open angle glaucoma, particularly eliminating the juxtacanalicular meshwork. This study was conducted to compare the effectiveness and complication profile among different glaucoma subgroups.
Single center prospective observational study. There were 557 consecutive eyes of 487 patients included in this study. Trabectome surgery was performed either alone or in combination with cataract surgery. Intraoperative and postoperative complications were documented systematically. Main outcome measures were IOP reduction over time and the preoperative and postoperative number of IOP-lowering medications. Due to subgroup sizes, only data from eyes with primary open angle glaucoma and pseudoexfoliation glaucoma were processed for statistical analysis.
For the 261 eyes classified as primary open angle glaucoma, preoperative IOP was 24 ± 5.5 mmHg (mean ± SD) under 2.1 ± 1.3 IOP-lowering medications. After a mean follow-up of 204 ± 238 days, IOP was reduced to 18 ± 6.1 mmHg, and medication was reduced to 1.2 ± 1.1. For the 173 eyes classified as pseudoexfoliation glaucoma, after a mean follow-up of 200 ± 278 days, IOP was reduced from 25 ± 5.9 mmHg to 18 ± 8.2 mmHg, and medication was reduced from 2.0 ± 1.2 to 1.1 ± 1.1. A Cox proportional hazards model hinted forward superiority of the combined surgery cases (Trabectome + Phaco + intraocular lens) in comparison to Trabectome surgery only in phakic or pseudophakic eyes. No serious complications were observed.
Minimal invasive glaucoma surgery with the Trabectome seems to be safe and effective. The subgroup analysis of different kinds of open angle glaucomas presented in this study may help in first-line patient selection. The lack of ocular surface alterations makes it a valuable addition to glaucoma surgery.
Albrecht von Graæes Archiv für Ophthalmologie 10/2013; · 1.93 Impact Factor
[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: Background: Glaucoma is an ocular disease with typical progressive damage of the optic nerve. In the past it was postulated that glaucoma induces acquired colour vision disorders. Until now all studies about glaucoma and colour vision disorders did not include vascular risk factors. In the present study we determined several vascular risk factors concerning the results of the colour vision test Roth 28-hue (E) desaturated in glaucoma patients.Patients and Methods: On the basis of an analysis of variance (ANOVA) we determined the influence of several risk factors, such as arteriosclerotic and vasospastic risk factors, on the results of the colour vision test Roth 28-hue (E) desaturated in glaucoma patients. 353 glaucoma patients were included in this study.Results: We detected a strong influence of age and mean defect in perimetry and an additional effect of arteriosclerotic and vasospastic risk factors on the results of the colour vision test Roth 28-hue (E) desaturated in glaucoma patients.Conclusions: We suspect that arteriosclerotic and vasospastic risk factors independently to glaucoma have an influence on colour vision. In the future attention additionally has to be given to vascular risk factors in the colour vision testing of glaucoma patients.
Klinische Monatsblätter für Augenheilkunde 07/2013; · 0.70 Impact Factor
[show abstract][hide abstract] ABSTRACT: Trabeculectomy is no longer the gold standard for combined cataract glaucoma surgery considering the successful results following cataract surgery combined with trabeculotomy, viscocanalostomy and canaloplasty. The main disadvantage of these mostly non-penetrating procedures is the induction of conjunctival scarring which jeopardizes subsequent filtering surgery. Ab interno glaucoma surgery, including trabecular surgery and endocyclophotocoagulation, does not interfere with the conjunctival situation. These surgical options have a relatively minor risk profile for combined cataract glaucoma surgery compared to traditional filtering surgery; however, the pressure reducing efficacy of these ab interno approaches is limited with respect to the absolute reduction of intraocular pressure (IOP) and the achievable level of IOP. This has to be kept in mind when planning surgery.
Der Ophthalmologe 04/2013; 110(4):310-5. · 0.53 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: The aim of the present study was to compare the measurement of intraocular pressure (IOP) through a therapeutic soft contact lens with the "native" measurement. We additionally investigate whether a rebound tonometer (RT) or non-contact tonometer (NCT) is more suitable to measure IOP through a bandage contact lens. METHODS: The IOP was determined using each of the two methods, three times successively with (lens measurement) and without (native measurement) a soft contact lens. The Icare tonometer (Icare® TA01i, Icare Finland Oy, 23 subjects) and the Airpuff tonometer (Nidek NT 53OP, Nidek CO., LTD, Hiroishi Gamagori, Aichi, Japan, 16 subjects) were used. We compared the mean values (validity parameter) and standard deviation (precision parameter) of the three individual measurements in each case using the paired t-test. In addition, we conducted a power analysis to estimate the maximum error in the measurement caused by the contact lens (power level set to 0.8). RESULTS: With the Airpuff tonometer we detected no statistically significant between the lens and the native measurement (15.6 ± 2.6 vs. 15.3 ± 2.6 mmHg; p = 0.42). The power analysis revealed that the maximum error caused by the contact lens was 1.2 mmHg. The Icare tonometry, however, trended toward higher values in the contact lens measurements (17.5 ± 4.3 vs. 16.4 ± 3.5 mmHg in the native measurements; p = 0.05). Interestingly, this difference exhibited a statistically significant correlation with the corneal thickness (0.03 mmHg per μm corneal thickness; p = 0.04). CONCLUSION: The use of NCT and RT for IOP measurement over a soft contact lens is feasible. The accuracy appears to be sufficient for the most common clinical applications.
Albrecht von Graæes Archiv für Ophthalmologie 03/2013; · 1.93 Impact Factor
[show abstract][hide abstract] ABSTRACT: PURPOSE:: Among other corneal biomechanical properties, Goldmann applanation tonometry (GAT) has been shown to depend on corneal edema. New tonometry devices have been designed, such as the Tono-Pen XL, iCare, and ocular response analyzer (ORA), to measure the intraocular pressure (IOP) accurately. This study aims to investigate the influence of corneal edema on the accuracy of these IOP-measuring devices in an in vitro model. METHODS:: A model of an artificial anterior chamber was developed using a guided trephination system. Eight donor corneas not suitable for keratoplasty were clamped into this artificial anterior chamber. All corneas showed signs of stromal edema. Intracameral pressure (ICP) was adjusted manometrically to 10, 20, 30, 40, and 50 mm Hg. The central corneal thickness (CCT) was determined by ultrasonic pachymetry. For each manometrically defined ICP, tonometry was performed using the iCare, Tono-Pen XL, GAT, and ORA. RESULTS:: The mean CCT increased from 616.1±29.6 µm to 626.9±36.1 µm. At 10 mm Hg, GAT yielded a higher ICP than those manometrically adjusted (10.4±3.3 mm Hg); at all other ICP levels, GAT yielded lower ICP levels than those adjusted. The Tono-Pen XL and iCare showed the greatest difference at 10 mm Hg, with the Tono-Pen XL yielding a value of 14.0±4.0 mm Hg and the iCare yielding a value of 12.5±2.6 mm Hg. All other results of the 2 devices fell within a range of ±2 mm Hg from the adjusted ICP. The ORA provided accurate results only at "physiological" ICP levels with a maximum difference of 2.6 mm Hg at 30 mm Hg. At higher ICP levels, corneal hysteresis decreased significantly with increasing ICP. None of the measurement devices revealed a statistically relevant dependence on CCT in this experimental setting. CONCLUSIONS:: The Tono-Pen XL and the iCare yielded the most accurate ICP values across all the adjusted ICP values. This may be because of their relatively small contact area with the cornea and, consequently, greater independence from corneal biomechanical properties. The ORA yielded accurate measurement results only at physiological ICP levels. As anticipated, GAT underestimated ICP. The Tono-Pen XL and the iCare should therefore be used to determine IOP in patients suffering from corneal edema, such as bullous keratopathy or Fuchs endothelial dystrophy.
[show abstract][hide abstract] ABSTRACT: The aim of this study was to differentiate the pressure-reducing results following trabecular aspiration combined with small incision cataract surgery in eyes with pseudoexfoliation depending on preoperative pressure and medication score.
A retrospective analysis was made of 104 exfoliative eyes of 104 patients who underwent combined phaco/trabecular aspiration. Success was defined as a relative reduction of IOP of at least 20 %, absolute IOP of ≤ 20 mmHg, stable or reduced medication score and a lack of any further pressure-reducing surgery.
The success rate was 0.68 and 0.64 after 1 and 2 years. In eyes with medically uncontrolled preoperative IOP (> 20 mmHg) the IOP dropped significantly from 25.4 ± 4.3 mmHg to 17.0 ± 3.4 mmHg after two years. In eyes with preoperative controlled IOP the pressure lowering effect was low (17.1 ± 2.3 to 15.9 ± 2.3 mmHg) with a significant reduction of medication.
Combined cataract surgery and trabecular aspiration is a reasonable option in exfoliative eyes with IOP values in the low twenties in order to achieve a reduction of topical medications and to reach a stable IOP level.
Klinische Monatsblätter für Augenheilkunde 02/2012; 229(6):641-4. · 0.70 Impact Factor
[show abstract][hide abstract] ABSTRACT: Disturbed axonal transport is an important pathogenic factor in many neurodegenerative diseases, such as glaucoma, an eye disease characterised by progressive atrophy of the optic nerve. Quantification of retrograde axonal transport in the optic nerve usually requires labour intensive histochemical techniques or expensive equipment for in vivo imaging. Here, we report on a robust alternative method using Fluorogold (FG) as tracer, which is spectrometrically quantified in retinal tissue lysate.
To determine parameters reflecting the relative FG content of a sample FG was dissolved in retinal lysates at different concentrations and spectra were obtained. For validation in vivo FG was injected uni- or bilaterally into the superior colliculus (SC) of Sprague Dawley rats. The retinal lysate was analysed after 3, 5 and 7 days to determine the time course of FG accumulation in the retina (n = 15). In subsequent experiments axona transport was impaired by optic nerve crush (n = 3), laser-induced ocular hypertension (n = 5) or colchicine treatment to the SC (n = 10).
Spectrometry at 370 nm excitation revealed two emission peaks at 430 and 610 nm. We devised a formula to calculate the relative FG content (c(FG)), from the emission spectrum. c(FG) is proportional to the real FG concentration as it corrects for variations of retinal protein concentration in the lysate. After SC injection, c(FG) monotonously increases with time (p = 0.002). Optic nerve axonal damage caused a significant decrease of c(FG) (crush p = 0.029; hypertension p = 0.025; colchicine p = 0.006). Lysates are amenable to subsequent protein analysis.
Spectrometrical FG detection in retinal lysates allows for quantitative assessment of retrograde axonal transport using standard laboratory equipment. It is faster than histochemical techniques and may also complement morphological in vivo analyses.
PLoS ONE 01/2012; 7(6):e38820. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: -Agonisten werden am Auge zur Behandlung des Glaukoms eingesetzt. Sie senken über eine Hemmung der Kammerwasserproduktion und über eine Steigerung des Kammerwasserabflusses den Augeninnendruck. Heutzutage werden aufgrund des geringeren Nebenwirkungsprofils bevorzugt selektive 2-Agonisten angewandt. Sie gehören aufgrund ihrer lokalen und systemischen Nebenwirkungen jedoch zu den Therapeutika der 2. Wahl. Experimentelle Ergebnisse weisen darauf hin, dass 2-Agonisten einen additiven neuroprotektiven Effekt haben. In klinischen Studien konnte dies jedoch bisher nicht belegt werden.
[show abstract][hide abstract] ABSTRACT: In vivo imaging of the retina is becoming an increasingly important research method. General anesthesia rapidly compromises the corneal surface, which increases scattering. In addition, wavefront aberrations limit the maximum imaging resolution. Three common methods of stabilizing the air-cornea interface and reducing scattering are the use of a contact lens, a microscopy slide coverslip, or mineral oil. These methods have not yet been analyzed regarding their impact on scattering and wavefront aberrations.
Nineteen eyes of 19 rats were analyzed with a custom-made Hartmann-Shack (HS) wavefront sensor. The amount of scattering was determined by analysis of the HS spot width, and the wavefront was reconstructed for the naked eye and each scattering-reducing method. Their effect on optical quality was determined by calculating the modulation transfer function (MTF).
The three methods applied significantly reduced scattering but were differentially effective, with the coverslip performing the best and the mineral oil the worst. The root mean square (RMS) of the wavefront aberration, as well as the intereye variability of the RMS, was significantly smaller with the contact lens than with the coverslip. The MTF was best for the contact lens and worst for the coverslip, which was also illustrated by image simulations.
The coverslip, contact lens, and mineral oil, when applied to the cornea, all reduced scattering. The best-performing method, the coverslip, increased wavefront aberrations. Overall, the contact lens had the best influence on image quality, and it appears to be the method of choice for high-resolution retinal imaging in rats.
[show abstract][hide abstract] ABSTRACT: The correct interpretation of measured tonometric values has become more and more complex in recent years. Large clinical studies have shown that an average central corneal thickness (CCT) of 550 µm can be assumed for the general population. Since the standard Glodmann applanation tonometry is based on a central corneal thickness of 520 µm, mathematical correction formula have been discussed for calculation of the true intraocular pressure. Newer tonometry devices, e. g. the dynamic contour tonometry (DCT) which seems to be independent from CCT, or the Ocular Response Analyzer® (ORA), taking into account the biomechanical properties of the cornea, have been designed to measure intraocular pressure (IOP). In this article, several IOP measurement devices and their clinical relevance for a correct and feasible determination of the IOP are discussed.
Klinische Monatsblätter für Augenheilkunde 02/2011; 228(2):118-24. · 0.70 Impact Factor
[show abstract][hide abstract] ABSTRACT: Applanation tonometry has been the gold standard in clinical ophthalmology for more than fifty years. The most popular factor is central corneal thickness that is now routinely considered in glaucoma management. However, other individual features of the cornea can also play a key role for the interpretation of the applanation values. Other factors influencing applanation tonometry that have been well known for decades include tear film, fluorescein illumination etc., and should be kept in mind. According to the available literature the absence of a correct calibration cannot be neglected.
Klinische Monatsblätter für Augenheilkunde 02/2011; 228(2):109-13. · 0.70 Impact Factor
[show abstract][hide abstract] ABSTRACT: The aim of this study was to evaluate the concordance of intraocular pressure (IOP) measurements in the supine glaucoma patient using a Perkins applanation tonometer (PAT) compared to the iCare® rebound tonometer (RT), a hand-held device requiring no local anaesthesia.
73 left eyes of 73 glaucoma patients were included in this consecutive case study and measured both by supine Perkins applanation tonometry and by right lateral posture rebound tonometry in the supine position (RLP). The patients were divided into three subgroups dependent on IOP (SG-1: 0 - 15 mmHg, SG-2: 16 - 22 mmHg, SG-3: more than 23 mmHg).
The mean deviation between RT and PAT was 2.6 ± 4.0 mmHg, the 95 % confidence interval was -5.3 to 10.4 mmHg. 69 % of the measurements showed deviations within 3 mmHg between the two devices. Deviation was smallest in SG-2, and largest in SG-3.
Rebound tonometry is comfortable to use even in supine patients. RT measurement agreed overall significantly with those of Perkins applanation tonometry, generally overestimating PAT measurement. In high IOP values, RT did not correlate as well with PAT as in moderate IOP levels.
Klinische Monatsblätter für Augenheilkunde 10/2010; 228(2):125-9. · 0.70 Impact Factor
[show abstract][hide abstract] ABSTRACT: The aim of this study is to assess the efficacy and complications of trabeculectomy with a biodegradable implant (ologen implant) vs trabeculectomy using mitomycin C (MMC) in patients with medically uncontrolled open-angle glaucoma in a prospective randomised clinical trial.
In the MMC group (10 patients), trabeculectomy was performed according to standard protocols. In the ologen group (10 patients) after standard trabeculectomy the implant was positioned on top of the scleral flap and no MMC was applied. Follow-up was continued for 12 months after surgery and included testing of intraocular pressure (IOP), visual acuity, visual field, ultrasound biomicroscopy, and filtering bleb score.
The mean preoperative IOP was 24.8+/-8.9 mm Hg for all patients enrolled. At 1 year after surgery, the mean IOP was 15.6+/-2.4mm Hg in the ologen group (P<0.01, 43% reduction) and 11.5+/-4.1 mm Hg in the MMC group (P<0.01, 50% reduction). No anti-glaucomatous medication was necessary in the MMC group in the first year of follow-up, whereas five patients in the ologen group required topical treatment. The absolute success rate was 100% in the MMC group and 50% in the ologen group (P=0.01). After 1 year, filtering blebs developed significantly more avascular areas in the MMC group (score=1.4) than in the ologen group (score=2.8; P<0.01).
The complete success rate using trabeculectomy with the ologen implant is lower than that achieved by trabeculectomy with MMC. However, the bleb morphology caused more problems in the MMC group (avascularity score).
[show abstract][hide abstract] ABSTRACT: The Trabectome provides a new perspective in angle surgery for open angle glaucoma. Through a 1.7 mm clear cornea tunnel, the juxtacanalicular meshwork is electroablated under gonioscopic control. Thereby, the collector channels in the outer wall of Schlemm's canal are uncovered and resistance to trabecular outflow is removed. From the literature and from our own experience, a pressure reduction by 30-35% can be achieved with a simultaneous reduction of eye drops by 50%. The Trabectome can conveniently be combined with phako-emulsification. Serious complications have not yet been reported. As the conjunctiva remains completely untouched, trabeculectomy, if necessary, could be performed without prognostic restrictions. With a realistic target pressure of approximately 16 mmHg, Trabectome surgery is indicated in patients with moderate optic nerve damage.
Der Ophthalmologe 09/2010; 107(9):855-60. · 0.53 Impact Factor
[show abstract][hide abstract] ABSTRACT: Die Zyklophotokoagulation mittels Dioden- oder Neodym-YAG-Laser gilt bei der Behandlung therapierefraktärer Glaukome als Standardverfahren
der Zyklodestruktion. Neben der transskleralen Zyklophotokoagulation steht seit Beginn der 1990er Jahre die endoskopische
Zyklophotokoagulation zur Verfügung, deren technische Grundlagen und Durchführung in diesem Artikel dargestellt werden. Durch
die direkte Visualisierung der koagulierten Ziliarkörperzotten und des somit scheinbar besser titrierbaren Effekts soll der
endoskopische Zugangsweg dem transskleralen Verfahren überlegen sein. In der Literatur wird die Endozyklophotokoagulation
als effektive Methode mit einer niedrigen Komplikationsrate beschrieben. Eigene retrospektive Daten zur endoskopischen Zyklophotokoagulation
zeigen hingegen keine suffiziente Drucksenkung. Die Indikation zur endoskpischen und damit invasiven und bulbuseröffnenden
Durchführung der Zyklophotokoagulation kann somit kontrovers diskutiert werden.
Cyclophotocoagulation is the standard cyclodestructive procedure for treating patients with refractory glaucoma. In addition
to transscleral cyclophotocoagulation, endoscopically controlled cyclophotocoagulation (ECPC) is a relatively new method,
introduced in the 1990s. Its clinical and technical background is outlined in this article. ECPC allows direct visualization
of the ciliary body and better control of the applied laser energy. Therefore, ECPC has been described as being more effective
and safer than the transscleral approach. Our own retrospective ECPC data, however, do not indicate that this method can sufficiently
decrease intraocular pressure. The indication for the invasive procedure of endoscopic cyclophotocoagulation is therefore
Der Ophthalmologe 01/2010; 107(1):68-74. · 0.53 Impact Factor
[show abstract][hide abstract] ABSTRACT: Zusammenfassung Das Trabektom bietet eine neue Möglichkeit der minimal-invasiven Kammerwinkelchirurgie bei Offenwinkelglaukomen. Über einen
1,7-mm-clear-Cornea-Zugang wird unter gonioskopischer Kontrolle das juxtakanalikuläre Trabekelmaschenwerk über mehrere Uhrzeiten
gezielt elektroabladiert. Es werden somit die Kollektorkanäle der skleralen Wand des Schlemm-Kanals freigelegt und der Abflusswiderstand
Trabekelwerk wird entfernt. Die zu erreichende Augeninnendrucksenkung liegt nach eigenen Erfahrungen und in der Literatur
bei 30–35% – dies bei einer simultanen Reduktion der erforderlichen Lokalmedikation um die Hälfte. Das Trabektom kann gut
mit der Operation der Katarakt kombiniert werden. Ernste Komplikationen wurden bislang nicht berichtet. Da die Bindehaut völlig
unberührt bleibt, ist eine spätere Trabekulektomie, sofern erforderlich, ohne prognostische Einschränkung möglich. Bei realistisch
erreichbaren Zielaugeninnendruckwerten um 16 mmHg ist das Trabektom bei moderatem Sehnervenschaden indiziert.
Der Ophthalmologe 01/2010; 107(9):855-860. · 0.53 Impact Factor
[show abstract][hide abstract] ABSTRACT: Cyclophotocoagulation is the standard cyclodestructive procedure for treating patients with refractory glaucoma. In addition to transscleral cyclophotocoagulation, endoscopically controlled cyclophotocoagulation (ECPC) is a relatively new method, introduced in the 1990s. Its clinical and technical background is outlined in this article. ECPC allows direct visualization of the ciliary body and better control of the applied laser energy. Therefore, ECPC has been described as being more effective and safer than the transscleral approach. Our own retrospective ECPC data, however, do not indicate that this method can sufficiently decrease intraocular pressure. The indication for the invasive procedure of endoscopic cyclophotocoagulation is therefore questionable.
Der Ophthalmologe 12/2009; 107(1):68-74. · 0.53 Impact Factor
[show abstract][hide abstract] ABSTRACT: Ongoing demographic changes in Europe are heightening the importance of adequate treatment for glaucoma, a disorder that is markedly more common in the elderly.
A selective search for relevant literature, including Cochrane Reviews and the guidelines of the European Glaucoma Society, regarding the topical and surgical treatment of glaucoma.
It is recommended that the intraocular pressure (IOP) should be lowered by 20% to 50% from its baseline value, depending on the extent of already existing damage, the rate of progression, the baseline IOP, and the age of the patient. Topical monotherapy can lower the IOP by 15% to 30%. The success rate of filtration surgery has risen because of the intraoperative application of topical antimetabolites and currently ranges from 50% to 90%, depending on the study.
The goal of glaucoma treatment is to protect the patient from blindness and visual impairment while keeping the treatment-related decline in quality of life to a minimum. Any type of glaucoma treatment, be it medical or surgical, must further this aim in consideration of the situation of the individual patient.