[Treatment of uveitis-associated refractory ocular hypotony with topical ibopamine]

BACKGROUND: Ibopamine is a non-selective dopamine- and adrenalin-receptor agonist that has been shown to cause pupillary dilation and an increase in aqueous humour secretion. This novel drug can be used as a mydriatic agent, as a provocative test in open-angle glaucoma, and for the treatment of persisting ocular hypotony. HISTORY AND SIGNS: This 47-year-old man had a history of uveitis associated with Crohn's disease. Six years after deep sclerectomy for uveitic secondary glaucoma, he developed severe hypotony in his left eye with drop of visual acuity (VA). The hypotony did not respond to topical steroid treatment. 2 % Ibopamine solution was ordered t. i. d. concomitant to 1 % prednisolone acetate. THERAPY AND OUTCOME: Intraocular pressure (IOP) began to rise after 3 weeks of Ibopamine treatment and returned to normal (12 mmHg) with continuous recovery of VA after 8 weeks. Ibopamine was discontinued at an IOP of 16 mmHg after a course of 12 weeks. IOP and VA remained stable during the 12-month follow-up period. CONCLUSIONS: Ibopamine 2 % eye drops in combination with topical steroids are a therapeutic option in uveitis-associated ocular hypotony.

Detection of regional blood perfusion changes in epileptic seizures with dynamic brain perfusion CT--a pilot study

BACKGROUND AND PURPOSE: Perfusion CT (P-CT) is used for acute stroke management, not, however, for evaluating epilepsy. To test the hypothesis that P-CT may identify patients with increased regional cerebral blood flow during subtle status epilepticus (SSE), we compared P-CT in SSE to different postictal conditions. METHODS: Fifteen patients (mean age 47 years, range 21-74) underwent P-CT immediately after evaluation in our emergency room. Asymmetry indices between affected and unaffected hemispheres were calculated for regional cerebral blood volume (rCBV), regional cerebral blood flow (rCBF), and mean transit time (MTT). Regional perfusion changes were compared to EEG findings. RESULTS: Three patients in subtle status epilepticus (group 1) had increased regional perfusion with electro-clinical correlate. Six patients showed postictal slowing on EEG corresponding to an area of regional hypoperfusion (group 2). CT and EEG were normal in six patients with a first epileptic seizure (group 3). Cluster analysis of asymmetry indices separated SSE from the other two groups in all three parameters, while rCBF helped to distinguish between chronic focal epilepsies and single events. CONCLUSION: Preliminary results indicate that P-CT may help to identify patients with SSE during emergency workup. This technique provides important information to neurologists or emergency physicians in the difficult clinical differential diagnosis of altered mental status due to subtle status epilepticus.

Intravitreal triamcinolone acetonide for serous retinal pigment epithelial detachments in exudative age-related macular degeneration

BACKGROUND: Due to the high risk of RPE tears PDT is usually not performed in eyes with serous RPE detachments (sRPED). For this reason this subform of exudative AMD was so far untreatable. PATIENTS AND METHODS: We report on a prospective uncontrolled observational case series. 20 eyes of 20 patients with subfoveal sRPED demonstrated by OCT were treated between June 2005 and April 2006 with intravitreal triamcinolone acetonide (IVTA). In 15 cases there was a primary sRPED, in 5 cases it had developed after one or more sessions of photodynamic therapy with Visudyne. RESULTS: There was a trend for better average visual acuity in the group with primary sRPED from 0.73 logMAR (0.19 Snellen equivalent) at baseline (n = 15) to 0.68 logMAR (0.21 Snellen) after one month (n = 15) (p = 0.19) and to 0.60 logMAR (0.25 Snellen) after three months (n = 14) (p = 0.41). The maximal height of sRPED decreased to an average of 35.3 % after one month (n = 15) and increased again to 56.9 % after 3 months (n = 14). One patient was lost to follow-up. In the group of eyes with sRPED after PDT, one eye developed an RPE tear with severe vision loss two weeks after IVTA. In the remaining four eyes average visual acuity improved from 0.90 logMAR (0.13 Snellen) at baseline to 0.73 logMAR (0.19 Snellen) after one month and to 0.80 logMAR (0.16 Snellen) after 3 months. Complete resolution of sRPED was observed in 8/20 eyes (4/5 eyes with sRPED after PDT and 4/15 eyes with primary sRPED). CONCLUSIONS: IVTA seems to be a therapeutic option in otherwise untreatable eyes with sRPED.

[Does cataract surgery increase the risk of exudative age-related macular degeneration? Results from a large retrospective case-control study]

BACKGROUND: Many epidemiological studies indicate a positive correlation between cataract surgery and the subsequent progression of age-related macular degeneration (AMD). Such a correlation would have far-reaching consequences. However, in epidemiological studies it is difficult to determine the significance of a single risk factor, such as cataract surgery. PATIENTS AND METHODS: We performed a retrospective case-control study of patients with new onset exudative age-related macular degeneration to determine if cataract surgery was a predisposing factor. A total of 1496 eyes were included in the study: 984 cases with new onset of exudative AMD and 512 control eyes with early signs of age-related maculopathy. Lens status (phakic or pseudophakic) was determined for each eye. RESULTS: There was no significant difference in lens status between study and control group (227/984 [23.1 %] vs. 112/512 [21.8 %] pseudophakic, p = 0.6487; OR = 1.071; 95 % CI = 0.8284-1.384). In cases with bilateral pseudophakia (n = 64) no statistically significant difference of the interval between cataract surgery in either eye and the onset of exudative AMD in the study eye was found (225.9 +/- 170.4 vs. 209.9 +/- 158.2 weeks, p = 0.27). CONCLUSIONS: Our results provide evidence that cataract surgery is not a major risk factor for the development of exudative AMD.

First clinical experience with anecortave acetate (Retaane)

BACKGROUND: Anecortave acetate is an angiostatic cortisene which is injected as a posterior juxtascleral depot and has been shown to be effective in the treatment of exudative age-related macular degeneration (AMD). The compound is not yet approved in Switzerland but can be used as "compassionate use" in individual cases. PATIENTS AND METHODS: An uncontrolled case series with standardised documentation of ETDRS visual acuity, near acuity, need for magnification and fluorescein angiography was performed. RESULTS: 22 eyes of 19 patients (8 male, 11 female, average age 78.8 years) were treated with a posterior juxtascleral depot injection (PJD) of 15 mg anecortave acetate. The mean change in visual acuity after 3 months in eyes treated with anecortave acetate was -2.6 ETDRS letters corresponding to 0.52 Snellen lines. 3/20 eyes gained more than 1 line. 11/20 eyes showed stable visual acuity (+/- 1 Snellen line, +/- 5 ETDRS letters). 5/20 eyes developed moderate vision loss (one to two Snellen lines, 6-10 ETDRS letters). 1/20 lost 18 ETDRS letters (> 3 Snellen lines). There were no moderate or severe adverse events. CONCLUSIONS: A PJD of 15 mg anecortave acetate is safe and well tolerated. In eyes with occult CNV without recent progression or with residual neovascular activity after photodynamic therapy anecortave acetate may be an alternative therapeutic option before considering intravitreal anti-VEGF agents due to the much less invasive character and lower risk profile.

Comparison of performance and patient satisfaction of two types of ERG electrodes

BACKGROUND: An age-controlled comparison concerning patient satisfaction and electrical performance of microfibres (DTL) and rigid contact lens (Henkes) corneal ERG electrodes was carried out. METHODS: 36 test persons underwent complete ophthalmological examination and were equally distributed into 3 age groups. Electroretinograms were recorded according to ISCEV standards. Randomly, in one eye a Henkes electrode was used and in the other eye a DTL electrode. Amplitudes of a- and b-waves and implicit times were measured and compared for the two electrode types. RESULTS: 34 of 36 test persons preferred DTL electrodes. Electrical performance concerning b-wave amplitudes was comparable. Statistically significant differences were detected only for scotopic combined cone-rod stimulation in the age groups 20 - 40 and 41 - 60 years between the different electrodes. Other recordings did not show differences. A statistically significant reduction of signal amplitudes with age was detected for scotopic isolated rod signals and combined cone-rod signals. Significance level was p < 0.05. No conjunctival or corneal erosions were found after ERG recordings for either electrode. CONCLUSIONS: Electrical performance is comparable between electrodes. For scotopic stimulations age was a significant influencing factor for signal amplitude and should be respected for normative values. DTL electrodes were preferred by the vast majority of patients. No adverse clinical effects were observed for either electrode. DTL electrodes should be preferred due to hygienic reasons (single use) and patient comfort.

Comparison of tendency-oriented perimetry and dynamic strategy in octopus perimetry as a screening tool in a clinical setting: a prospective study

OBJECTIVE: The aim of this study was to compare the results of tendency-oriented perimetry (TOP) and a dynamic strategy in octopus perimetry as screening methods in clinical practice. DESIGN: A prospective single centre observational case series was performed. PARTICIPANTS AND METHODS: In a newly opened general ophthalmologic practice 89 consecutive patients (171 eyes) with a clinical indication for octopus static perimetry testing (ocular hypertension or suspicious optic nerve cupping) were examined prospectively with TOP and a dynamic strategy. The visual fields were graded by 3 masked observers as normal, borderline or abnormal without any further clinical information. RESULTS: 83% eyes showed the same result for both strategies. In 14% there was a small difference (with one visual field being abnormal or normal, the other being borderline). In only 2.9% of the eyes (5 cases) was there a contradictory result. In 4 out of 5 cases the dynamic visual field was abnormal and TOP was normal. 4 of these cases came back for a second examination. In all 4 the follow-up examination showed a normal second dynamic visual field. CONCLUSIONS: Octopus static perimetry using a TOP strategy is a fast, patient-friendly and very reliable screening tool for the general ophthalmological practice. We found no false-negative results in our series.

Pleomorphic adenoma in an atypical location near the temporomandibular joint: a case report

Pleomorphic adenomas primarily arise in the major salivary glands, especially in the parotid. The most common area is the lower pole superficial to the plane of the facial nerve. In this report, a pleomorphic adenoma in an atypical location--the region of the temporomandibular joint (TMJ)--is presented. The tumor was solitary, closely attached to the capsule of the TMJ and superior to the parotid gland, with clear demarcation. Clinically, the tumor resembled TMJ pathology, but MRI examination led to diagnosis of a benign tumor attached to the TMJ. This report shows that pleomorphic adenoma can be a possible diagnosis for lesions at the joint capsule.

[Positive ibopamine provocative test in normal-tension glaucoma suspects]

BACKGROUND: Ibopamine is an alpha-adrenergic agent and causes an elevation of intraocular pressure in eyes with increased outflow resistance. It has been proposed as a test substance for the detection of early ocular hydrodynamic disorders. PATIENTS AND METHODS: A total of 64 normal-tension glaucoma suspect eyes without anti-hypertensive treatment were enrolled. A daily pressure curve was registered with measurements at 7:00 am, 8:00 am, 12:00 am, 17:00 pm using an applanation tonometer and a contour tonometer followed by instillation of ibopamine 2% in both eyes. Tonometry was performed every 15 minutes during the following hour. An IOP increase of > 2.0 mmHg was considered positive. RESULTS: The positive test group showed a significant pressure increase from 18.04 to 22.06 mmHg. Ocular pulse amplitude increased from 2.96 to 3.97 mmHg and was positively correlated with the pressure. Intraocular pressure was unchanged in the negative test group. Central corneal thickness was not significantly different in the two groups (p = 0.32). CONCLUSIONS: Ibopamine 2% eye drops have a positive pressure effect in 50% of suspected normal-tension glaucoma eyes and may differentiate between eyes with normal trabecular outflow capacity and eyes with increased resistance in the trabecular meshwork that are prone to pressure peaks and deterioration to glaucoma.

Alternative methods to kyphoplasty: vertebroplasty — lordoplasty

Percutaneous cement augmentation (vertebroplasty) was used for the first time in the 1980s, primarily for treatment of vertebral hemangioma [Galibert 1987]. It was only in the middle of the 1990s that it was used for treatment of metastases and increasingly for osteoporotic fractures of the spine [Cotten 1996; Weill 1996; Jensen 1997; Cortet 1999; Heini 2000]. In the meantime, this method has become established for treatment of painful osteoporotic fractures and for tumorous osteolysis of the spine. The clinical success rate is very high, with rapid pain relief in 70–90% of treated patients [Legroux-Gerot 2004; Zoarski 2002; Peh 2002; Barr 2000].

Periprocedural embolic events related to carotid artery stenting detected by diffusion-weighted MRI: comparison between proximal and distal embolus protection devices

PURPOSE: To evaluate and compare the efficacy of proximal versus distal embolus protection devices (EPD) during carotid artery angioplasty/stenting (CAS) based on diffusion-weighted magnetic resonance imaging (DW-MRI). METHODS: Forty-four patients (31 men; mean age 68 years, range 48-85) underwent protected CAS and had DW-MRI before and after the intervention. The cohort was analyzed according to the type of EPD used: a proximal EPD was deployed in 25 (56.8%) patients (17 men; mean age 66 years, range 48-85) and a distal filter in 19 (14 men; mean age 70 years, range 58-79). Fifteen (60.0%) patients with proximal protection were symptomatic of the target lesion; in the distal protection group, 10 (52.6%) were symptomatic. RESULTS: New lesions were seen on the postinterventional DW-MRI in 28.0% (7/25) of the proximal EPD group versus 32.6% (6/19) of those with a distal filter (p = NS). The majority were clinically silent. The new lesions in the vascular territory of the stented carotid artery in the group as a whole and per patient were fewer in the proximal EPD group (p = NS). No significant differences were noted in the T(2) appearance of the new lesions or the number of new lesions observed away from the vascular territory of the stented artery. CONCLUSION: Proximal embolus protection devices show a nonsignificant trend toward fewer embolic events, which warrants large-scale studies. Furthermore, proximal protection devices can be useful to control and treat acute in-stent thrombosis.

[Lower eyelid reconstruction of traumatically caused cicatricial entropion with amniotic membrane or mucosal membrane grafts]

BACKGROUND: A retrospective evaluation was undertaken of eyelid reconstruction with amniotic membrane or oral mucosal membrane transplantation in patients with lower lid cicatricial entropion after orbital surgery. PATIENTS AND METHODS: Seven patients (four women) were treated with a scar tissue dissection and an amniotic membrane or mucosal membrane transplantation between 2003 and 2006 (Five amniotic membrane grafts and two oral mucosal membrane grafts). In selected cases additional procedures like a lateral tarsal strip operation, a tarsal fracture, or the reinsertion of the lower lid retractors were performed. RESULTS: All patients showed a favourable postoperative result with a good anatomic correction of the entropion and a regression of the preoperative disturbances. All the grafts took well. Two patients had to be reoperated twice and one patient three times as a result of a relapse of the cicatricial entropion. However, as well in these patients the anatomical and functional result was favourable at the end. CONCLUSIONS: The difficult scar dissection with the subsequent amniotic membrane or oral mucosal membrane transplantation seems to be an appropriate procedure to reconstruct complicated cicatricial entropion after orbital surgery.

Unilateral papilledema after trabeculectomy in a patient with intracranial hypertension

BACKGROUND: Increased intracranial pressure usually leads to bilateral disc swelling. HISTORY AND SIGNS: A patient presented with recurrent visual disturbances following trabeculectomy in the right eye. Intraocular pressure in the right and left eye were 11 and 24 mmHg, respectively. The optic nerve head was swollen in the right, but not in the left eye. Lumbar puncture showed an opening pressure of 32 cmH (2)O. Magnetic resonance imaging, neurological examination and composition of cerebrospinal fluid were normal. According to the modified Dandy criteria, an idiopathic intracranial hypertension was diagnosed. THERAPY AND OUTCOME: Treatment with acetazolamide led to resolution of papilledema in the right eye within six months. CONCLUSION: The intracranial-intraocular pressure gradient in the right eye was markedly higher as compared to that of the left eye. We suggest that this pressure gradient induced the collapse of axoplasmatic transport at the lamina cribrosa with subsequent disc swelling. As no significant pressure gradient was present in the left eye, the optic disc remained normal. Based on analogous calculations in three additional published cases of unilateral papilledema we thus suggest that intraocular pressure should be taken into account when evaluating patients with papilledema.

Orbitale Fettgewebsatrophie bei lokaler Bimatoprost-Therapie - Kann Bimatoprost einen Enophthalmus verursachen?

PURPOSE: The aim of this communication is to report enophthalmos as a possible new adverse effect of topical bimatoprost treatment. PATIENTS AND METHODS: A retrospective case series of five glaucoma patients under long-term topical bimatoprost treatment was evaluated. Documentation with photo and Hertel exophthalmometry was reviewed. RESULTS: In all five patients a deep lid sulcus, reduced infraocular fat pads and enophthalmos-suspicious Hertel values were found (mean 11.9 mm; SD 2.4). Other aetiologies for enophthalmos were excluded anamnestically and by clinical examination. CONCLUSION: Bimatoprost may lead to an alteration of the eyelid with deepening of the lid sulcus and may also be responsible for an iatrogenic orbital fat atrophy. A possible mechanism of action might be the induction of apoptosis of orbital fibroblasts with a remodelling of the extracellular matrix. Prospective studies are necessary to confirm this cross-sectional observation.