Search

Die Chorioretinitis centralis serosa wird in atiologischen Uberlegungen immer wieder mit einem unspezifischen Distresskonzept in Zusammenhang gebracht. Die depressive Storung stellt hingegen einen klar benennbaren, spezifischen Stressor dar, der nicht zuletzt in der Kardiologie wie Diabetologie als bedeutender, eigenstandiger Risikofaktor bekannt ist. In vorliegendem Fallbericht wird aus psychosomatischer Sicht die klinische Korrelation zwischen einer Chorioretinitis centralis serosa und einer depressiven Storung aufgezeigt, wobei ein lediglich ad hoc naheliegendes sequenziell-reaktives Storungsverstandnis demjenigen einer simultanen Verschrankung gegenubergestellt wird, welches nach unserem Ermessen zu bevorzugen ware.

Background The subjective and objective results during the training phase of phacoemulsification using a 6 mm sclero-corneal tunnel incision at 12 h were evaluated. Patients and methods In a prospective study we evaluated the first 221 cases of phacoemulsification by a cataract surgeon during his training phase. Objective parameters which were analyzed included intraoperative complications, preoperative, early postoperative (p. o.) (1 - 13 days) and late p. o. (to the third month) assessment of refraction, visual acuity and corneal astigmatism. Calculation of the induced astigmatism was performed using the subtraction method and the vector analysis according to Jaffe. For evaluation of subjective results we used a questionnaire in the late p. o. phase. The questionnaire contained questions concerning satisfaction with the explanation of the surgical procedure, the medical personnel, the procedure itself and the result of the operation. Results During surgery, 6 posterior capsular ruptures (2.7 %) and 3 zonular dialyses (1.4 %) occurred. In 6 cases (2.7 %) an anterior vitrectomy was necessary, in two cases (0.9 %) an anterior-chamber lenses had to be implanted. Preoperatively, the average visual acuity was 0.5 +/- 0.14 (n = 221), the early p. o. visual acuity was 0.49 +/- 0.23 (n = 220) and the late p. o. visual acuity was 0.73 +/- 0.31 (n = 121). The average spheric equivalent was early p. o. 0.04 D +/- 1.18 D (n = 208) and late p. o. 0.11 D +/- 1.08 D (n = 118). The difference to the planned refraction was early p. o. 0.68 D +/- 1.13 D, and late p. o. 1.39 D +/- 1.18 D. The mean induced astigmatism early p. o. was 0.55 D +/- 0.97 D (n = 166) and late p. o. 0.37 D +/- 0.87 D (n = 121) (subtraction method). Utilizing vector analysis for calculation of the induced astigmatism we obtained 1.43 D +/- 0.86 D (n = 121) for the early p. o. situation and 1.22D +/- 0.88 D (n = 121) for the late p. o. situation, respectively. 80 % of the patients (n = 119) were satisfied with the results (highest rating), 3 % were unhappy (lowest rating). Conclusion The results of this study reveal that phacoemulsification is a safe and satisfactory procedure for patient, even during the training phase of a cataract surgeon.

BACKGROUND Postoperative hyperopia is a frequent result of cataract surgery in eyes after previous myopic kerato-refractive surgery. One reason for the underestimation of intraocular lens (IOL) power is the wrong corneal refractive power measurement obtained by keratometers and corneal topography systems after LASIK. The aim of this study was to compare the precision of measurements of three different keratometers after LASIK. METHOD We studied 58 eyes of 34 refractive patients aged between 20 and 51 years. The preoperative measurements and the measurements one month after LASIK were performed with the Keratometer (Zeiss), the corneal topograph (EyeSys Technologies) and the IOL-Master (Zeiss). We compared our postoperative measurement results obtained with the three keratometers with the results obtained by using the clinical history method (chm). RESULTS The smallest mean deviation was achieved with the IOL-Master (measured mean +/- SD: 38.94 +/- 1.88 D, vs. chm: 38.35 +/- 2.13 D). The Keratometer (Zeiss) showed a larger deviation (measured: 39.12 +/- 1.76 D, chm 38.34 +/- 2.07 D) and the largest deviation was shown with the corneal topograph (measured: 39.84 +/- 1.85 D, chm: 38.86 +/- 2.10 D), which measured in mean one diopter higher than what was obtained utilizing the chm. A positive correlation between corrected myopia and the postoperative difference between the measured and calculated value for each keratometer was found. CONCLUSION This study demonstrates that with common keratometers central corneal power is measured too high after LASIK. For IOL calculation in patients after LASIK, the wrongly positive deviation from measured central corneal power has to be taken into account.

Hintergrund: Das Pseudoexfoliationssyndrom (PEX) fuhrt zu einer Lockerung des kapsularen Aufhangeapparats. Deshalb besteht bei einer Kataraktoperation ein erhohtes Risiko fur intraoperative Komplikationen wie Kapselruptur und Zonulolyse und postoperativ fur eine Druckerhohung. Postoperativ auftretende Luxationen des Kapselsacks mit der in den Kapselsack implantierten Hinterkammerlinse sind bisher selten beschrieben. Patienten und Methode: Innerhalb eines Jahres wurde bei funf Patienten im Alter von 67, 74, 79, 90 und 92 Jahren mit Pseudoexfoliationssyndrom und Zustand nach Kataraktoperation eine Subluxation des Kapselsacks mit der kapselsackimplantierten Hinterkammerlinse beobachtet. Ergebnisse: Bei drei Patienten war vor 6, bei einem vor 3 Jahren und bei einem vor 11 Jahren eine komplikationslose extrakapsulare Kataraktextraktion mit Implantation einer Hinterkammerlinse durchgefuhrt worden. In vier Fallen war vor dem Auftreten der Subluxation der Nachstar mittels YAG-Kapsulotomie entfernt worden. Keiner der Patienten hatte abgesehen vom Pseudoexfoliationssyndrom einen weiteren Risikofaktor fur eine Schwache der Zonulafasern. Die Dislokationen der Hinterkammerlinsen waren ohne vorhergehendes Trauma aufgetreten, bei einem Patienten war es zu einer sekundaren Druckerhohung bei vorbestehendem Glaukom gekommen. Die subluxierte Hinterkammerlinse wurde in allen funf Fallen mit dem Kapselsack entfernt und durch eine kammerwinkelgestutze Vorderkammerlinse ersetzt. Schlussfolgerung: Moglicherweise besteht fur Patienten mit Pseudoexfoliationssyndrom nicht nur intraoperativ ein erhohtes Risiko fur Komplikationen bei Kataraktoperation, sondern auch fur eine spate spontane Zonulolyse. Diese erst in letzter Zeit beobachtete Spatkomplikation sollte bei der operativen Planung fur diese Patienten mitberucksichtigt werden. Eventuell konnten die Patienten von einer sulkusfixierten Hinterkammerlinse profitieren. Purpose: Pseudoexfoliation syndrome (PEX) is associated with zonular weakness and a higher frequency of intraoperative complications during cataract surgery, including rupture of the posterior lens capsule, zonular dialysis and a rise of intraocular pressure occurring postoperatively. Delayed dislocation of an IOL is a rarely reported phenomenon. Patients: Within one year, late dislocation of the lens capsule with the in the bag fixated IOL was observed following cataract surgery in five patients (67, 74, 79, 90 and 92 years old) with pseudoexfoliation syndrome. Results: All patients had an uneventful in the bag implantation of the IOL 6 (three patients), 3 and 11 years ago, respectively. Postoperatively occurring secondary cataract was treated by a YAG-capsulotomy in four cases. No patient had any other predisposing factors that would lead to zonular weakness besides the pseudoexfoliation syndrome. The dislocation of the IOL and capsule occurred spontaneously. In one patient with preexisting glaucoma, the dislocation was followed by an increase of intraocular pressure. All cases were successfully treated with IOL explantation, anterior vitrectomy and placement of an anterior chamber IOL. Conclusion: Patients with pseudoexfoliation syndrome undergoing cataract surgery may be at risk not only for intraoperative complications but also for delayed spontaneous dislocation of the IOL and capsule. This possible complication should be considered in surgical planning for patients with pseudoexfoliation syndrome. In these patients it may be better to implant the IOL in the ciliary sulcus.

In the past few years, there have been many changes in ophthalmic anaesthesia. Application of drugs in general anaesthesia with excellent controllability enhances patient safety and allows a more efficient OR-management. Regional anaesthesia is gaining widespread use for ophthalmic surgery, especially topical anaesthesia for cataract surgery. Patients for ophthalmic surgery concomitantly often display high age and a high level of co-morbidity and, therefore, belong to the anaesthesiological risk groups ASA III-IV. Life-threatening adverse events including cardiovascular depression are associated with general and regional anaesthesia. Intervention by anaesthesiologists is frequently required for treatment of hypertension or dysrhythmias, and sedation. Thus, monitored anaesthesia care ("standby") is justified. Drugs applied for regional and general anaesthesia may change intraocular pressure. There are a lot of publications about the impact of anaesthesia on intraocular pressure (IOD), however, few on the effects of anaesthesia on pulsatile ocular blood flow. it has to be kept in mind that the effects of anaesthesia on intra-ocular pressure and pulsatile ocular blood flow may diverge. To avoid an increase of the IOD, especially during anaesthesia induction, drugs, such as succinylcholin, rocuronium and opiates, in particular remifentanil, can be applied. In addition, the use of the laryngeal mask may be advantageous compared to general anaesthesia associated with laryngoscopic tracheal intubation. The management of patients treated with anticoagulants and antiplatelet agents, has to be taken on the balance of risks. There are risks not only in continuing therapy, but also in discontinuing it perioperatively. Postoperative nausea and vomiting (PONV) remains a distressing and common problem after strabismus repair in particular in children. The incidence of PONV depends on the type of ophthalmic surgery and drugs applied. To reduce PONV in ophthalmic surgery, application of long-lasting opiates should be avoided, and non-opiate analgesics and, depending on the kind of operation, antiemetic prophylactics are recommended.

BACKGROUND Crohn's disease is a chronic inflammatory bowel disease, leading to ocular manifestations in 4 - 8 % of patients. We report on a patient with Crohn's disease, who developed in association with epidermolysis bullosa acquisita a progressive corneal ulcer. PATIENT A 26-year old patient with a 3-year history of Crohn's disease presented with a peripheral corneal ulcer of the right eye. The anterior chamber was deep and quiet. Fundus examination was normal. Corneal smears displayed no bacterial growth. Visual acuity of the right eye was 20/25. Examination of the left eye was normal. Furthermore, he had developed cutaneous blisters on the arms and legs. Despite treatment with topical antibiotics and systemic immunosuppressive therapy with tacrolimus, azathioprine and methylprednisolone the corneal manifestation deteriorated. Therefore, an amniotic membrane was transplanted for treatment of the corneal ulcer; however, this was followed by melting of the amniotic membrane within a few days. Additional therapeutic procedures including further amniotic membrane transplantations and autologous conjunctival grafts have been performed. This was regularly unsuccessful. The corneal ulcer increased in size and extended into the sclera. Therefore a tectonic sclerokeratoplasty was necessary. Histologic examination of the excised corneoscleral tissue revealed an extensive stromal thinning associated with inflammatory infiltration of the cornea and sclera. CONCLUSIONS Corneal complications in patients with Crohn's disease are very rare in contrast to conjunctivitis, episcleritis und uveitis. To the best of our knowledge, this is the first description of a patient with Crohn's disease and epidermolysis bullosa acquisita developing progressive corneal ulcer. How closely an assumed autoimmune mechanism in the cornea is related to Crohn's disease or epidermolysis bullosa acquisita, is not known.

Background: MALT (mucosa associated lymphoma tissues) reveal specific histological specifications, such as cells like B-lymphocytes with circular structure, B-lymphocytes in the epithelium and a region of larger B-lymphocytes, from the centre to the epithelium. The difference between local and systemic infiltration of tissue is important, and hence MALT must be diagnosed via an interdisciplinary approach. Patient: A 45-year old female patient presented initially to our institution in December 1997. She complained of swelling and redness of her upper eyelid which had developed during the last 9 months. Additionally, her visual acuity in the involved eye had decreased steadily over the last 6 months. Ophthalmological examination revealed a swollen right upper eyelid associated with bilateral salmon-coloured conjunctival lesions of the inferior fornices. Additionally, there was a serous detachment of the neurosensory retina in the peripapillary area of the right eye. Systemic work-up including biopsy of the ocular lesions revealed the presence of a localised B-cell lymphoma of the MALT type. Initial treatment with topical and systemic steroids resulted only in a temporary improvement of signs and symptoms. Another treatment trial with steroids was unsuccessful and radiotherapy was therefore performed. Radiotherapy resulted in a complete remission and no signs of recurrent disease during a follow-up period of 4 years. Conclusions: In patients with isolated MALT lymphomas of the periocular regions radiation may be a successful treatment modality. Side effects as observed in former radiation procedures can be avoided by state-of-the-art treatment modalities. Treatment with steroids may be associated with merely temporary improvement of signs and symptoms. In these patients an interdisciplinary approach utilizing ophthalmology, internal medicine, pathology and radiology is imperative.

Background: The value of ultrasound biomicroscopy in the diagnosis of conjunctival lesions is not well established. Patients and methods: For the examination of conjunctival lesions, we used an ultrasound biomicroscope (Humphrey, Zeiss, Oberkochen) with a high frequency transducer (30MHz). Between January 2000 and August 2001, 28 patients (16 female, 12-male) with conjunctival lesions, aged 9 to 81 years, were available for this study. Results: Histological examination of the excised tissue displayed the presence of a compound naevus (8/28), cysts (6/28), inflammatory processes (3/28), granulomatous processes (2/28), lymphomas (2/28), foreign bodies (2/28), a pterygium (2/28), a malignant melanoma (1/28), a primary acquired melanosis (1/28), and a conjunctival amyloidosis (1/28). Using ultrasound biomicroscopy we were able to demonstrate a cystic tumour in the six patients (21 %) with a cyst of the conjunctiva. In patients suffering from solid tumours of the conjunctiva the definite diagnosis could not be made with ultrasound biomicroscopy alone. The eight patients with compound naevus displayed a somewhat heterogeneous sonographic structure within the tumour. In the patient with a foreign body we were able to demonstrate posterior shadowing of the underlying tissue. Conclusion: For evaluation of conjunctival lesions caused by a cyst or a solid tumour, ultrasound biomicroscopy may be an additional diagnostic tool, e.g. for assessing the margins of the tumour. However, up to now it is not possible to differentiate between different lesions solely by means of ultrasonography.

BACKGROUND: Bird spiders, known in the US as tarantulas, are large hairy spiders that have become increasingly popular as pets in the Western world. We present a patient with a red irritated eye from exposure to the hairs of a spider of the Theraphosidae family, and review the literature. PATIENT AND METHODS: We report on a 28-year old patient who was referred to our clinic with a red irritated eye following playing with a Chilean rose-haired bird spider (known in the US as tarantula). In addition, we reviewed the literature concerning similar cases using the Medline database and cited literature in the retrieved articles. RESULTS: Our patient displayed theraphosidae (tarantula) hairs in the cornea of the right eye and developed a uveitis and a retinochoroiditis with associated vitritis. Treatment with topical corticosteroids resulted in an improvement of signs and symptoms, although the improvement was slow and incomplete. The disease process consists of a granulomatous reaction to the spider hairs. Hairs of Theraphosidae spiders (tarantulas) may cause inflammation at all levels of the eye, from the conjunctiva to retina. We were able to identify 14 cases of Ophthalmia nodosa secondary to the exposure to the tarantula hairs in the literature. Therapy includes removal of the offending hairs when possible and topical treatment with steroids. CONCLUSION: Although the large hairy bird spiders (tarantulas) are considered harmless pets, ophthalmia nodosa is a potential danger when handling them. Ophthalmia nodosa has an unknown prognosis and may be difficult to manage. Language: de

Background: The value of ultrasound biomicroscopy in the diagnosis of eyelid lesions is not well known. Methods: For the examination of eyelid lesions, we used an ultrasound biomicroscope (Humphrey, Zeiss, Oberkochen) with high-frequency transducers (30 and 50 MHz). Between November 1998 and December 1999, 30 patients with eyelid lesions, range 8 to 86 years, were available for this study. Results: Histological examination of the excised tissue displayed the presence of chalazion (9/30), basal cell carcinoma (7/30), seborrhoic keratosis (4/30), a granulomatous process (4/30), cysts (2/30), an epidermoid cyst (1/30), a nevus (1/30), a pilomatrixoma (1/30), and a comedo (1/30), With ultrasound biomicroscopy we were able to demonstrate a cyst or a cystic tumour in six patients (20%); i.e. two patients with a cyst of the eyelid, two patients with chalazion, one patient with a granulomatous process and one patient with an epidermoid cyst. In the patients with solid tumours of the eyelid, final diagnosis with ultrasound biomicroscopy only is not possible. Conclusion: For evaluation of cystic or solid eyelid lesions, ultrasound biomicroscopy may be an additional diagnostic tool, e.g. for assessment of the margins of the tumour. However, up to now it is not possible to differentiate tumours if only ultrasound biomicroscopic findings are available.

Background Postoperative endophthalmitis can be subdivided into acute and chronic forms which are typically caused by different organisms. Enterococcus faecalis is an organism which normally causes an acute form of endophthalmitis. Patients and methods We report on four cases of different forms of endophthalmitis following cataract extraction and intraocular lens (IOL) implantation who had been referred to our institution between 1998 and 2001. Enterococcus faecalis was the causative organism in all of them. Results Two patients presented with an acute form and were immediately treated in our hospital after symptom onset utilizing pars plana vitrectomy with and without IOL explantation. The two other patients were initially treated with subconjunctival and/or systemic antibiotics and steroids over a period of about two months before referral to our hospital. After initial improvement the inflammation exacerbated in these two patients and vitrectomy with or without IOL and capsular bag explantation was performed. The explanted IOL and capsular bag of one patient were examined using scanning electron microscopy and it was shown that the enterococci were adherent to the IOL and the capsular bag. Conclusion Enterococcus faecalis can be the causative organism both of an acute and of a recurrent form of postoperative endophthalmitis. The recurrent form may be caused by organisms which tend to adhere to the IOL and the capsular bag. This should be kept in mind when considering different treatment options.

Background Necrobiotic xanthogranuloma is a rare disorder which predominantly affects the periorbital region and is frequently associated with paraproteinemia and lymphoproliferative diseases. Patient and methods A 49-year old woman presented with bilateral, yellowish, subcutaneous lesions involving all four eyelids. These lesions have developed over the last year. Additionally, similar skin lesions developed on the trunk and the lower extremities. Two years ago, the patient had a bilateral episcleritis. An incisional biopsy was taken form the lesion. In addition, we reviewed the literature concerning similar cases. Results Histologic examination revealed a granulomatous process consisting of histiocytes, foamy cells, multinucleated giant cells (touton- and foreign body-type) and associated with necrobiotic collagen and cholesterol clefts. General examination revealed the presence of a paraproteinemia of the IgG-typ associated with a hyperlipidemia. The patient was treated with a low dose chemotherapy which resulted in improvement of signs and symptoms. We could identify in the literature 75 similar cases. The mean age of those patients was 53 years. Conclusion The clinical and histologic findings in our patient were typical for a necrobiotic xanthogranuloma with associated paraproteinemia. The most favorable treatment response has been reported with low doses of systemic administered chemotherapeutic agents in combination with radiation therapy; however, the mortality due to underlying diseases is high.

Central serous chorioretinitis serosa is repeatedly brought into aetiological considerations with a rather unspecific concept of distress. Depressive disorder represents a specific stressor, which is known in cardiology or diabetology as a significant risk factor. In the present case report, the clinical correlation between a central serous chorioretinitis and a depressive disorder is shown from a psychosomatic point of view, comparing a sequentially-reactive understanding of the disorder complex with a preferable model of simultaneous entanglement.

Background: Evulsion of the optic nerve is a rare form of traumatic optic neuropathy. It is a rupture of the optic nerve at the disc without damage of its sheaths occurring in association with a blunt skull trauma or a blunt bulbar trauma. Material and Methods: We searched the literature using Medline database for all articles with evulsion of the optic nerve. The bibliographies of the papers found therein were used to get a complete review. The data were analyzed with special regard to age, sex, mechanism of injury, and (if available) defects of visual field. Results: Sixty-three patients with a mean age of 22 years (range 4 to 60 years) were included in the study. In 22 patients (35%) a partial and in 41 patients (65%) a complete evulsion was present. In 31 patients (49%) the cause was a small blunt object or finger that stroke the eye or entered the orbita. In 19 patients (30%) a severe blunt skull trauma had occurred. The analysis of visual fields in eyes with partial evulsion of the optic nerve revealed a defect in the superior visual field in 6 of 12 patients and a defect in the inferonasal visual field in 3 of 12 patients. Pathogenesis: Our review suggests that the most common mechanism of injury is a severe rotation of the eye leading to rupture, of the optic nerve fibers and an anterior displacement of the bulbus, possibly with deformation of the posterior eye walls.

Background Brachytherapy is a well established procedure for treatment of malignant choroidal processes. Approximately 5 % of the cases, will show local recurrences within 6 years. We report a patient who has developed a malignant transformation of an uveal nevus following brachytherapy of a non-contiguous uveal melanoma. In addition, we reviewed the literature concerning similar cases. History and signs In 1991 a Ruthenium application was performed on a 65-year old patient suffering of an equatorial malignant choroidal melanoma. At that time, a nevus at the posterior pole was present. From 1997 to 1998 the nevus continuously increased in size. Visual acuity decreased and a retinal detachment developed. Combining the clinical and the sonographic findings, the diagnosis of a malignant melanoma arising of a nevus was established. Enucleation was performed in 1998. Therapy and outcome Histologic examination revealed the diagnosis of an epithelioid-cell-type malignant uveal melanoma arising in a nevus. Till now, the patient is free of metastatic disease. Conclusion Non-contiguous development of uveal melanomas in the same eye are extremely rare. We could identify in the literature 5 cases of non-contiguous melanomas following brachytherapy of an uveal melanoma. In none of these cases, the secondary melanoma has arisen in a nevus. Follow-up examination of patients with uveal melanoma treated with brachytherapy should include not only examination of the treated area, but also the whole fundus of the eye in order to recognize secondary tumours as early as possible.

Background: The aim of this study was to assess clinical and histologic features of primary basal cell carcinomas of the periocular region and to calculate the rate of recurrence of these tumors after surgical excision without intraoperative frozen section control. Methods: All primary basal cell carcinomas of the periocular region which were treated by surgical excision at the University Eye Hospital and Clinic of Ulm between 1993 and 1998 were reviewed and special attention was paid to age and sex of the patient and localization and histology of the tumor. The recurrence rates were calculated depending on whether the margins were free or involved on histologic examination of the excised specimens. Results: We could include 137 patients with 141 tumors into this study. In 92 patients with 95 tumors, follow-up data of at least 3 months was available with a mean follow-up period of 31.3 months. The mean age of the patients was 68.9 years, range 28.7-91.3 years. The tumor was located at the lower eyelid, medial canthus, upper eyelid and lateral canthus in 63.1%, 29.8%, 5.7% and 1.4%, respectively. The solid (53.9%) and the solid-cystic (17.7%) type were the most common encountered histology followed by the mixed type with sclerosing foci (12.1 %) and the morphea or sclerosing type (10.6%). A free margin on histologic examination was achieved in only 47.6% of cases. The overall recurrence rate was 9.5% [definite recurrences: 6 cases (6.3%); questionable recurrences: 3 cases (3.2%)]. With histologically complete excision the recurrence rate was only 2.3% (1 case) and in the case of an incomplete excision definite recurrent tumors were observed in 11.8% (6 cases) and questionable recurrences in 3.9% (2 cases) of cases during the follow-up period. Conclusions: Surgical excision of basal cell carcinomas of the periocular region without utilizing intraoperative frozen section control or Mohs' micrographic surgery is associated with a high rate of positive tumor margin on histologic examination. However, our study showed that this is only infrequently followed by local recurrences. This result may raise the question whether simple surgical excision is still an option in the case that more cumbersome methods such as Mohs' micrographic surgery or intraoperative frozen section control are not available. However, with positive tumor margin on histologic examination of the excised tissue or with the presence of a sclerosing type regular follow-up is mandatory.

Background: Alport's syndrome is a hereditary disease with renal, cochlear, and ocular involvement. We report a patient with Alport's syndrome who exhibited morphologic macular changes similar to cone dystrophy. History and signs: A 46-year old man was evaluated for peculiar macular changes, which have caused a significant decrease in visual acuity over the last years. His general history was remarkable for the presence of sensorineural hearing impairment since infancy as well as end stage renal failure followed by renal transplantation. The ophthalmological findings in this patient included circumscribed macular lesions consisting of atrophy of the retinal pigment epithelium and bilateral anterior lenticonus. Conclusion: Alport's syndrome is a characteristic prototype of a genetic basement membrane disease with ocular, renal, and cochlear involvement. Common ocular findings are the dot-and-fleck retinopathy and the anterior lenticonus. In contrary to the anterior lenticonus retinal changes are rarely associated with visual impairment. An association with a macular lesion similar to the cone dystrophy has only infrequently been reported.

BACKGROUND It is well known that topical as well as systemic treatment with corticosteroids may have ocular side effects. The most common are the development of cataract and increase of intraocular pressure, however, alteration of the retinal pigment epithelium may also occur. PATIENT A 64-year old male experienced a progressive decrease of visual acuity over a time period of 6 weeks. Ophthalmologic examination revealed a severe diffuse retinal pigment epitheliopathy with serous detachment of the neurosensory retina. This patient was treated with systemic methylprednisolone for chronic glomerulonephritis. After cessation of the treatment with systemic corticosteroids visual acuity improved and the serous retinal detachment resolved. CONCLUSION Ophthalmologic examination including biomicroscopy of the retina is recommended on a regular basis for patients treated with systemic corticosteroids. With development of pigment epithelial changes steroids should be reduced or discontinued if possible.

Background The Markel cell carcinoma is a rare malignant skin tumor. The tumor was first described in 1972 by Toker and he named it trabecular carcinoma. We had the opportunity to treat two patients with a Merkel cell carcinoma of the upper and lower eyelid and reviewed the literature using the "Medline" database concerning Merkel cell carcinomas of the ocular adnexa. History and signs A 76-year-old female patient was referred to our hospital because of an inflammatory tumor of the left upper eyelid present for two months. A 91-year-old male patient noticed for four weeks a painless itching lesion at the left lower eyelid. The remaining ophthalmologic examination in these patients was unremarkable. Therapy and outcome Both tumors were excised. Histological and immunohistochemical examination verified a Merkel cell carcinoma in both cases. The 76-year-old female patient exhibited no recurrent tumor after a follow-up of 18 months. The 91-year-old male patient had a recurrent tumor inferior to the temporal lower eyelid 7 months after tumor excision, however, lymph node metastasis is not present as of yet. The patient underwent radiation therapy with cobalt of the left orbit with a total dose of 60 Gy. Conclusion Merkel cell carcinomas can occur everywhere on the skin; the eyelids are affected in 10% of all cases. Best histochemical markers are cytokeratin 20 and neurospecific enolase. A review of the literature revealed 31 patients with Merkel cell carcinomas involving the eyelids. Female patients were more often affected than male patients. The upper eyelid was more frequently involved than the lower eyelid. Recurrent disease is frequent.

BACKGROUND Cataract patients often display concomitant ocular and systemic diseases which may influence the decision between general and regional anesthesia. The aim of this study was to quantify co-morbidity of these patients and assess the influence of the two types of anesthesia an the anesthesiological risk on the frequency of intra- and post-operative complications and visual outcome. METHODS In this prospective study, in patients scheduled for cataract extraction at the University Eye Hospital and Clinic of Ulm (tertiary eye care center) all systemic and ocular diseases as well as intra- and postoperative complications were analyzed. The prevalence of the co-morbidity in our patients was compared to other studies including age-matched controls. The anesthesiological risk was quantified using the classification scheme of the American Society of Anesthesiologists (ASA). RESULTS Eighty-eight patients with a mean age of 70.4 +/- 11.7 years were analyzed. Sixty-one% of patients displayed systemic as well as ocular co-morbidity. Only systemic or ocular comorbidity was present in 32% and 5% of patients, respectively. Two% of patients exhibited neither ocular nor systemic comorbidity. In 61% of patients the surgery was performed in regional anesthesia and in 39% in general anesthesia. The prevalence of systemic and ocular co-morbidity as found in our study was significantly higher as compared to that in the general population of the same age. Visual improvement and the frequency of intra- and postoperative complications were independent on type of anesthesia and anesthesiological risk. CONCLUSIONS Patients who were scheduled at our institution for cataract surgery exhibited a high frequency of ocular as well as systemic co-morbidity. This can be interpreted in such a way that patients with a high level of co-morbidity are referred to tertiary eye care centers for cataract surgery.

BACKGROUND For more than a century it has been recognized that bacteria may infect the eye by way of the blood stream. Until fifty years ago, eyes so afflicted nearly always were blinded and a majority of the victims died from overwhelming sepsis. Although effective antibiotics are available today the prognosis is still guarded. CASE REPORT A 39-year-old physician died 6 years after he was diagnosed for idiopathic aplastic anemia. He had developed pseudomonas aeruginosa bacteremia and later a therapy refractive pneumonia caused by aspergillus which had led to respiratory failure. The patient had experienced a marked loss of visual acuity in his left eye ten days before he died. Ophthalmic examination at that point displayed signs of endophthalmitis, hyphaema, and heterochromic irises. The eyes were obtained postmortem and histologic examination of the left eye displayed numerous bacilli forming cuffs around blood vessels and a sheet between the necrotic retinal pigment epithelium and Bruch's membrane. No inflammatory response to the bacilli was present. The bacilli could be demonstrated with a Giemsa stain and could also be identified with electron microscopic examination. DISCUSSION The histologic results in our patient displayed numerous bacilli without inflammatory reaction which was a result of the aplastic state. Therefore, this disease was classified as "ocular bacteriosis". The blood-ocular barrier undergoes direct assault with intraocular inflammation and the impermeability to blood-borne antibiotics is lost. However, with the lack of an inflammatory reaction the permeability to antibiotics may be too low and the achieved concentration insufficient.

Ocular manifestations can be the presenting symptom of hematological diseases. Ocular changes can be found in up to 90% of the patients depending on the underlying disease. Most patients with ocular manifestations however are asymptomatic. Hematological disorders can manifest in all structures and adnexa of the eye. The most common manifestations are conjunctival pallor and hemorrhages, intraretinal hemorrhages and cotton wool spots. Retinal infiltrates, manifestations in the lids, anterior segment, optic nerve, orbit and adnexa are rare. Different ocular manifestations in anemia, leukemia, malignant Non-Hodgkin lymphoma, Hodgkin's disease, chronic myeloproliferative diseases, plasmocytoma, myelodysplastic syndromes, coagulopathies, and reticulo-histiocytic diseases are described. Not only the underlying disease but also chemotherapy, bone marrow transplantation can lead to ocular complications.

Background Age-related macular degeneration (AMD) is the leading cause of blindness in industrialized countries. In this study, we used optical coherence tomography for evaluation of patients with AMD. Methods Optical coherence tomography imaging is analogous to ultrasound, except that reflected light instead of sound is used. The analysis of the reflected light is processed with the technique of low-coherence interferometry. In this study, 33 patients with different stages of AMD were examined with optical coherence tomography. The classification of AMD was according to the guidelines as proposed by the "International ARM Epidemiological Study group". Results With this method we were able to identify drusen, alteration of the retinal pigment epithelium, and secondary retinal changes. Other structures such as basal laminar (linear) deposits could not be identified with this method. Choroidal neovascularization was evident in the tomogram. Classic choroidal neovascular membranes presented with well-defined boundaries on optical coherence tomography and occult choroidal neovascular membranes had a less delineable structure with optical coherence tomography. Conclusion Optical coherence tomography cannot replace conventional diagnostic techniques. This method provides no additional information in patients with non-exsudative AMD. In patients with choroidal neovascular membranes secondary to AMD optical coherence tomography may be able to characterize the relation of the membrane to the retinal pigment epithelium and imaging may be possible through hemorrhage. The interpretation of the optical coherence tomogram needs further studies including clinicopathologic correlation.

Purpose This study was undertaken in order to histologically characterize surgically-excised choroidal neovascular membranes and to correlate theses histologic findings with the fundus and fluorescein angiographic appearance. Material and methods Surgically-excised subfoveal choroidal neovascular membranes submitted in the time period from November 1994 to July 1996 were included in this study. The membranes were processed and evaluated by light and transmission electron microscopy. Some membranes were oriented by the surgeon and marked on their inner surface with India ink and the configurations of these membranes were recorded and correlated with the fundus and fluorescein angiographic features. Results Sixty-two choroidal neovascular membranes were available for this study. In 74% age-related macular degeneration was the underlying disease. Retinal pigment epithelium and endothelial lined vascular channels were present in over 87.5% of cases. Basal laminar (linear) deposit was only present in membranes excised from patients with age-related macular degeneration. In six cases with Gass Type II choroidal neovascular membranes the histologic-clinical-fluorescein angiographic correlation showed well-defined (classic) neovascular membranes according to the criteria of the Macular Photocoagulation Study. Two membranes were not surrounded by retinal pigment epithelium and were classified as Type IIa membranes. Four membranes were surrounded by retinal pigment epithelium and classified as Type IIb membranes. Conclusions Choroidal neovascular membranes represent a stereotypic, non-specific wound repair response to a specific stimulus. Retinal pigment epithelium may proliferate around and attempt to wall off choroidal neovascular membranes. We propose a new classification of surgically-excised choroidal neovascular membranes as Types I, IIa, and IIb.

Retinal vascular occlusions are the second most common retinal vascular diseases following diabetic retinopathy. Central retinal artery occlusion and branch retinal artery occlusion are most often caused by emboli. The mean age of patients with retinal artery occlusion and branch retinal artery occlusion is 62 and 58 years, respectively. The most common risk factors are arterial hypertension (65%), diabetes mellitus (25%), valvular diseases of the heart (25%), and carotid artery stenosis or plaques (45%). Rare causes are arteritis and vascular spasm. The pathogenesis of retinal branch vein occlusion and central retinal vein occlusion remains speculative. Two different mechanisms have been postulated, i.e. thrombosis in the vein due to a compression by atherosclerotic changes in the adjacent artery and a local alteration of the blood flow due to unfavourable physiologic factors. Retinal vein occlusion manifests at a mean age of 65 years. The most common risk factors are arterial hypertension in 34-75% and primary open angle glaucoma in 2.1-82%. In 5.6% of the patients with retinal branch vein occlusion retinal vasculitis is present.

Background Pseudoexfoliation syndrome (PEX) is associated with an increased risk for the development of capsular fibrosis including capsular phimosis. A complete occlusion of the anterior capsular opening is, so far, a rarely reported phenomenon. Patient Here we report the case of a 75-year-old female patient who suffered from a secondary open-angle glaucoma caused by PEX. Three months after an uneventful cataract surgery with capsulorhexis, phakoemulsification and implantation of a posterior chamber lens (PMMA) the anterior capsular opening of her left eye was completely occluded. Results The patient reported a slow loss of vision (20/40 immediately after cataract surgery to 20/200 at the follow-up visit three months later). The examination revealed a complete closure of the capsulorhexis with thick, central fibrous material. The diameter of the capsulorhexis was extensively diminished. Reopening of the anterior capsular opening utilizing a YAG laser was achieved and visual acuity increased to 20/40. Additionally, the fibrotic, secondary cataract of the posterior capsule was removed, again with a YAG laser, five weeks after the first intervention and, now with a free optical axis, the patient's visual acuity increased further to 20/30. Conclusion The excessive production of fibrosis and the tendency towards a shrinkage of the diameter of the capsulorhexis postoperatively in patients with PEX may lead to a complete occlusion of the capsulorhexis. Even in such extreme cases, the reopening of the anterior and posterior capsule by a YAG laser is possible and, as demonstrated here, leads to a morphologically and functionally satisfying result.

Background Over 98% of all meningiomas originate in the central nervous system including the optic fascicle. Spread outside this area occurs in 20% of cases. Ectopic (extradural) meningiomas that do not originate from either the optic fascicle or the intracranial meninges are exceedingly rare. We treated a patient with an ectopic meningioma of the orbit and reviewed the literature concerning ectopic orbital meningiomas. History and signs A 30-year-old man presented with a painless tumor in the left medial canthal area. This tumor had developed over a period of two years. The patient complained of intermittent epiphora. Ophthalmologic examination revealed a slight lateral displacement of the left eye. There was a palpable medial orbital mass with an otherwise normal ophthalmological examination. Computed tomography and magnetic resonance imaging showed a homogeneous, well-marginated soft tissue mass. Therapy and outcome The lesion which had neither a contact to the dura of the anterior cranial fossa nor to the optic fascicle was excised and histologic examination showed a fibroblastic meningioma. There was no recurrent tumor after a follow-up of 18 months. Conclusion Less than 50 ectopic (extradural) meningiomas of the orbit have been described in the literature. The most common histologic type is the meningotheliomatous (syncytial or transitional) meningioma. The mean age at diagnosis of these tumors is 31 years. After complete resection the prognosis is good.

BACKGROUND: Deferoxamine, an iron chelating agent, has been used for the treatment of hemochromatosis for more than 30 years. Ocular toxicity has begun to be reported only in the last few years. In most cases differentiation of the true etiology, i.e. the underlying disease versus the toxicity of the substance, is not clear. We report a patient with development of severe ocular toxicity during treatment with deferoxamine for transfusional hemochromatosis. HISTORY AND SIGNS: An 8-year-old boy was routinely evaluated in the eye clinic before initiation of treatment with deferoxamine. Over the last three years the boy had developed a transfusional hemochromatosis after multiple blood transfusions for his aplastic anemia. Ophthalmologic examination displayed normal anterior segments with the exception of a unilateral small opacification of the posterior lens cortex, bilateral tortuous vessels, and mottling of the retinal pigment epithelium. After four months the patient developed a decrease in visual acuity, distortion of color vision, visual field defects, alteration of electrophysiological parameters, and severe changes of the retinal pigment epithelium. THERAPY AND OUTCOME: The deferoxamine was discontinued. Over a period of 3 months the patient displayed a normalization of visual acuity and visual fields. The changes of the retinal pigment epithelium and electrophysiological parameters showed further deterioration and did not return to normal. The patient subsequently was restarted on an adequate treatment dose of deferoxamine and maintained an essentially uneventful course with close ophthalmologic followup. CONCLUSION: Deferoxamine can cause severe ocular toxicity with incomplete recovery. Measurement of dark adaptation was especially valuable for follow-up examination.

Background Compared to lens luxations into the vitreous body, luxations into the anterior chamber are rare. We report on two patients in whom a lens luxation into the vitreous body was followed by a luxation into the anterior chamber. Case report In a 61-year old male patient and a 47-year old female patient a lens luxation into the vitreous body occurred after a blunt ocular trauma and as a result of Marfan syndrome, respectively. During follow-up the patients presented with a spontaneous lens luxation into the anterior chamber. In both cases a YAG iridotomy and a surgical lens extraction were immediately performed. Conclusion As a result of whiplash-like movements of the vitreous body, a dislocation of a lens luxated into the vitreous body, into the retroiridal or intrapupillary space may occur. This may be facilitated by focally undamaged zonular fibers. The immediately retroiridal lens position may cause a pupillary block with fluid misdirection into the space behind the iris-lens diaphragm resulting in a consecutive pressure increase in this space. This pressure rise causes an anterior movement of the lens and may be followed by a complete dislocation into the anterior chamber especially in the case of coexisting traumatic mydriasis. As a result of this lens dislocation into the anterior chamber an inverse pupillary block develops. This situation necessitates an iridotomy prior to the surgical lens extraction.

Background After bone marrow transplantation various ocular diseases have been described. Ocular involvement is very common in patients with chronic Graft-versus-Host Disease (GvHD). These patients show clinical and histological evidence of a dry-eye condition in 60-100 per cent. A severe complication is the development of a corneal ulcer with possible corneal perforation. Two patients with a severe dry-eye condition and development of corneal stroma ulceration are described. The corneal ulcers healed after treatment with collagen-shield. History and signs In a 13-year-old boy an allogeneic bone marrow transplantation was performed in April 1989 because of Fanconi's anemia. In November 1989 a severe dry-eye condition occurred due to GvHD with skin, liver, and gastrointestinal tract manifestation. In April 1991 he presented with corneal stroma ulceration of the right eye. In a 24-year-old patient an allogeneic bone marrow transplantation was performed because of chronic myeloid leukemia in August 1989. In December 1989 he developed dry-eye condition due to GvHD with skin, mucosa and liver involvement. In December 1991 a corneal ulcer of the left eye occurred. Therapy and outcome Repeated conjunctival and corneal smears were negative. Local antibiotic and antiviral treatment showed no effect. Corneal ulcers deteriorated progressively with corneal thinning. Both patients were therefore treated with daily collagen-shields and hourly polyvinyl-pyrrolidon eye-drops resulting in healing of the corneal ulcer within 3 and 2 weeks respectively. Conclusion Treatment of corneal stromal ulceration in dry eye condition caused by chronic GvHD is difficult. In noninfectious ulcers daily application of collagen-shields and hourly artificial tears may prevent severe ocular complications like corneal perforation.

Background A 73-year old man presented with a bilateral reduction of visual acuity which had slowly occurred over the last 20 years. Ophthalmologic examination revealed the presence of stromal opacifications which were denser in the central cornea associated with cataractous changes. His general history was remarkable for a status post polio infection in the early childhood and a medically treated arterial hypertension. We performed a triple procedure and histologic examination of the corneal button revealed the presence of a lipid keratopathy. Conclusion Lipid keratopathy is mostly caused by corneal vascularization or chronic inflammation or is a consequence of systemic disorders of lipid metabolisms. Our patient did not exhibit these underlying disorders and therefore we made the diagnosis of a primary lipid keratopathy. The underlying corneal pathomechanisms are incompletely understood but they should be limited to the corneal keratocytes.

Background Ferry et al. (8) showed that 35 % of eyes which have been enucleated because of a clinically suspected malignant iris lesion did not reveal a histologically malignant iris tumor. Patient A 43-year old male presented with a blind, painful left eye, which has developed over a time period of 6 months. Ophthalmologic examination revealed the presence of pigmented iris stromal lesions associated with diffuse pigmentation of the chamber angle and the development of absolute glaucoma. A diffuse iridociliary malignant melanoma (ring melanoma) was suspected and the blind painful eye was enucleated. Histologic examination revealed the presence of a benign melanocytic lesion, i.e. a spindle cell nevus of the iris with surface plaques causing diffuse extension of the chamber angle, trabecular meshwork, Schlemm's canal, and the ciliary body. Conclusion The malignant potential of iris lesions may be difficult to assess on clinical grounds only. Histologically, benign melanocytic proliferation may cause diffuse extension into the ciliary body as well as the chamber angle leading to an increase in intraocular pressure. In order to reach a final diagnosis a biopsy of the lesion is necessary.

Patient A 44-year-old woman has a history of multiple sclerosis since 20 years. Besides recurrent numbness she had many instances of optic nerve neuritis which has led to a pronounced optic atrophy on her left eye. Additionally, she has developed recurrent iridocyclitis on her right eye. This was the reason why she was referred to our outpatient department for evaluation. Ophthalmic examination revealed an iridocyclitis associated with a multifocal retinal periphlebitis and severe cystoid macular edema in her right eye. Conclusion Patients with multiple sclerosis develop in approximately 30% of cases retinal periphlebitis which may rarely be associated with anterior uveitis or cystoid macular edema as observed in our patient.

Patient A 62-year-old woman was evaluated for a bilateral subconjunctival mass that had been present for 6 months. With magnetic resonance imaging the lesion could not be delineated form the lacrimal glands. A biopsy was performed and histologic examination exhibited a xanthogranulomatous lesion with multiple giant-cells of the Touton type. The differential diagnosis of the adult xanthogranuloma is Erdheim-Chester disease, necrobiotic granuloma, xanthoma, Langerhans histiocytosis, and Rosai-Dorfman syndrome. Conclusion Hyperlipemia should be excluded, in addition, in the presence of necrobiosis, paraproteinemia.

Foldable intraocular lenses (IOLs) are established in ophthalmic surgery and increasingly more complex geometries are available. This study investigates different designs of the optics of the IOL as well as the imaging quality of these optics utilizing electron microscopic photographs and mathematical approximations.Included in this study were two different lens powers of common IOLs (+ 13 D and + 26 D). All studied IOLs were processed depending upon their water content: Aqueous IOLs with up to 25 % water content were fixed with 2.5 % glutaraldehyde in 0.1 M phosphate buffer (mPP), and then contrasted with 2 % OsO (4) and processed in an alcohol series of 30 - 100 % propanol. Subsequently, the IOLs were transferred into EPON (epoxy resin) and polymerization took place at 60 degrees C. After hardening, the samples were cut out with a leaves saw and divided into halves. Afterwards these were polished with glass and diamond knifes at the ultramicrotom (Ultracut, Rückert-Jung). After coal vaporization measurement took place in the scanning electron microscope (DSM 962, Zeiss). In the case of dry stored IOLs, the samples were sputtered with Au-Pd 20 nm and afterwards measurement was performed as described above. The measurement of the optical imaging quality was performed with correctly and inversely oriented IOLs according to the standard EN ISO 11979 -- 2 by means of a measuring system which works on the basis of the point spread function (PSF) and/or the modulation transfer function (MTF). From this the Strehl ratio was computed in each case.Utilizing a correlation of the electron microscopic investigation of the optics of different IOLs with their imaging quality (Strehl ratio), we were able to show that the optical design of the IOL has substantial influence on the imaging quality of an intraocular lens. In particular, with non-symmetrical designs of the optics (e. g., AR40 e; AMO) the orientation of an IOL in the eye is crucial; i. e., the Strehl ratio increased thereby from 0.68 to 0.87.The design of asymmetrical optics is crucial and much attention should be paid to the fact that the imaging quality can substantially be affected. A correct orientation of the lens within the eye is very important with these asymmetrical optics.

Today, for the preparation of donor and recipient cornea during keratoplasty either single-use or reusable metal trephines are commonly used although excimer and femtosecond laser systems are available. Due to the surgical techniques as well as the configuration of metal trephine's cutting edge irregular corneal surfaces may be induced. These will result in a postoperative astigmatism. Contemporary manufacturing processes do allow for the production of minimal cutting edge diameters (400 nm -- 1 microm), however, this is related with a reduced mechanical stability of such delicate cutting edges. It has been observed that the cutting edge of metal blades is immediately bent with the first exposure to tissue. As a result, the cutting forces are increasing and the wound configuration is negatively effected. Due to the complex geometry of trephine cutting edges, no diamond trephines are currently available. We are investigating the cutting performance of conventional trephines that were modified using nanotechnology.Different metal trephines were characterised using a scanning electron microscope (SEM). The diameter of the cutting edge was measured. Pig cornea were studied histologically after trepanation. Selected trephines were ion-forged in a modified PVD (physical vapour deposition) reactor using highly accelerated ions which are concentrated by magnetic fields at low temperature. The consecutive processing steps were controlled by SEM analysis of the cutting edge diameters. Randomly chosen areas of treated trephines were analysed. After processing the trephines, pig cornea were cut and analysed by histological and SEM examination. Additionally, the relevant mechanical cutting parameters of untreated as well as treated trephines were measured when penetrating into a PU (polyurethane) foil.Preliminary microscopic analysis already reveals differences in the quality of the cutting edges. The nanotechnological modification of the cutting edges does not result in larger diameters. Compared with the initial cutting edges, the optical analysis of the modified trephine cutting edges reveals subjectively smoother surfaces. The force measurements prove a reduction of cutting forces for the treated trephines compared to the untreated ones. The SEM analysis show for the cornea treated with the modified trephines a subjectively smoother surface. Histology reveals that the surfaces of the treated cornea do not exhibit a smooth and unidirectional structure. This divergence became larger when untreated trephines were used. The mechanical characterisation of the treated trephines resulted in harder and longer-lasting surfaces.The newly developed ion-forging of trephines in combination with nanostructured carbon coatings yield complex cutting edges of higher stability with diamond-like properties. This study shows that the performance of laser trepanation cannot be reached; however, the use of nanotechnology can further improve manual trephine techniques.

The subjective and objective results during the training phase of phacoemulsification using a 6 mm sclero-corneal tunnel incision at 12 h were evaluated.In a prospective study we evaluated the first 221 cases of phacoemulsification by a cataract surgeon during his training phase. Objective parameters which were analyzed included intraoperative complications, preoperative, early postoperative (p. o.) (1 - 13 days) and late p. o. (to the third month) assessment of refraction, visual acuity and corneal astigmatism. Calculation of the induced astigmatism was performed using the subtraction method and the vector analysis according to Jaffé. For evaluation of subjective results we used a questionnaire in the late p. o. phase. The questionnaire contained questions concerning satisfaction with the explanation of the surgical procedure, the medical personnel, the procedure itself and the result of the operation.During surgery, 6 posterior capsular ruptures (2.7 %) and 3 zonular dialyses (1.4 %) occurred. In 6 cases (2.7 %) an anterior vitrectomy was necessary, in two cases (0.9 %) an anterior-chamber lenses had to be implanted. Preoperatively, the average visual acuity was 0.5 +/- 0.14 (n = 221), the early p. o. visual acuity was 0.49 +/- 0.23 (n = 220) and the late p. o. visual acuity was 0.73 +/- 0.31 (n = 121). The average spheric equivalent was early p. o. 0.04 D +/- 1.18 D (n = 208) and late p. o. 0.11 D +/- 1.08 D (n = 118). The difference to the planned refraction was early p. o. 0.68 D +/- 1.13 D, and late p. o. 1.39 D +/- 1.18 D. The mean induced astigmatism early p. o. was 0.55 D +/- 0.97 D (n = 166) and late p. o. 0.37 D +/- 0.87 D (n = 121) (subtraction method). Utilizing vector analysis for calculation of the induced astigmatism we obtained 1.43 D +/- 0.86 D (n = 121) for the early p. o. situation and 1.22D +/- 0.88 D (n = 121) for the late p. o. situation, respectively. 80 % of the patients (n = 119) were satisfied with the results (highest rating), 3 % were unhappy (lowest rating).The results of this study reveal that phacoemulsification is a safe and satisfactory procedure for patient, even during the training phase of a cataract surgeon.

Postoperative hyperopia is a frequent result of cataract surgery in eyes after previous myopic kerato-refractive surgery. One reason for the underestimation of intraocular lens (IOL) power is the wrong corneal refractive power measurement obtained by keratometers and corneal topography systems after LASIK. The aim of this study was to compare the precision of measurements of three different keratometers after LASIK.We studied 58 eyes of 34 refractive patients aged between 20 and 51 years. The preoperative measurements and the measurements one month after LASIK were performed with the Keratometer (Zeiss), the corneal topograph (EyeSys Technologies) and the IOL-Master (Zeiss). We compared our postoperative measurement results obtained with the three keratometers with the results obtained by using the clinical history method (chm).The smallest mean deviation was achieved with the IOL-Master (measured mean +/- SD: 38.94 +/- 1.88 D, vs. chm: 38.35 +/- 2.13 D). The Keratometer (Zeiss) showed a larger deviation (measured: 39.12 +/- 1.76 D, chm 38.34 +/- 2.07 D) and the largest deviation was shown with the corneal topograph (measured: 39.84 +/- 1.85 D, chm: 38.86 +/- 2.10 D), which measured in mean one diopter higher than what was obtained utilizing the chm. A positive correlation between corrected myopia and the postoperative difference between the measured and calculated value for each keratometer was found.This study demonstrates that with common keratometers central corneal power is measured too high after LASIK. For IOL calculation in patients after LASIK, the wrongly positive deviation from measured central corneal power has to be taken into account.

Pseudoexfoliation syndrome (PEX) is associated with an increased risk for the development of capsular fibrosis including capsular phimosis. A complete occlusion of the anterior capsular opening is, so far, a rarely reported phenomenon.Here we report the case of a 75-year-old female patient who suffered from a secondary open-angle glaucoma caused by PEX. Three months after an uneventful cataract surgery with capsulorhexis, phakoemulsification and implantation of a posterior chamber lens (PMMA) the anterior capsular opening of her left eye was completely occluded.The patient reported a slow loss of vision (20/40 immediately after cataract surgery to 20/200 at the follow-up visit three months later). The examination revealed a complete closure of the capsulorhexis with thick, central fibrous material. The diameter of the capsulorhexis was extensively diminished. Reopening of the anterior capsular opening utilizing a YAG laser was achieved and visual acuity increased to 20/40. Additionally, the fibrotic, secondary cataract of the posterior capsule was removed, again with a YAG laser, five weeks after the first intervention and, now with a free optical axis, the patient's visual acuity increased further to 20/30.The excessive production of fibrosis and the tendency towards a shrinkage of the diameter of the capsulorhexis postoperatively in patients with PEX may lead to a complete occlusion of the capsulorhexis. Even in such extreme cases, the reopening of the anterior and posterior capsule by a YAG laser is possible and, as demonstrated here, leads to a morphologically and functionally satisfying result.

Pseudoexfoliation syndrome (PEX) is associated with zonular weakness and a higher frequency of intraoperative complications during cataract surgery, including rupture of the posterior lens capsule, zonular dialysis and a rise of intraocular pressure occurring postoperatively. Delayed dislocation of an IOL is a rarely reported phenomenon.Within one year, late dislocation of the lens capsule with the in the bag fixated IOL was observed following cataract surgery in five patients (67, 74, 79, 90 and 92 years old) with pseudoexfoliation syndrome.All patients had an uneventful in the bag implantation of the IOL 6 (three patients), 3 and 11 years ago, respectively. Postoperatively occurring secondary cataract was treated by a YAG-capsulotomy in four cases. No patient had any other predisposing factors that would lead to zonular weakness besides the pseudoexfoliation syndrome. The dislocation of the IOL and capsule occurred spontaneously. In one patient with preexisting glaucoma, the dislocation was followed by an increase of intraocular pressure. All cases were successfully treated with IOL explantation, anterior vitrectomy and placement of an anterior chamber IOL.Patients with pseudoexfoliation syndrome undergoing cataract surgery may be at risk not only for intraoperative complications but also for delayed spontaneous dislocation of the IOL and capsule. This possible complication should be considered in surgical planning for patients with pseudoexfoliation syndrome. In these patients it may be better to implant the IOL in the ciliary sulcus.

In the past few years, there have been many changes in ophthalmic anaesthesia. Application of drugs in general anaesthesia with excellent controllability enhances patient safety and allows a more efficient OR-management. Regional anaesthesia is gaining widespread use for ophthalmic surgery, especially topical anaesthesia for cataract surgery. Patients for ophthalmic surgery concomitantly often display high age and a high level of co-morbidity and, therefore, belong to the anaesthesiological risk groups ASA III-IV. Life-threatening adverse events including cardiovascular depression are associated with general and regional anaesthesia. Intervention by anaesthesiologists is frequently required for treatment of hypertension or dysrhythmias, and sedation. Thus, monitored anaesthesia care ("standby") is justified. Drugs applied for regional and general anaesthesia may change intraocular pressure. There are a lot of publications about the impact of anaesthesia on intraocular pressure (IOD), however, few on the effects of anaesthesia on pulsatile ocular blood flow. it has to be kept in mind that the effects of anaesthesia on intra-ocular pressure and pulsatile ocular blood flow may diverge. To avoid an increase of the IOD, especially during anaesthesia induction, drugs, such as succinylcholin, rocuronium and opiates, in particular remifentanil, can be applied. In addition, the use of the laryngeal mask may be advantageous compared to general anaesthesia associated with laryngoscopic tracheal intubation. The management of patients treated with anticoagulants and antiplatelet agents, has to be taken on the balance of risks. There are risks not only in continuing therapy, but also in discontinuing it perioperatively. Postoperative nausea and vomiting (PONV) remains a distressing and common problem after strabismus repair in particular in children. The incidence of PONV depends on the type of ophthalmic surgery and drugs applied. To reduce PONV in ophthalmic surgery, application of long-lasting opiates should be avoided, and non-opiate analgesics and, depending on the kind of operation, antiemetic prophylactics are recommended.

Crohn's disease is a chronic inflammatory bowel disease, leading to ocular manifestations in 4 - 8 % of patients. We report on a patient with Crohn's disease, who developed in association with epidermolysis bullosa acquisita a progressive corneal ulcer.A 26-year old patient with a 3-year history of Crohn's disease presented with a peripheral corneal ulcer of the right eye. The anterior chamber was deep and quiet. Fundus examination was normal. Corneal smears displayed no bacterial growth. Visual acuity of the right eye was 20/25. Examination of the left eye was normal. Furthermore, he had developed cutaneous blisters on the arms and legs. Despite treatment with topical antibiotics and systemic immunosuppressive therapy with tacrolimus, azathioprine and methylprednisolone the corneal manifestation deteriorated. Therefore, an amniotic membrane was transplanted for treatment of the corneal ulcer; however, this was followed by melting of the amniotic membrane within a few days. Additional therapeutic procedures including further amniotic membrane transplantations and autologous conjunctival grafts have been performed. This was regularly unsuccessful. The corneal ulcer increased in size and extended into the sclera. Therefore a tectonic sclerokeratoplasty was necessary. Histologic examination of the excised corneoscleral tissue revealed an extensive stromal thinning associated with inflammatory infiltration of the cornea and sclera.Corneal complications in patients with Crohn's disease are very rare in contrast to conjunctivitis, episcleritis und uveitis. To the best of our knowledge, this is the first description of a patient with Crohn's disease and epidermolysis bullosa acquisita developing progressive corneal ulcer. How closely an assumed autoimmune mechanism in the cornea is related to Crohn's disease or epidermolysis bullosa acquisita, is not known.

Compared to lens luxations into the vitreous body, luxations into the anterior chamber are rare. We report on two patients in whom a lens luxation into the vitreous body was followed by a luxation into the anterior chamber.In a 61-year old male patient and a 47-year old female patient a lens luxation into the vitreous body occurred after a blunt ocular trauma and as a result of Marfan syndrome, respectively. During follow-up the patients presented with a spontaneous lens luxation into the anterior chamber. In both cases a YAG iridotomy and a surgical lens extraction were immediately performed.As a result of whiplash-like movements of the vitreous body, a dislocation of a lens luxated into the vitreous body, into the retroiridal or intrapupillary space may occur. This may be facilitated by focally undamaged zonular fibers. The immediately retroiridal lens position may cause a pupillary block with fluid misdirection into the space behind the iris-lens diaphragm resulting in a consecutive pressure increase in this space. This pressure rise causes an anterior movement of the lens and may be followed by a complete dislocation into the anterior chamber especially in the case of coexisting traumatic mydriasis. As a result of this lens dislocation into the anterior chamber an inverse pupillary block develops. This situation necessitates an iridotomy prior to the surgical lens extraction.