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A 65-year-old woman was referred for sudden bilateral loss of vision. She was vaccinated a few days earlier. The ophthalmological examination showed a massive optic disc swelling on both eyes. Magnetic resonance imaging (MRI) revealed suspected bilateral optic neuritis without cerebral involvement or transverse myelitis. After serological detection of anti-MOG (myelin oligodendrocyte glycoprotein) antibodies, the patient was treated with high-dose corticosteroid pulse therapy until vision recovered. Discussion: an atypical optic neuritis may indicate a neuromyelitis optica spectrum disorder (NMOSD), which should be further characterized by determination of Aquaporin 4(AQP4)-IgG and MOG-IgG.

Background: The biomechanics of accommodation are of particular interest in terms of the causes of presbyopia and the function of intraocular lenses., Objective: The aim of the present article is to model the mechanism of accommodation in detail., Materials and Methods: The state of the art of applying biomechanical models to accommodation is presented, which enables the accommodation process to be understood., Results and Conclusion: The established models, which are based on the Helmholtz theory, can explain the accommodation process in a plausible manner. These models thereby also enable further investigations on the genesis of presbyopia as well as on the development of accommodative intraocular lenses and implants. However, measurements are always necessary to compare the simulation results with reality, and to provide input and material data as well as geometric dimensions of components of the eye.

In 1999 the global initiative "Vision 2020 - The Right to Sight" was established by the World Health Organization (WHO), the International Agency for the Prevention of Blindness (IAPB) and several non-governmental organizations (NGOs) with the goal of reducing avoidable blindness. Based on this initiative, the working group "International Ophthalmology" of the German Ophthalmological Society (DOG), which was established in 1994, was converted into a DOG section with the same name in 2004 and represents one of the core components of the DOG; however, even before there were a number of established partnerships of German and African eye hospitals. The first cooperation of this kind was the partnership between the Department of Ophthalmology, Ludwig-Maximilians University Munich and the University of Nairobi, Kenya, which was founded in 1978. As a result of this cooperation, the Department of Ophthalmology in Nairobi has evolved into one of the major centers of ophthalmological training and ophthalmic care in East Africa. Since then a number of similar cooperation projects between several hospitals and numerous further projects (e. g. in Myanmar) have been implemented and some of these are presented in this manuscript.

Confocal laser scanning microscopy is a versatile tool in medical research and enables noninvasive in vivo imaging of the corneal subbasal nerve plexus. The aim of this work is to provide a structured overview about the detection and quantification of nerve fibers of the subbasal nerve plexus from images acquired by confocal laser scanning microscopy. Relevant steps are explained and potential factors influencing the quality of the results are pointed out. Information obtained from the quantification of subbasal nerve fiber structure can be potentially used as clinical parameters in the context of diagnostics and therapy control of diabetic neuropathy.

The sub-basal nerve plexus (SNP) of the cornea provides the possibility of in vivo and non-invasive examination of peripheral nerve structures by corneal confocal microscopy (CCM). Thus morphological alterations of the SNP can be directly detected and quantified. A single CCM image is insufficient for a well-founded diagnosis because of the inhomogeneous distribution of the nerve fibers; therefore, there is a demand for techniques for large area imaging of the SNP. This article provides an overview of published approaches to the problem. Current developmental work at the Karlsruhe Institute of Technology and the University of Rostock Eye Clinic is expected to lead to a simplified handling of the technology and a further improvement in the image quality.

Background: Even though macular edema (ME) in patients with retinal vein occlusion (RVO) is resolved after intravitreal treatment with anti-vascular endothelial growth factor (VEGF), impairment of visual acuity (VA) often persists., Objective: A qualitative and quantitative evaluation of spectral domain optical coherence tomography (SD-OCT) images was carried out in patients with RVO and resolved ME to investigate a correlation between retinal morphology and functional results., Material and Methods: Foveal SD-OCT scans of 13 patients with RVO and resolved ME after treatment were retrospectively evaluated. The thickness of inner retinal layers up to the external limiting membrane (ELM) and up to the photoreceptors in the retinal pigment epithelium (RPE) was measured by automatic segmentation software. Foveal continuity of the four outer hyperreflective bands, the ellipsoid zone of the inner segments (ISe), the ELM, the interdigitation zone (IZ), the RPE and the location of the initial ME were evaluated. Patients with good  (≤ 0.3 logMAR, n = 10) and poor VA (≥ 1.0 logMAR, n = 3) were compared., Results: Inner retinal layers up to ELM were thinner in the the poor VA group. In the good VA group the initial ME was significantly more often above the ISe and after resolution of ME the ISe tended to be intact more frequently., Conclusion: In patients with poor VA despite resolved ME the inner retinal layers up to the ELM were significantly thinner, which could be a sign of atrophy. Qualitative differences were seen at the photoreceptor level, which could be explained by ischemia or an involvement of the outer retina during initial ME that leads to permanent destruction of the ISe.

In industrialized countries glaucoma is one of the most common causes that leads to blindness. It is also the most common cause of irreversible blindness worldwide. In addition to local treatment of intraocular pressure and filtering glaucoma surgery, alloplastic implants are increasingly being used in glaucoma therapy. As long-term results published in the literature of commonly used implants are unsatisfactory, it seems useful to search for new concepts. In order to avoid the well-known short-term and long-term postoperative complications a pressure-controlled microstent with antiproliferative surface modifications was developed. Additionally, the functionality of such a microstent should be investigated using an animal glaucoma model. This paper describes the concept of a microstent which drains aquous humour from the anterior chamber into the suprachoroidal space. In addition, the glaucoma models described in the literature are discussed. Unfortunately, none of the methods could be reproduced permanently. First results show a correct implantation of a coated microstent with valve where the anti-proliferative effect could be demonstrated histologically. The promising results should lead to further investigations and the final goal will be the testing of the stent in the human eye.

Introduction: Counterfeit drugs are often ineffective and are considered a problem with an immense risk potential especially in the treatment of infectious diseases. Emerging and developing countries are particularly affected. Little is known about the extent of counterfeit antibiotic drugs used in eye care. In the present study we investigated antibiotic eye drops purchased in two African countries with respect to the active substance and its concentration in the sample., Methods: A total of 33 antibiotic eye drops purchased in Kenya and the Democratic Republic of Congo were tested. The bottles were labeled to contain one of the following substances: the quinolones ciprofloxacin, levofloxacin and ofloxacin and the aminoglycosides gentamicin and tobramycin. Imported quality products as well as cheaper generic drugs were tested. Fluoroquinolones were determined by high pressure liquid chromatography (HPLC) and quantified by fluorescence measurement and aminoglycosides were tested by using a fluorescence polarization immunoassay., Results: All samples were found to contain the declared drug. Nine samples (27%) showed an under-concentration by 10% or less and ten (30%) showed an increased concentration of 10% or more than indicated on the label. 75% of the original drugs but only 12% of the generic drugs had measured concentrations within the standard advisory ranges of ± 5% from the nominal value., Conclusion: Our results provide no evidence for significant criminal counterfeiting of eye drops in the studied countries. The frequent deviation from the stated concentration in the generic samples is cause for concern and justifies further investigation.

Objective: The aim of this clinical study was to demonstrate the practicability of self-measured intraocular pressure and to evaluate the reliability by comparing the data with those obtained by Goldmann applanation tonometry (GAT)., Methods: A total of 40 patients aged between 44 and 82 years with glaucoma were introduced to the handling of the tonometer. The self-measurements were done for 1-3 days following the medical measurement by GAT. The data were saved as "correct" or in the case of wrong handling as "false". The impressions of the patients were obtained by a questionnaire., Results: A total number of 191 single measurements were registered by the Icare ONE and of these there were 97 (50.8%) signed "false". Of the patients 45% reached a maximum difference of ±5 mmHg between GAT and self-measurement in every single measurement. In the subgroup of under 60-year-old patients 70% reached this result. There were no indications of a systematic error. Of the probands 60% considered the handling of the Icare ONE as difficult. Nevertheless, 80% could imagine using the self-tonometer at home., Conclusions: The differences between the self-measurements and the GAT were highly fluctuating in some cases. In the group of patients younger than 60 years the agreement was better, so problems with the handling of the Icare ONE may be an important factor. However, the acceptance in the patients tested was high and continuous pressure measurements at home could be reasonable. Advancements in the handling and reliability are needed to improve clinical application of the measured values.

Background: When pars plana vitrectomy is performed, the sizes of the sclerotomy cannula vary between 20 and 23 gauge. We examined the morphology of the scleral tunnels by ultrasound biomicroscopy additionally taking into account the incision angle., Material and Methods: In each of 16 enucleated porcine eyes three 20 or 23 gauge sclerotomies with varying angles between 30 and 90° to the horizontal level were performed. The vertical 20 gauge sclerotomies were additionally sealed by 7.0 vicryl cross-stitching. The resulting scleral channels were analysed by 3-D ultrasound biomicroscopy., Results: The sclerotomies were echographically detectable in all cases. Analysis revealed that the sutured straight 20 gauge tunnels were hyporeflective in only some parts while the other incisions showed continuous hyporeflectivity along the complete channel in many cases. The smaller the instruments used and the flatter the scleral angles chosen, the smaller were the measured widths of the incision tunnels., Conclusion: Imaging sclerotomies ex vivo by ultrasound biomicroscopy is reliably reproducible. In the echographic pictures straight 20 gauge incisions appeared to be safely sealed by the sutures while the nonsealed tunnels often showed continuous patency. By choosing small instruments and flat incision angles the width of the resulting scleral channels can be reduced.

A 53-year-old female patient presented with a palpable mass in the right medial orbit which had been present for 18 months. The left eye had been enucleated in childhood due to a perforating injury. An orbital biopsy performed ex domo showed unspecific inflammatory tissue but no definite diagnosis was made and systemic therapy with corticosteroids was unsuccessful. A second orbital biopsy was performed in our clinic and revealed a solitary fibrous tumor (SFT) of the orbit. Medial orbitotomy with tumor excision followed and the histological examination of the excised tumor established the diagnosis of SFT of the orbit with focal sarcomatous transformation. The patient presented 3 years later with a new orbital mass in a control MRI examination. Relapse was suspected and orbitotomy with excision of the mass was performed. The histological examination revealed a relapse of the SFT with sarcomatous transformation in the whole extent of the tumor. Radiotherapy with a dosis of 59.4 Gy was subsequently performed. The patient remained tumor-free in the most recent control examination 3 years later.

A 55-year-old woman underwent autologous keratoplasty because of band keratopathy and corneal decompensation of the left eye. Previously recurring events of uveitis had affected the eye. A vitrectomy had been performed on the left side for tractional retinal detachment of the posterior pole. The visual acuity of the right donor eye had been reduced to hand movements after occlusion of the central retinal artery. Twelve months after the transplantation, a circumscribed opacity appeared on the endothelial side of the cornea. Cells in the anterior chamber were detected, as well as a moderate rise in ocular tension. Despite intensive anti-inflammatory therapy, the membrane extended over the complete cornea. We diagnosed an ingrowth of epithelial cells as responsible for the changes.

Purpose: In ophthalmology, it is very often necessary to determine the axial eye length. When standard measuring techniques fail, B-scan sonography may be used. However, coupling problems inhibit exact measurement. The aim of this study was to counter these problems., Patients and Methods: Correction values were created for the ultrasonic devices (1) Master-Vu (Sonomed), (2) CineScan (Quantel Medical), and (3) System-ABD (Innovative Imaging), including the position of the coupling layer of the hand pieces and the lid thickness. For evaluation of the method, the axial eye lengths of 35 eyes were measured transpalpebrally. These data were compared to those from the (4) IOL Master (Carl Zeiss Meditec). The usefulness of the developed method was shown by two patients., Results: The correction values were (1) 3.0 mm, (2) 1.5 mm, and (3) 1.5 mm. The medial aberrations to (4) were (1) 0.4+/-0.5 mm, (2) 0.9+/-0.7 mm, and (3) 0.2+/-0.7 mm., Conclusions: The introduced method enables transpalpebral eye length measurement and is also applicable in cases of missing compliance or in eyes with an obfuscated optical medium.

Objective: After unsuccessful surgery for macular holes re-vitrectomy is often conducted with silicone oil endotamponade. In the postoperative management uncertainty exists whether the macular hole is actually closed. Standard time domain OCT (Stratus OCT and its predecessors, Carl Zeiss Meditec AG) is rarely successful in depicting the central retina under silicone oil. High resolution Fourier domain OCT (Cirrus OCT) may be superior in delineating macular structures under these conditions., Methods: A total of 10 eyes from 10 patients were examined with the Cirrus OCT (Carl Zeiss Meditec AG) after vitrectomy with silicone oil for persistent macular holes. Sufficiently clear optical media were a prerequisite for the examination. Macular morphology was analyzed under silicone oil and compared with the findings after silicone oil removal., Results: Of the 10 eyes 5 showed macular hole closure under silicone oil with retinal tissue in the center of the fovea. In 3 eyes there was a shallow subretinal cyst in the center of the fovea and the other 5 eyes showed a persisting hole. The macular hole remained closed after oil removal in all 5 eyes with a foveal contour. In 4 of the other 5 eyes the macular hole reopened and for 1 eye the hole remained stable., Conclusions: This pilot study showed that the aspect of macular holes under silicone oil seems to influence the prognosis after oil removal. Thus, silicone oil removal as well as further surgery may be planned. The reliable analysis of macular holes under silicone oil has only become possible with high resolution Fourier domain OCT.

A 60-year-old man presented with left exophthalmos and deterioration in visual acuity of slow evolution. Bilateral orbital Erdheim-Chester disease was diagnosed. Systemic evaluation revealed a retroperitoneal fibrosis. Treatment with interferon-alpha followed, but bilateral compressive optic neuropathy with visual acuity deterioration and visual field defects evolved. Bilateral orbital decompression was performed.

We present two cases of Peters anomaly (Peters plus syndrome and a maximum manifestation variant) with abnormally thickened cornea and corneal staphyloma. Both patients presented to our hospital shortly after birth and were treated with perforating keratoplasty and lensectomy. Histological analysis showed marked thickening of the corneal stroma due to abnormal stromal connective tissue deposition. Additionally, both eyes showed the characteristic changes of Peters anomaly with corneal opacity, adherence of the iris stroma and anterior lens surface to the posterior corneal surface, absence of the corneal endothelium, Descemet and Bowmans layers. Peters anomaly with abnormally thick intracorneal fibrosis with or without congenital corneal staphyloma is a very rare manifestation.

Background: The purpose of this study was to develop a microstent with valve function, which normalizes the intraocular pressure (IOP) and drains into the suprachoroidal space. In comparison to the subconjunctival space the suprachoroidal space is attributed with less fibroblast colonization and activity., Methods: Different glaucoma drainage devices were idealized as tubes and the flow rates were calculated according to Hagen-Poiseuille. The dimensions of the ideal glaucoma implant were modified with respect to an aqueous humor production of 2 microl/min and the different outflow pathways. Specific components of glaucoma drainage devices at the inlet and outlet were not included., Results: The volume flow calculation of the tested glaucoma implants showed that the dimensions of all lumina were too large to prevent postoperative hypotension. A maximum inner tube diameter of 53 microm was calculated for drainage into the suprachoroidal space based on an intra-ocular pressure (IOP) of 20 mmHg., Conclusion: The glaucoma microstent has to guarantee an aqueous humor flow for physiological IOP. An increase of IOP has to be regulated to physiological pressure conditions by the microvalve.

The struggle against childhood blindness is being given high priority by the WHO. In regions of the world countries where the income per head is low there are 5 times as many blind children as in wealthy countries (1.5/1000 vs 0.3/1000 children). In developing countries cataract is regarded as the main cause of blindness in both childhood and adulthood. If all cataracts that would lead to blindness were operated on, despite a comparatively smaller number of affected persons a similar number of sighted life-years could be achieved throughout the world to that for patients with senile cataract. The partnership between the Rostock Ophthalmological Department and St. Joseph's Hospital in Kinshasa focuses on the analysis and treatment of avoidable blindness in children. Its main concern is the introduction of appropriate procedures for cataract surgery, in most cases combined with the implantation of injectable synthetic intraocular lenses. In the last 7 years about 600 procedures have been jointly performed, including 400 of congenital cataract, mostly bilateral.

Background: Wearing orthokeratology contact lenses (OCL, Hecht-see free; Hecht, Germany) overnight can change corneal refraction by up to -4.5 dioptre (dpt) based on corneal adaptation to the double reverse surface of the OCL. This allows a temporary independence on glasses or contact lenses. It is known that the central corneal thickness decreases while the corneal thickness in the periphery probably increases. The aim of this study was to investigate the corneal changes of volunteers wearing OCL with in vivo confocal microscopy., Materials and Methods: Five young adults (mean 22.8 years, three female, two male) with low to moderate myopia (range -1.75 to -3.5 dpt; sphere equivalent -2.7+/-0.59 dpt) were fitted with OCL of reverse-geometry design in both eyes. Lenses were worn in both eyes overnight and were removed immediately in the morning. The volunteers were examined with in vivo confocal microscopy using a combination of Heidelberg retina tomograph II and the Rostock cornea module before wearing the OCL and after the 1(st), 3(rd), 5(th), 7(th), 13(th), 20(th) and 25(th) nights. The central and mid-peripheral total corneal thickness as well as the epithelial thickness were examined in the morning between 7.30 am and 9.30 am., Results: The central and the mid-peripheral epithelial corneal thickness was reduced significantly (p<0.05) from day 1 to the 13(th) day. This stabilized later until the the examination was concluded. No significant changes (p>0.05) were found in the central or mid-peripheral total corneal thickness after 25 days of wearing the OCL., Conclusion: Wearing OCL leads to a reduction in the central corneal epithelial thickness. Our inability to find an increase in mid-peripheral total and epithelial corneal thickness may be because the expected increase of the mid-peripheral cornea is limited to a defined area, which makes repeated measurements at a particular point difficult.

Background: Use of an implantable mechatronic microsystem (artificial accommodation system) is a novel approach to restoration of the accommodative capacity of the human eye. One such system, based on the triple-optic approach, has been selected for investigation of its suitability., Methods: Optical modelling of the dioptric apparatus is carried out by means of an optical simulation tool. Postoperative refractive compensation plus at least 3 dpt of accommodation are required., Results: An axial shift of 300 microm or less is achieved for the entire range of biometric data ascertained before surgery. In addition, the defined requirements made of optical imaging quality are met., Conclusions: The triple-optic approach is basically suitable for application in the restoration of accommodative capacity. It seems that flexure hinges could be used in association with conducting polymers as actuator material. One question that is still open concerns the deformability of such implants as this relates to minimally invasive corneal incisions.

Background: In the rare condition of endogenous (or metastatic) endophthalmitis, septicemia leads to intraocular colonization by bacteria, fungi or parasites. Immunologically compromised or multimorbid patients are commonly affected by this ophthalmological emergency. Although appropriate anti-infective drugs and modern surgical treatment are available, this disease still has a poor prognosis in terms of organ and function preservation., Patients and Methods: Between March 2003 and September 2005 nine patients (5 male, 4 female, average age: 60.6 years) with a diagnosis of endogenous endophthalmitis were treated in the Ophthalmology Department of Rostock University Hospital. The infection was in a very advanced stage in eight cases. Six patients offered no fundus view, and in three cases the intraocular view was heavily blurred. Eight patients had an initial visual acuity of

Scarring of the filtering bleb is the main complication after glaucoma filtration surgery. Postoperative care most importantly determines success or failure of the operation. Both, preoperative antiinflammatory treatment and reduction or discontinuation of topical medication have a positive effect on postoperative conjunctival wound healing. After conventional postoperative care only about 40% of patients reach target pressures in the long-term without topical medication. Intensified postoperative care (IPC) increases the success rate by 25% after 5 years. Central to the concept of IPC is a wound modulating therapy which is adapted to the phases of wound healing of the filtering bleb. Evaluation of filtering bleb morphology is a prerequisite for the application of topical steroids and 5-fluorouracil. In addition, dedicated counseling of the patient and close follow-up are mandatory. In order to further increase the success rate of penetrating glaucoma surgery and decrease the side effects of the current antimetabolite therapy more research on wound healing as well as specific therapy to prevent scarring are necessary.

Background: In various ocular diseases, cytomorphological findings of the ocular surface are an essential component of clinical diagnostics. When evaluating the conjunctival epithelium, minimally invasive acquisition of biomaterial is necessary for lab and technical processing and in vitro histological examination. To examine corneal structures in vivo, confocal laser scanning microscopy is a successful standard method. Our aim was to employ in vivo confocal laser scanning microscopy also for examining the conjunctival epithelium., Material and Method: Results were analyzed and compared with cytomorphological findings of impression cytology. Accordingly, the basic features of conjunctival in vivo examination using RLSM were described and defined. In vivo images were analyzed and compared with impression cytological slide preparations (n=110) of 23 healthy test persons. Examination was standardized. Finally, the confocal laser scan images were compared to the impression cytological patterns., Results: Due to the distribution of reflectors (pixel brightness), diagnostic analysis of important morphological structures (cell nucleus, cytoplasm, nucleus/plasma relation) of the conjunctiva is possible. Secretory cells of the epithelium (goblet cells) can be easily recognized by their size. Highly reflective pixels depict cell walls or wide intercellular spaces with high contrast., Conclusions: The in vivo investigation of important anatomical and morphological structures of the conjunctival epithelium is possible using RLSM. The distribution pattern of goblet cell pixel brightness may correlate with various secretion contents or suggest distinct, recognizable, functional conditions (hypo- or hypersecretion).

Listeria monocytogenes is a rare cause of endogenous endophthalmitis. During the last 20 years about 30 cases have been published, all of which showed similar clinical features and a profound visual loss mainly owing to delayed diagnosis. This case report is about an otherwise healthy 41-year-old woman whose diagnosis was established 17 days after the onset of symptoms by microbiological cultures. Under sufficient therapy signs of local inflammation disappeared and intraocular pressure decreased. Pars plana vitrectomy was necessary; although post-surgery complications developed, the result was complete recovery of visual acuity.

Purpose: Epidemic keratoconjunctivitis (EKC) is a highly contagious infection caused by adenovirus types 8, 19, and 37. The formation of subepithelial nummular infiltrates may lead to permanent visual disturbance. These infiltrates consist histopathologically of an accumulation of lymphocytes, histiocytes, and fibroblasts., Patient and Method: The reasons for the persistence of these nummular infiltrates are not fully understood. We examined a 28-year-old female patient with typical signs of EKC infection clinically and additionally with the RLSM., Results: Nummuli were identified by the RLSM as areas with an accumulation of dendritic cells (supposed to be Langerhans cells) as well as so far unidentified punctiform structures located in the basal cell layer and in the region of the subepithelial nerve plexus., Conclusions: The RLSM allows us to investigate corneal microstructures in vivo with precise depth localization related to epidemic keratoconjunctivitis. Further investigations may disclose the role of dendritic cells in the pathogenesis of the nummular formation as well as their contribution to the variable persistence of partially threatening vision opacities.

Experience with the differential diagnosis of lacrimal gland illnesses is limited in daily practice due to their rarity. It is therefore of particular importance to have guidelines for the practitioner by which he can decide on the application of conservative or surgical therapy, and whether it is necessary to take a biopsy to clarify the diagnosis. There is a wide spectrum of possible illnesses which include systemic diseases, inflammatory disorders, neoplastic, benign and malignant tumors. When a pleomorphic adenoma cannot be excluded, biopsy is contraindicated and complete tumor excision with its capsule is necessary to prevent the possibility of malignant transformation and a negative effect on long-term prognosis. In this overview, special interest is placed on the typical clinical aspects and imaging features of lesions of the lacrimal gland fossa, their differential diagnosis and management.

Purpose: The principal ability of potentially accommodative IOLs is based on an axial shift of the IOL optics induced by the ciliary body action in interaction with a reversible change in haptic angulation. The aim of this study was to investigate the accommodative performance of this new IOL generation., Method: The authors have designed a test device to study IOL performance experimentally. These results were extrapolated to the in vivo situation in patients with accommodative implants., Results: The 3D high-resolution presentation of the anterior segment of the eye allows a separation of the IOL haptic elements. In vitro and in the selected in vivo cases a change in haptic angulation <10 degrees in combination with a maximal IOL shift of 0.5 mm was found., Conclusions: The simulation model used in combination with 3D ultrasound biomicroscopy provides information about the potential of accommodative IOL designs. Conclusions corresponding to changes in haptic angulation during accommodation can be drawn and applied to the in vivo situation.

Background: Conjunctival carcinomas are tumors especially of the 6th/7th decades. They occur in Germany with a frequency of 1/20,000. For years it has been well known that in Africa the number of malignant tumors of the conjunctiva has been increasing. The reasons for that are not well known. HIV is a possible pathogenetic cofactor., Method: A histological examination of 34 specimens was performed in Rostock on conjunctival tumors removed at the Ophthalmologic Department of the University of Kinshasa in 2001. The study included 23 female and 11 male patients aged 20-75 years (mean 42). All patients underwent serological investigation for HIV infection., Results: Of 34 patients 18 were HIV positive. Of the HIV-positive patients, six had a squamous cell carcinoma, seven a CIN (conjunctival intraepithelial neoplasia) I-III, and five a pinguecula. Of the HIV-negative patients, five showed a squamous cell carcinoma, eight a CIN I-III, one a pinguecula, one a sebaceous gland carcinoma, and one a papilloma. The average age of the HIV-positive patients with a squamous cell carcinoma was 41 years compared to the HIV-negative patients with 58 years., Conclusions: There was no difference in frequency of conjunctival intraepithelial neoplasia between HIV-positive or HIV-negative patients. HIV-positive patients with a squamous cell carcinoma were on average 17 years younger. UV radiation is the main risk factor and HIV infection is a possible carcinogenic cofactor. Investigations on additional viral infections as possible pathogenetic factors and on changed tumor suppressor genes are needed.

Purpose: Keratoconus is a non-inflammatory disease characterized by progressive thinning of the central cornea. There are indications for an autosomal dominant heredity. Our purpose was to find correlations between gene expression and structural changes in extracellular matrix components., Methods: Stromal RNA (keratoconus and comparison) was isolated from corneas, transformed to cRNA and analysed using biochips (Affymetrix). Structural investigations were performed by laser scanning and transmission electron microscopy., Results: In keratoconus corneas there was an upregulation of different extracellular matrix components (collagen XV, metalloproteases) and a down-regulation of collagen IV (alpha1, alpha3) and versican. The morphological changes correlated to genetic obtained data. The orthogonal arrangement of the collagen fibrills (anteriorly and central) was altered in the collagen matrix of keratoconus corneas., Conclusions: The changes point on deregulation of the matrix arrangement. The interest in the cause of the disease is focused on the interfibrillar arrangement, the interaction between collagen and proteoglucanes.

Purpose: In Graves' disease a discrepancy between volume increase of the orbital soft tissues and fixed volume of the orbital cavity leads to exophthalmos. The patients do not only feel cosmetically disfigured, they often complain about more or less painful retroorbital pressure sensation or show symptoms of compressive optic neuropathy or corneal exposure because of a significant lid lag. To solve this problem, different orbital decompression techniques have been developed. This is to report about our results with a modified Dollinger technique for lateral orbital decompression., Patients and Methods: A total of 27 patients aged 19-76 years (mean: 45.1 years) with Grave's ophthalmopathy were recorded who had undergone orbital decompression by a lateral approach between June 1999 and April 2003. The modified Dollinger technique was performed by deepening the osteotomy to the level of the sphenoid wing and by additional resection of intraconal fat., Results: The reduction of exophthalmos achieved after decompressive surgery averaged 2.9 +/- 1.1 mm. Of the patients whose indication for orbital decompression was a compressive neuropathy, the visual acuity improved postoperatively for 3 lines. Of the 16 patients with preoperative retrobulbar pressure sensation, 12 had no complaints after the operation. Remarkably no significant impairment of the ocular motility resulted after surgery., Conclusions: Decompression of the orbit by the modified Dollinger technique is a safe and effective approach to reduce exophthalmos, retrobulbar pressure sensation, and compression neuropathy as a result of diffusely elevated orbital tissue tension. In the case of direct compression of the optic nerve in the orbital apex, additional medial orbital wall decompression has to be considered.

Background: Primary pulmonary hypertension (PPH) is a rare but fatal disease that results in right heart failure from idiopathic occlusion of the pulmonary arteries. Patients develop stagnation of venous pressure. PPH occurs most commonly in young and middle-aged women and the mean survival time from onset of symptoms is 2-3 years. The aetiology of PPH is unknown, although familial occurrence of the disease suggests a genetic predisposition. Pulmonary transplantation is reserved for patients who fail medical therapy. Pathophysiologically, PPH is a functional and structural alteration of the pulmonary blood vessels., Methods: The authors retrospectively reviewed the clinical records of three patients (mean age 34 years) diagnosed with PPH and retinal diseases., Results: All three patients developed central retinal vein occlusion (CRVO). One patient developed a neovascular glaucoma and on the other eye a serous retinal detachment with uveal effusion. A few months after the central vein obstruction was diagnosed two patients died as a result of PPH., Conclusions: The elevated venous pressure found in PPH is responsible for decreased choroidal perfusion and reduced venous blood outflow from the eye. This would explain the clinical findings of serous retinal detachment and central retinal vein occlusion in these patients.

Introduction: Children presenting with congenital anophthalmos usually develop a smaller bony orbit, a constricted mucosal socket, and a shortened eyelid fissure. This causes problems when fitting these patients with a prosthesis. Clinical evaluation of the Wiese self-inflating hydrogel expanders has demonstrated their ability to expand the socket and eyelid fissure for inserting a more realistic prosthesis in shorter periods of time., Patients and Method: The study included 13 consecutive anophthalmic patients, eight unilateral and five bilateral. Each patient received a hemispherical osmotic tissue expander in the rudimentary mucosal socket and later a sphere implanted in the deeper soft orbital tissue., Results: The use of hydrogel expanders enlarged the lid and palpebral fissure in all children, with good cosmetic results. It allowed insertion of custom-made glass prostheses with good cosmetic appearance very early in life. Growth of the bony orbit may be stimulated successfully by these expanders in the soft orbital tissue., Conclusions: The enlargement of constricted mucosal sockets and short palpebral fissures using self-inflating hydrogel expanders is a new and successful concept in treating congenital anophthalmos.

Introduction: Keratoconus is a non-inflammatory ocular disease characterised by conical deformation, progressive thinning and scarring of the central cornea. Despite intensive investigations, the exact cause of the disease still remains unclear. Clinical studies provide strong indications of a major genetic role in the aetiology. We set out to examine the involvement in the manifestation of keratoconus of any of the 5,600 gene specificities available on the Affymetrix GeneChip HuGeneFL., Methods: After examination of two corneas they were stored in RNAlater, RNA was extracted and hybridised on the chips. Using a combination of dyes it was possible to read the chips with laser detection and to visualise the gene expression pattern., Results: We found an upregulation of collagens, versican, metalloproteinases and cell adhesion proteins. A downregulation was observed for TIGR protein, cytokeratins, eyes absent homologue (Eab1) and the proteins for radical treatment selenoprotein P and monooxygenase., Conclusions: Our results indicate that keratoconus is a process in which repair and scar-formation mechanisms operate at the same time. As candidate genes for this mechanism, collagen IV and related proteoglycans were favoured.

Congenital anophthalmia and blind microphthalmia are very rare conditions and there is no standard treatment available. Various previously reported therapeutical concepts are reviewed. The clinical picture can be divided into three subgroups with different therapeutical options recommended: in microphthalmia the conjunctival sac size is usually normal or slightly decreased. The use of non-expandable conformers is possible with good results. Patients treated with hydrogel expanders can wear a prosthesis earlier and with better cosmetic results. In congenital anophthalmia the conjunctival sac is very small and contracted and patients cannot wear a prosthesis or even a conformer. Hydrogel expander treatment--first for the conjunctival sac and second for the orbit--is the therapeutical option which may lead to good cosmetic results. Children >5 years of age and/or unsuccessful pre-treated cases may benefit from osteotomy to reduce mid-face asymmetry. To attain the main therapeutical goal in this subgroup, the ability to fit a normal prosthesis, a combination of different techniques like hydrogel expanders, dermis fat graft, lid surgery etc. may be necessary.

Orbital implants following enucleation are able beyond all doubt to compensate volume adequately and improve artificial eye motility. In recent decades progress has been made concerning implant material. Nevertheless, in most designs wrapping with homoplastic or alloplastic materials is advocated. In this report a microsurgical concept is presented to avoid wrapping material and at the same time to improve prosthesis motility in a hydroxyapatite-silicon implant. In a retrospective study two groups of patients (15 individuals each) were compared concerning prosthesis motility 6 months after surgery. In group 1 the horizontal and vertical eye muscles were sutured cross-wise in front of the implant (as done since the introduction of this type in 1989). In group 2 autologous muscle pedunculated scleral flaps were dissected microsurgically and used to cover the anterior part of the porous hydroxyapatite component of the implant. There was a highly significant better prosthesis motility and so far no complications concerning implant coverage in this second group. The authors consider the use of muscle pedunculated sclera to be a modification to improve the cosmetic outcome which may also reduce the postoperative complication rate in enucleation surgery.

Porous hydroxyapatite of various origins has proven to be a suitable material for orbital volume replacement. Its biocompatibility surpasses all other options. The transmitted motility to the artificial eye has nevertheless, not always been to the full satisfaction of patients, oculists and ophthalmologists. Our study has shown a strong correlation between the depth of the superior and interior fornices as well as the thickness of tissue material covering the implant anterior surface.

Background: At present, confocal tandem scanning microscopes with halogen or mercury lamps are used to depict all corneal structures in vivo, e.g., before and after PRK or LASIK. Insufficient imaging quality and irregular corneal illumination are the main problems for automatic quantitative evaluation of the keratocyte density when applying this instrument. A high correction is required for correcting the background irregularities of pictures. Our aim was to find out whether it is possible to change the Heidelberg retina tomograph (HRT) into a high-resolution digital laser scanning microscope for the visualization of anterior segments of the eye, coupled with a special evaluation software., Material and Method: We developed a lens adapter for the HRT that focusses the laser beam onto the cornea by combining with an external, computer-controlled hydraulic z-scan sledge. By using a programmable adaptation for the external stepmotor on the z-scan sledge in combination with all internal control functions and patient data, it is possible to create a digital confocal laser scanning microscope with retention of all the original HRT functions. For evaluation of the corneal images and automatic count of keratocytes, we used special 3D and Chemotaxis software., Results: First investigations show a regular illumination of all corneal structures as the epithelium, endothelium, and keratocytes. The hydraulic z-scan allowed a precise shift of the focus through the cornea to take series of images for the evaluation of the keratocyte profile and 3D reconstruction of all corneal structures.

Background: The incidence of dacryoliths ranges between 8 and 14% of patients undergoing a dacryocystorhinostomy. Lacrimal duct stenoses with dacryoliths can be managed either by surgery or minimally invasive techniques. We present two patients who underwent removal of dacryoliths by dacryocystotomy and microsurgical reconstruction without osteotomy., Patients and Methods: Case report 1: A 47-year-old male patient presented with chronic epiphora. The dacryocystogram revealed a filling defect in the dilated lacrimal sac. Case report 2: A 22-year-old female patient suffered from a hemorrhagic right-sided dacryocystitis. Two years previously the patient had undergone lacrimal endoscopy with silicone intubation for 3 months. Preoperative dacryocystography showed an obliteration of the superior portion of the lacrimal sac. In both patients, we performed the extraction of the dacryolith by dacryocystotomy followed by silicone tube intubation of the lacrimal system for 3 months. Both patients with a follow-up of 24 and 29 months, respectively, showed good clinical results and patent nasolacrimal pathways on digital dacryocystography., Results: Methods to extract dacryoliths include minimally invasive techniques such as nonsurgical radiologic or endoscopic removal during dacryoplasty or surgical approaches such as external or endonasal dacryocystorhinostomy., Conclusion: Dacryocystotomy with primary microsurgical lacrimal sac reconstruction combined with silicone intubation is an alternative surgical procedure to remove dacryoliths. An osteotomy is not always required.

Background: Phacoemulsification of the lens induces changes in the inner corneal architecture. This study quantified the corneal pre- and postoperative volumes., Methods: Corneal volume was measured by noninvasive corneal topography using Orbscan. Following phacoemulsification with lens implantation, 56 eyes of 55 persons were examined by three Orbscan tests: preoperatively and 6 h and 24 h after cataract surgery. Healon was used as viscoelastic medium., Results: The mean corneal volume in the 3-mm central corneal diameter was 4.64 mm3 preoperatively, 5.36 mm3 6 h postoperatively, and 5.05 mm3 24 h postoperatively. Corneal volume thus increased by 0.72 mm3 within 6 h after phacoemulsification and decreased by 0.31 mm3 over the following 18 h., Conclusion: Orbscan offers a noninvasive method for obtaining useful and accurate information in defining the corneal volume. This method may represent a new parameter for describing the function of corneal endothelial cells in cataract surgery.

Background: The magnitude of anterioaxial shift of the human ciliary muscle during accommodation and its ceasing of ciliary function with advanced age are still unknown., Patients and Methods: A total 105 patients (aged 10-91 years) were examined by high-resolution ultrasound biomicroscopy during disaccommodation and voluntary accommodation. Accommodative changes in the total area of the ciliary muscle and in the outer contour were quantified with a specially developed software program for automatic contour determination., Results: A significant anterior shift independent of age was observed in the total area of the ciliary muscle and defined points on the outer contour of the muscle in the range of 56-121 microns, while the inward displacement was less obvious. A decrease in the magnitude of configurational changes during accommodation was observed with age., Conclusion: The new software program could be useful in further investigations of the accommodative process and evaluation of the potential causes of presbyopia.

Background: Sufficient and regular wetting of the cornea with a normal preocular tear film is an essential requirement for the accurate visual functioning of the eye. Multiple factors may cause tear film instability. Measuring the break-up time of the preocular tear film is a necessary, clinically reliable means for evaluating tear film stability. We designed a new instrument to observe the preocular tear film at high magnification which can contribute to the in vivo imaging of the physiological and pathophysiological dynamics of the tear film and its break-up phenomena., Materials and Methods: To image the tear film phenomena at sufficient magnification (x200) we used a confocal laser scanning microscope. Modification of an additional adaptor allows the tear film to be imaged at high magnification. This study evaluated the dynamics and microarchitecture of the break-up phenomena in the preocular tear film of normal patients and patients with "dry eye"., Results: Laser scanning microscopy allows high magnification imaging of the preocular tear film and evaluation of a number of break-up mechanisms. The dynamics and structure of the tear film was analyzed and documented. Based on our observations we formulate a new hypothesis on the break-up mechanism of the preocular tear film caused by alterations in the epithelial surface, for example, an elevation or tear film microparticle. By evaluating video sequences in the fluorescence and reflection modus of the laser scanning ophthalmoscope we also found early thinning of the aqueous layer simultaneously with an intact lipid layer covering the aqueous layer., Conclusion: Additional criteria result from using high-magnification microscopy, for example, laser scanning microscopy. This method reveals more microstructures of the corneal surface and the preocular tear film. The morphological representation of break-up phenomena leads to a better understanding of the underlying mechanisms and can be used for further investigations. Confocal laser scanning microscopy supplements the examination facilities and can be used in addition to slit lamp microscopy and to diagnose "dry eye".

Background: This study quantified the geometric deformation of the capsular bag following implantation of various intraocular lenses (IOL) using a three-dimensional capsular bag model made of silicone caoutchouc., Methods: After implantation of 13 different IOLs (polymethylmethacrylate, silicone acrygel) into the artificial bag, the induced capsular bag deformation was measured and analyzed. The posterior space between IOL and capsule was examined by ultrasonographic biomicroscopy., Results: Polymethylmethacrylate IOLs with C-haptic design induced a greater deformation of the capsular bag than silicone lenses; however, both types showed a larger gap posterior to the IOL than acrygel lenses. Acrygel IOLs with different haptic design revealed only minimal deformation with close contact posteriorly., Conclusions: The presented three-dimensional model simulates the biomechanical and geometrical parameters of the vital capsular bag. Further investigations may determine a correlation of close posterior IOL contact and lens epithelial cell progression.

Background: An orbital carcinoid metastasis can be specifically imaged by octreotide scintigraphy. Orbital metastases of carcinoid tumors are rare. In the current literature only 27 cases have been published., Case Report: We report on a 59 year-old woman who presented with diplopia 6 years after resection of a carcinoid tumor of the ileum. She also complained about flush and diarrhea. The diplopia was caused by limited extensibility of the right inferior muscle. Computed tomography with contrast revealed an enhancing tumor in the area of the right inferior rectus muscle, which appeared in the MRT as an isointense structure in the T1-weighted image. On staging, we found a contrast-enhancing nodular hepatic lesion. In octreotide scintigraphy, enhancement of the liver, thoracic and abdominal para-aortic lymph nodes and of the right inferior orbit was found., Conclusion: The survival times of patients with orbital metastasis of carcinoid tumors range between 7 months and 11 years. No specific treatment is available. Surgical excision is indicated for a symptomatic solitary metastasis. Octreotide is helpful in two ways: (1) as a radiolabeled tracer to detect extra-abdominal and extrahepatic secondary tumors; (2) as a treatment modality for flush and diarrhea, which is successful in over 60% of patients (life expectancy uninfluenced). Our patient is presently being treated with 200 micrograms of octreotide three times a day subcutaneously. Flush episodes and diarrhea have been reduced, but her ophthalmologic symptoms remain unchanged, and she has recently developed cardiac insufficiency.

Unlabelled: The purpose of this report is to evaluate the efficacy of transpupillary thermotherapy (TTT) to treat choroidal melanoma., Patients and Methods: Twelve patients with choroidal melanoma were treated. Four with small tumors close to the posterior pole received TTT alone; 8 were treated simultaneously with TTT and Ru-106 brachytherapy. To perform TTT a diode laser with a beam diameter of 3 mm was used. Exposure time ranged from 60 to 90 s until the retinal surface became light gray. Follow-up examinations were performed at 1-month intervals. If the tumor was partially regressed, additional TTT was performed to reach the endpoint of a chorioretinal scar., Results: All tumors exhibited a reduction of tumor height in a maximal follow-up period of 6 months. Four cases showed complete regression within 3 months. Side effects were minimal., Conclusions: Treatment with TTT may be useful as a complementary modality to brachytherapy. A longer follow-up time is necessary for final evaluation.