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Einleitung: Die chronische Graft-versus-Host-Krankheit (cGVHD) ist eine Komplikation nach allogener Stammzelltransplantation (allo-HSCT), die mit hoher Morbidität und Mortalität einhergeht. Die gegenwärtig verfügbaren Medikamente sind nicht nur mit ausgeprägten Nebenwirkungen verbunden, sondern oftmals unzureichend wirksam. Ein neuer und vielversprechender Behandlungsansatz besteht in dem adoptiven Zelltransfer natürlicher regulatorischer T-Zellen (nTreg-ACT). Durch die Eigenschaft von nTregs, konventionelle T-Zellen (Tconv) zu supprimieren, könnte ihr adoptiver Transfer positive Effekte auf die immunologische Dysregulation der cGVHD erzielen. Erste klinische Studien deuteten bereits einen sicheren und effektiven Einsatz von nTreg-ACTs an, dennoch bestehen weiterhin Herausforderungen in der Produktherstellung und Daten zu pädiatrischen Patienten sind fehlend. Ziel dieser Arbeit war es daher, die weitere Charakterisierung von nTreg-Zellprodukten zu erarbeiten und nTreg-ACTs als adjuvante Therapieoption bei pädiatrischer cGVHD zu evaluieren. Methodik: Zwei Kinder mit schwerer cGVHD wurden im Rahmen eines individuellen Heilversuchs mit 3,0x106 nTregs/kg behandelt. Nach Zelltransfer wurde an definierten Follow-Up-Zeitpunkten der klinische cGVHD-Status erhoben und 71 verschiedene Immunzelltypen im peripheren Blut durchflusszytometrisch analysiert. Zusätzlich wurden nTregs aus unbehandelten und G-CSF mobilisierten Stammzellspendern magnetisoliert und polyklonal expandiert. Neben dem Expansionsverhalten wurde durch Färbung von CD4, CD25, FoxP3, IFN-γ, TNF-α, IL-2, CD154 und CD137 die nTreg-Produktreinheit und CD154/CD137-Expression durchflusszytometrisch bestimmt. Die Suppressionskapazität der nTregs wurde durch Nutzung CFSE-basierter Proliferationsassays ermittelt. Ergebnisse: Die Zellkulturexperimente zeigten, dass sich durch dreiwöchige Expansion mit IL-2, Rapamycin und wiederholter Beadstimulation Expansionsraten von bis zu ~100.000-fach erzielen lassen. Die Zellprodukte zeigten eine hohe Reinheit und eine deutliche Tconv-Suppression in vitro. Der Vergleich von unbehandelten und G-CSF stimulierten nTreg-Linien ergab eine ähnliche Zellexpansion und Produktreinheit. Weitere Experimente zeigten, dass CD137 keinen geeigneten Selektionsmarker für polyklonale nTregs darstellt. Der klinische Einsatz von nTreg-ACTs erwies sich als gut verträglich und führte zu keiner quantitativen Beeinträchtigung der angeborenen Immunität. Nach dem Zelltransfer konnte entweder eine klinische Stabilisierung oder eine deutliche, langfristige Verbesserung der cGVHD erzielt werden. Die immunologischen Begleituntersuchungen zeigten nicht nur einen nTreg-Anstieg in vivo, sondern auch erstmalig eine Zunahme von naiven B- und T-Lymphozyten nach nTreg-ACT. Schlussfolgerung: Diese Arbeit zeigt, dass sich nTreg-Produkte mit hoher Reinheit und suffizienter Funktionalität herstellen lassen. Die klinische Anwendung erwies sich als gut verträglich und zeigte neben einer Reduktion der cGVHD-Aktivität auch eine verbesserte lymphozytäre Rekonstitution sowie einen nachhaltigen Anstieg von nTregs in vivo. Nun sind große systematische Studien nötig, um künftig die breite und evidenzbasierte Anwendung von nTreg-ACTs in der Behandlung der (pädiatrischen) cGVHD zu ermöglichen., Introduction: Chronic Graft-versus-Host-Disease (cGVHD) is a severe complication after allogeneic stem cell transplantation (allo-HSCT) and associated with a high morbidity and mortality rate. The efficacy of currently available drugs is limited and frequently related with significant adverse effects. A new and promising therapeutic approach is the adoptive cell transfer of natural regulatory T cells (nTreg-ACT). Due to the ability of nTregs to suppress activated conventional T cells (Tconv), their adoptive transfer could achieve positive effects on immune dysregulation in cGVHD. First clinical data already implied safety and efficacy of nTreg-therapy, yet challenges remain with respect to cell manufacturing and data from pediatric patients are lacking entirely. Thus, this work aims at establishing an advanced characterization of nTreg-products and evaluating nTreg-ACTs as an adjuvant therapy in pediatric cGVHD. Methods: As a case of compassionate care, two children with severe cGVHD received treatment with 3.0x106 nTregs/kg. After cell transfer the clinical cGVHD status was assessed and 71 different immune cell subsets analyzed via flow cytometry at specific follow-up-timepoints. Additionally, nTregs from untreated and G-CSF-mobilized donors were immunomagnetically isolated and polyclonally expanded. Apart from its cell expansion, the product’s purity and CD154/CD137 phenotype were assessed via staining of CD4, CD25, FoxP3, IFN-γ, TNF-α, IL-2, CD154 and CD137 and flow cytometry. nTregs’ suppressive capacity was obtained via CFSE-based proliferation assays. Results: The experiments showed that three-week cell culture with IL-2, rapamycin and repeated bead stimulation achieved up to ~100.000-fold expansion. The cells showed high purity and distinct Tconv suppression in vitro. Comparing untreated and G-CSF-stimulated nTregs showed equal cell expansion and purity. Further experiments revealed that CD137 represents no feasible selection marker for polyclonal nTregs. The clinical application of nTreg-ACTs was well-tolerated and did not provoke a quantitative impairment of the innate immunity. After nTreg-ACT, either a short-term clinical stabilization or a significant, long-term improvement of cGVHD could be achieved. Immunological follow-ups showed not only an increase of nTregs in vivo, but also, for the first time, an enhanced engraftment of both, the Naïve B- and T-cell compartment, after nTreg-ACT. Conclusion: This work shows that nTreg products of high purity and sufficient function can be manufactured. Clinical application showed good tolerability and revealed, apart from a reduction of cGVHD activity, an improved lymphoid reconstitution as well as a long-term increase of nTregs in vivo. Now systematic studies are required to enable the broad and evidence-based implementation of nTreg-ACTs in the treatment of (pediatric) cGVHD.

The concept of a "comprehensive stroke unit" (in German: Erweiterte Stroke-Unit) is an additional structural option for those stroke units already certified in Germany. Its aim is to complement the semi-intensive management of stroke unit patients in Germany by early mobilisation and neuropsychological rehab procedures. This concept is recommended in many European countries as well. It is based on the proof of efficacy of the combined treatment package in several randomised controlled trials. According to the Helsingborg Declaration, every stroke patient in Europe should have access to a chain of care best provided by a comprehensive stroke unit. Both early mobilisation and rehabilitation treatment can be integrated and continued without creating an interface between the acute stroke unit and the general neurological or medical ward. The monitoring beds of the acute stroke unit and the non-monitoring "enhanced care" beds are located within the same geographical area of the hospital and are run as a comprehensive stroke care entity. Continuous management of the acute stroke patients by the same team on the same unit means an increase in quality of care, better usage of staff resources and an additional gain in time. The scientific background of the advantages of a comprehensive stroke unit is described as are the structural and staff requirements. The clientel particularly benefiting from treatment on wards with enhanced care beds is described, and the spectrum of treatment services is defined. This concept will be used as the basis for an add-on qualification of already certified German stroke units. An important step was to fit the requirements of the comprehensive stroke unit to the already existing facilities and their infrastructures. From an economic point of view, the comprehensive stroke unit is expected to be cost-effective, either balanced or even positive.

For prophylaxis or therapy of lagophthalmic keratopathy ointment application or hour glass dressing is indicated. The hour glass dressing has the disadvantage of a continuous visual impairment by steaming up of the moisture chamber. The main problem for the patients is the strong subjective feeling of physical handicap. A therapeutic alternative is the gravity dependent lidloading, which is known as gold implantation in cases of irreversible lagophthalmos.By lead weights of 0.8 to 2.0 g, which are fixed to the upper lid by a foil glueing on both sides (Tesafix) or in allergic patients by an adhesive layer, well tolerated by the skin (Combihesive), the lidclosure can become restored without impairment of lid-opening. In a controlled study the described method was first tested on 10 normal persons and than applied to 22 patients with lagophthalmos. Meanwhile the new method was applied to 32 further patients.The "liddynamic" procedure is effective and well tolerated; it is more accepted, especially during the day, because of better visual function and better cosmetics. The hour glass dressing, is still of importance in serious cases of keratopathy during the night."lidloading" with lead weights, which are glued by an adhesive layer to the upper lid, can be recommended as a new method in cases of reversible lagophthalmos or as a preparing step before a gold implantation.

In facial palsies with lagophthalmic keratopathy an hour-glass dressing is indicated, which has the disadvantage of a moisture chamber with visual impairment by steaming up. After weeks of placement dermal irritations are possible. An alternative is the gravity dependent lidloading, using gold implantation in cases of irreversible lagophthalmos.Lead weights of 0.8 to 2.0 g are glued to the upper lid with an adhesive layer, that is well tolerated by the skin (Combihesive*), or by a simple foil that is glued on both sides (Tesafix). This results in a lidclosure without impairment of lid opening. After tests on 10 normal persons the described method was placed on 22 patients with lagophthalmos and compared with hour-glass dressing. The new method was applied to 36 additional patients.The dynamic lead weight is effective and well-tolerated. It was more accepted cosmetically especially during the day because of better cosmetic appearance and better visual function than was the hour-glass dressing. These latter dressings are still important for use in serious cases during the night.lidloading with lead weights that are glued by an adhesive layer to the upper lid can be recommended as a new method in cases of reversible lagophthalmos or as a preparatory step before gold implantation.

In facial palsies with lagophthalmic keratopathy, an hour-glass dressing is indicated. This dressing has the disadvantage of a moisture chamber, visual impairment occurs by steaming up. After weeks of placement dermal irritations are possible. An alternative is gravity-dependent lid-loading, using gold implantation in cases of irreversible lagophthalmos.Lead weights of 0.8 to 2.0 g are glued to the upper lid with an adhesive layer that is well-tolerated by the skin (Combihesive*) or by a simple foil that is glued on both sides (Tesafix). This results in a lid closure without impairment of lid opening. After tests on 10 normal persons lid-loading implants were placed on 22 patients with lagophthalmos and compared with hour-glass dressing. The new method was also applied to 26 additional patients.The dynamic lead weight was effective and well-tolerated. It was more accepted eosine tically, especially during the day because of its better cosmetic appearance and better visual function than was the hour-glass dressing. These latter dressings are still important for use in serious cases during the night.Lid-loading with lead weights that are glued by an adhesive layer to the upper lid can be recommended as a useful method in cases of reversible lagophthalmos or as a preparatory step before gold implantation.

Thirty patients with irreversible facial palsy were treated with gold implants from 0.5 to 1.8 g. For the immediate treatment of postoperative facial palsies and reversible kinds of lagophthalmos, lead weights of 1.2 to 1.8 g ("lid dynamic eye dressing") are preferred to hourglass dressings. Insufficient orbicularis muscle function is compensated by the weight. The observation time for gold implants is more than 2 years; the fixation time of the adhesive lead weights is 1 to 10 days. Tolerance is excellent to both treatments. The principle is gravity dependent and is limited to the vertical and oblique head position. For sleeping at night, ointment application and pressure on the upper lid by a pillow are advisable; an additional hourglass dressing is possible. No serious keratopathies were seen in any cases. All patients found the return of lid motility from the restored levator muscle function to be a functional and cosmetic advantage. After weighing the advantages and disadvantages, especially the operative/technical expense in relation to the effective results, it would appear that simple lid-loading is so far the best method of treating lagophthalmos.

Therapeutic decisions in cases of arteriosclerotic stenosis of the internal carotid artery usually depend mainly on the degree of stenosis. However, the recommendations with regard to suitable ultrasonographic criteria are so controversial that even authors of repute describe "confusion" and "chaos in methodology".The aim of this study is to assess which of the most frequently recommended sonographic criteria for stenosis best fulfill the requirements of an exact quantification of stenoses of the internal carotid artery.In 42 consecutive cases the preoperative ultrasound findings were compared with the degree of stenosis in surgically removed specimens. The sonographic technique employed consisted of the analysis of 2 direct and 3 indirect hemodynamic criteria of stenosis. In 34 of these cases planimetry was performed, too. The specimens were obtained by eversion thrombendarteriectomy or arteriotomy; for determination of the degree of stenosis a Paladur molded cylinder was prepared and measured.Quantification of the haemodynamic criteria carries provided well with the endarterectomy specimens. Only in two cases there was a deviation of more than 10 %; however, in these two cases a change with time in the degree of stenosis was probably responsible for the discrepancy. In contrast, planimetry usually underestimated the degree of stenosis: In 61 % of the findings the ultrasonographic results differed by more than 10 % from the reference standard.Quantification of stenosis of the internal carotid artery should be made using a combination of direct and indirect haemodynamic ultrasonographic criteria.

In early stages choroidal peripapillary choroidal melanoma may be confused with a choroidal nevus or melanocytoma.A 41-year old female was diagnosed having a choroidal nevus in close proximity to the optic nerve head. Unfortunately the patient did not show up for annual review of this lesion. Ten years after the patient was examined for the second time. A massive increase in tumor size and prominence was noted including serous retinal detachment. Medical work up excluded any metastatic growth, and the globe was enucleated. Three years later, the patient is still healthy and there are no signs of metastatic spreading.Heavily pigmented peripapillary choroidal melanoma with fascicularly vasocentric proliferative structure, but no infiltration of the sclera or the lamina cribrosa of the optic nerve. The tumor cells were of midgrade size and some of the nucleoli were slightly enlarged. Mitosis and a syncytial structure were present. Immunohistochemically S-100 proteins, HMB 45 and NSE were found. The TNM classification was: ICD-O C 69.3; pT2, G1, S0, V0, pNx, pMx, microscopically RO.Pigmented juxtapapillary tumors resembling choroidal nevi require annual surveillance.

Limbal relaxing incision (LRI) is an easy and safe procedure to reduce astigmatism. It should be clarified, whether the effect is discussed controversely, because the varying corneal diameter and consequently the varying LRI position was not considered.56 patients aged 76 +/- 9 years with preoperative astigmatism of 1.6 D (0.6 to 7.0 D) underwent an almost astigmatically neutral cataract procedure (3.2 mm temporal clear corneal phacoemulsification with foldable lens implantation) and received independently from the given corneal diameter limbus related relaxing incisions of 80 degrees length and 0.6 mm depth. We performed the paired LRI in 4.5 mm, 5 mm and 5.5 mm distance from the corneal center on the steeper meridian.4.3 months postoperatively we observed an astigmatic reduction of -1.0 D (-0.1 to -3.2 D) following LRI with a 9 mm optical zone, LRI with 10 mm diameter led to an astigmatic reduction of -0.4 D (-0.1 to -2.9 D) and LRI with 11 mm diameter were followed by an astigmatic reduction of -0.3 D (+0.5 to -1.1 D). Undercorrections were more frequently observed in younger patients, overcorrections more in elderly people.The application of three different kinds of limbus related relaxing incisions, with 4.5, 5 and 5.5 mm distance from the corneal center or 9, 10 and 11 mm optical zone respectively, corresponds to the variable anatomic situation of the limbus, therefore leading to nearly predictable data and explaining the divergent results of previous reports. The nearer the LRI is applied to the corneal center, the stronger is the relaxing effect.

In case of a spheric cornea preoperatively the refractive effect of a clear corneal cataract incision is undesirable. We studied two actual techniques to minimize the surgically induced astigmatism.Temporal clear corneal incision was performed in 77 patients with practically spherical cornea (0.2 +/- 0.1 D). 27 patients with 4.1-mm clear corneal stretch incision and 5 mm PMMA lens implantation served as control. 25 further patients were operated on with the same technique, but 2 additional limbal relaxing incisions (LRI) of 0.55-mm depth and 8 mm length at 6 and 12 o'clock were performed. In 25 patients a foldable acrylic lens (Acrysof) was implanted through a 3.2-mm temporal clear corneal incision. Corneal topography results were evaluated in all patients by the Jaffe and the Holladay analysis.The surgically induced astigmatism of 0.8 +/- 0.5 dpt in the control group was reduced to 0.4 +/- 0.3 dpt by LRI and by reduction of the incision size as well in the treatment groups. With-the-wound-change (WTW) in the Holladay analysis was 0.6 +/- 0.7 dpt in the control group and around 0 in the groups with astigmatism reducing techniques.To preserve a spherical cornea in clear corneal-tunnel incision, compensating limbal relaxing incisions (LRI) or ultra-small incisions with foldable lens implantation should be performed.

To prevent surgically induced astigmatism following clear corneal cataract surgery.Limbal relaxing incisions of 6 or 8 mm length respectively and 0.5 mm depth were performed in 52 patients with spheric cornea or astigmatism with the rule of 0.8 +/- 0.3 dpt after temporal corneal cataract incision. The same amount of patients, operated on with the same surgical procedure except keratotomies, served as control.After 6 months the with-the-wound-change (WTW) in the LRI axis using the Hollady method was -0.08 +/- 0.5 dpt in the spheric cases with limbal keratotomy and +0.5 +/- 0.7 dpt in the control cases. The patients with preoperative astigmatism with the rule showed a WTW in the LRI axis of -0.09 +/- 0.5 dpt in the keratotomy cases and +0.39 +/- 0.7 dpt in the corresponding control patients.Limbal relaxing incision is a reliable and safe procedure to reduce postoperative astigmatism after cataract surgery.

We report the clinical course of a 48 year old woman, who underwent a cranial MRI-examination in 1995, which confirmed the diagnosis of encephalomyelitis disseminata, but also showed a left temporal venous malformation without evidence of prior hemorrhage. Three month after immunosuppressive treatment with Methotrexate in 1997 begun, first hemorrhage in the left temporal lobe occurred with de novo formation of a cavernoma in association to the known venous malformation. The lesion was totally removed after stereotactic guided craniotomy without any complication. The pathogenetic relationship of de novo cavernomas and associated venous malformations and the remarkable association with immunosuppressive treatment will be discussed.

Refractive cataract surgery using corneal incisions is aiming at neutralization of preoperative astigmatism.61 patients with preoperative astigmatism of 2.25 +/- 0.98 were included in the treatment. A self-sealing corneal tunnel incision measuring 4.0 to 4.1 mm in external diameter and 6.5 to 7.0 mm in internal diameter (stretch incision) was performed on the steeper axis. After capsulorhexis and phacoemulsification a 5 mm PMMA lens was implanted without suturing. Keratometry and corneal topography were performed preoperatively, 3 days and 1 year respectively following surgery. The statistical analysis was based on the Wilcoxon signed ranks test.Surgical induced astigmatism (IA) following superior incisions in cases of astigmatism with the rule (n = 29) amounted to 1.93 +/- 0.97, while lateral incisions in cases of astigmatism against the rule (n = 29) led to an IA of 1.35 +/- 0.73. Axial shifts by more than 30 degrees were 23% following superior incisions and 17%, after lateral incisions. We observed. astigmatic reduction of 1.3 D after superior incisions and 0.7 D following lateral incisions.By 4 mm corneal cataract incisions on the steeper axis a high preoperative astigmatism can be reduced significantly without additional keratotomies.

No reviews of orbital gunshot injuries have been published in German ophthalmological journals. In this article biomechanical and prognostic factors of this rare type of injury are analysed.We report on 4 patients, aged 20-63 years, who tried to commit suicide by shooting themselves in the right temple. Clinical and radiological diagnosis as well as treatment by an interdisciplinary team are reported.All patients became blind on the right side despite immediate surgery including reconstruction of the injured bones and soft tissues. Three of four patients suffered severe functional defects in the left eye; one of them is now blind.Orbital gunshot wounds are severe injuries. The prognosis depends on the course of the bullet and the interdisciplinary care.

Unpigmented tumorous changes of the conjunctiva can frequently be classified as chalazion, basalioma or carcinoma.In a 70 years old diabetic female a 2.5 x 2.5 cm tumor of the lower conjunctival fornix was observed. After complete excision the tumor was examined by histologic routine procedures and immunohistochemically. The patient was irradiated by 40 Gy with the linear accelerator.The monotypical secretion of the heavy chain gamma and the light chain kappa demonstrated a well differentiated extramedullar plasmocytoma. A MALT lymphoma could be excluded by the absence of centrocytoid cells. The bone cytology and histology did not give any evidence for a medullar plasmocytoma. The patient is free from local or diffuse tumor growth since 2 1/2 years.Since the worldwide most important ophthalmopathologic statistics of the AFIP from 1984-1989 describes only 1 plasmocytoma out of 2104 tumors of the lids and conjunctiva, the demonstrated case is an important rarity.

The procedures for prophylaxis and treatment of keratopathy following facial palsy with lagophthalmos are unsatisfying from the functional point of view.Three years ago we created a "lid-dynamic" procedure and applied it to 46 patients with Bell's palsy or before implantation of a gold lid weight. Fixation of lead weights of 0.8-2.0 g to the upper lid by a foil adhesive on both sides (Tesafix), can lead to restoration of lid closure. Within 6 years we implanted 24-carat gold weights into the upper lid in 72 patients.In all cases lid function was markedly improved; all patients appreciated the procedure. The lead weights were well tolerated. In 27% of the operative cases we observed a slight underdosage, in 10% a slight overdosage.Lid loading is a simple and effective method for functional and cosmetical rehabilitation of patients with lagophthalmos. Despite the dependence upon gravity, the procedure can be recommended for all cases of facial palsy.

Having changed our cataract operation technique from ECCE to phacoemulsification (PE) we had the impression of less fibrinous membranes postoperatively.To ascertain whether our impression was correct, we examined the last 2056 IOL implanted cataract patients retrospectively.In the 2056 cataract cases we found 152 fibrinous reactions (7.4%). We observed after ECCE (n = 586) a 12.8% rate of fibrinous membranes, after phacoemulsification (PE) with sutured 6.5-mm corneoscleral incision (n = 546) 7.0%, and after PE with clear corneal self-sealing 4.1-mm incision (n = 924) only 3.9%. In 56% of these patients we found diabetes, in 13% former uveitis with posterior synechiae, in 11% glaucoma with rigid pupil, and in 10% pseudoexfoliation syndrome. In those cases with no diabetic retinopathy but known diabetes (n = 198), we found a 27% rate of fibrin reactions following ECCE (12 mm), 12% following PE (6.5 mm) and 8% following PE (4.1 mm). In non-proliferative diabetic retinopathy (n = 80) a 32% rate of fibrinous changes was observed after ECCE, 18% after PE (6.5 mm), and 9% after PE (4.1 mm). In cases of uncomplicated ECCE (n = 341) the rate of fibrinous reactions amounted to 22.4% following prolonged procedures (50 min) by residents, while it was as low as 9.5% following operations of short duration (30 min) by experienced surgeons. Intraocular injection of tPA (25 micrograms) was the most effective treatment.The self-sealing corneal small incision cataract technique guarantees a short duration of the surgical procedure and the last fibrinous reactions.

Postoperative fibrinous reactions following the small-incision technique seem to be very rare. Problem cases can be treated with tissue Plasmin Activator.To investigate the new prophylactic and therapeutic possibilities the last 2,056 cataract procedures with PMMA lens implantation were statistically analyzed.In 152 (7.4%) fibrin cases we observed after ECCE (n = 586) 12.8%, after phacoemulsification (PE) with sutured 6.5-mm corneoscleral incision (n = 546) 7.0% and after PE with clear corneal selfsealing 4.1-mm incision (n = 924) only 3.9% fibrinous reactions (p0.01). In case of ECCE the rate of fibrinous reactions amounted to 22.4% following prolonged procedures (50 min), while it was low as 9.5% with a short period of time (30 min) (p0.01). In 8 steroid-resistant cases we applied 25 micrograms Plasmin Activator intraocularly. The injections led to complete dissolution of the fibrinous membranes without complications.Postoperative fibrinous reactions can be reduced statistically significantly by application of the corneal small-incision technique. The most efficient therapy is intraocular Plasmin Activator fibrinolysis.

Self-sealing corneal cataract procedures have been known since 1992 and are recommended for foldable silicon lenses. Our goal was a technical modification without refractive disadvantages, which would also allow for the implantation of more rigid, but less expensive PMMA lenses of high optical quality.The "scleral stretch incision" by Freeman (1991) was applied to the corneal situation by widening the inner wound lip up to 6.5 mm; this makes it possible to implant a 5 mm optic through an outer wound opening of 4-4.2 mm. This method has been used since October 1992 on 980 patients, whereby the lamellar corneal incision was placed 1.5-1.8 mm deep to compensate for the astigmatism, if possible in the steeper meridian.The first 107 cases were followed up for longer than 6 months; they showed a surgically induced astigmatism of 1.18 +/- 0.79 D and a postoperative astigmatism of 0.86 +/- 0.70 D. Neither postoperative infection nor hypotony was observed in any of the cases.The modified corneal tunnel incision is recommended for 5 mm PMMA lenses; this is especially suited for cases of low to midgrade preoperative astigmatism that can be optimally improved by this procedure. In cases of pure spheric refraction, a 3 to 3.5 mm incision with foldable lens implantation is preferred.

Can the capsulotomy with small radial incisions compared to the continuous curvilinear capsulorhexis with perfect IOL centration still be recommended? This problem should be clarified under standard conditions.On 100 patients both procedures were applied alternating with corneoscleral incision, phacoemulsification and endocapsular implantation of a 6 mm one-piece PMMA lens.The perfect IOL-centration following capsulorhexis (0.25 +/- 0.31 mm) is confirmed. But the circular capsular fibrosis can make it difficult to examine the fundus periphery or to perform a secondary cataract aspiration. The IOL centration after capsulotomy is not always ideal (0.55 +/- 0.51 mm) but sufficient. Advantages are the simplicity of the procedure and an easy approach to the posterior capsule in case of secondary cataract.Both methods are still appropriate.

In 20 patients with irreversible facial palsy, dynamic voluntary lid closure was achieved by implantation of 0.8-1.6 g gold weights in the upper lid. Because of the high rate of efficiency, low complication rate and technical simplicity, this method is recommended more often than comparable procedures (magnet or wire-spring implantation).

Results of the 32P uptake test for the diagnosis of choroidal melanoma in 41 patients are reported. The sensitivity was 80%, the specificity 86%, if a count rate ratio of more than 1.4 between tumor and normal tissue was considered as pathological. Ratios between 1.4 and 1.6 ought to be considered as equivocal in which case specificity increases to 90%. The 32P uptake test still remains a method of clinical relevance in the diagnosis of choroidal melanoma.

Seven weeks after a generalized cerebral seizure a 27-year-old woman from Ghana developed nausea, vomiting and weight loss, gradually increasing over two weeks. Cranial computed tomography revealed several hyperdense formations with extensive associated oedema and a midline shift. Among extensive biochemical tests only a raised erythrocyte sedimentation rate of 24/50 mm and leukopenia of 2,600/microliters (with normal differential count) were notable. Diagnostic laparotomy was performed because of sonographic and computed tomographic evidence of enlarged abdominal lymph nodes. Histological examination of representative lymph nodes and of tiny nodules deposited on the peritoneum revealed caseous granulomatous inflammation. Mycobacterium tuberculosis was cultured from these specimens. Antituberculosis treatment was started with 0.3 g/d isoniazid, 0.6 g/d rifampicin, 2 g/d pyrazinamide and 1 g/d streptomycin, plus dexamethasone, 4 mg four times daily. After eight weeks treatment an intracerebral focus, removed to exclude neoplasm, proved histologically to be a tuberculoma. Only after four months was it possible to reduce the glucocorticoid dosage to prednisone, 20 mg/d. The antituberculosis treatment was continued for 18 months, with only isoniazid and rifampicin taken during the last 14 months. Final clinical and biochemical examinations were unremarkable. Computed tomography demonstrated regression of the abdominal lymph nodes and the cerebral foci. The patient was without any symptoms.

Of 57 patients at Karlsruhe Municipal Eye Hospital with manifest acquired immune deficiency syndrome, ocular involvement was found in 34%. In the prefinal stage (on average 6 months ante finem), 25% of these patients developed typical, rapidly progressing cytomegalovirus retinitis with intraretinal hemorrhages and necrosis, which responded well to combined intravenous and intravitreal DHPG therapy. Almost all the patients died of global respiratory insufficiency caused by pneumocystis carinii or atypical mycobacteria.

This study reports on clinical and electromyographical findings which were obtained from an examination of male dizygotic twins and their father, who all suffered on a paramyotonia congenita. A simple coldness test can be used to distinguish paramyotonia congenita from myotonia congenita. Systematic cooling of the muscle of subjects with paramyotonia congenita leads to muscle stiffness and paresis, and finally to paralysis. An electromyographic analysis was carried out at various degrees of coldness. More than 300 paramyotonic series of discharges were analysed in respect to duration, amplitude and frequency. The results showed that the paramyotonic series are more similar to those of dystrophia myotonica than those of myotonia congenita.

Infrared pupillography was used to determine physiological time parameters of the direct phasic light reflex in 101 normal subjects. These parameters include latency, contraction and redilatation times as well as total reaction time, measured in response to 4 different light stimulus intensities. A total of more than 4000 pupillary stimulations in these subjects was analyzed statistically. The study of these time parameters included determination of the mean, the standard deviation and three dimensional analysis of variance, with the following results: 1. The physiological time parameters are bilaterally symmetrical. 2. The most stable parameters with least variability in an individual subject were latency and contraction time. The redilatation time, however, showed marked intra-individual variability. 3. Variance analysis revealed a high degree of correlation among the different parameters to light stimuli of varying intensity. 4. There was a highly significant prolongation of latency and of contraction time with increasing age. 5. No sex dependent effect on physiological time parameters was found. In addition, no interaction among light stimulus intensity, age and sex could be detected. Possible applications of the method for clinical neurological examination are discussed.

A report on 22 patients with idiopathic facial paralysis is given. A systematic interdisplinary examination in short intervals was carried out. The efficiency of the more time consuming and technically more difficult methods was checked. At the same time it was investigated whether as a result of these findings new aspects of early therapy and prognosis could be expected.

With a modified method of infrared pupillography--especially developed for the use in clinical neurological routine diagnosis--the time course of the direct phasic pupillary light reflex in man was investigated under physiological and pathological conditions. The described method allows a high resolution of the time course of the light reflex and is superior to kinematographic as well as video-methods described so far. Normally the physiological time parameters are bilaterally symmetrical, also in cases of so-called physiological anisocoria. On the other hand in pathological anisocorias of various etiology pronounced side-differences and abnormal time parameters can be found. Also in cases of isocoria with clinically no abnormal findings of pupillomotor response pathological side-differences can be determined by infrared pupillography. Disturbances of the afferent arc, of the efferent arc and of combination of those as well as pupillary abnormalities to be located in the midbrain area, can be exactly analyzed and documented. Furthermore the method allows an objective documentation of the course in cases of dysfunction of the autonomic nervous system, like in intoxications, or to monitor drug-induced therapeutical measurements. The investigations and findings indicate that infrared pupillography, an objective method for analyzing the dynamics of the pupillary light reflex, is suitable for clinical neurological routing diagnosis.

A report on the neurological results of an investigation carried out on 38 patients with pigmentary degeneration of the retina. The ophthalmological investigation did not indicate a systemic disease. The neurological findings, however, revealed a systemic disorder in many cases.-The constitutions of 20 patients (52.5%) were marked by pathological stigmata. The EEG was abnormal in more than 50% of the cases. The EMG showed a prolonged nerve conduction time for 2 of a total of 4 deaf patients. The EMG also revealed a patient with both pigmentary degeneration of the retina and a mold form of myasthenia gravis. The biochemical results indicated hyperlipoproteinemia in 6 cases (15.8%), diabetes mellitus in 2 cases and a pathological increase of uric acid in the serum in 8 cases. These results suggest that pigmentary degeneration of the retina is not a homogenous disease. It must be seen as a "phenomenologically identical, polygenetic type of reaction" (Janzen). A comprehensive analysis of the individual case can therefore lead to implications which are of direct therapeutic significance.

A report given of a 32-year-old female patient who exhibited a unilateral paradoxical pupillary reaction to light, but was obviously healthy in all other respects. All of the neuroophthalmological findings, including the infrared reflex-pupillographic results registered, are indicated and discussed in detail in the report. An analysis of the findings leads to the conclusion that this disturbance has a central, prenuclear location. Apart from a stenosis at the junction of the arteria vertebralis, which was determined angiographically, further examination did not reveal any pathological findings.

In a survey of 46 patients with haemagioblastoma of the CNS (Neurology Dept. University Hamburg, 1950-1980) most (n = 40) were found to have angioblastomas of the cerebellum (Lindau tumors). Of these patients 21 were re-examined in 1983. Headache was the most frequent initial symptom (43%), and within this group one-third (10%-15%) had dizziness, sensorymotor deficits and cerebellar gait disturbances. Signs of elevated intracranial pressure much more often led to the correct diagnosis than dizziness or dystaxia. After the introduction of CCT to the diagnostic procedure the combined evaluation of angiography of the vertebral arteries and CCT always permitted the correct diagnosis. The low neurosurgical mortality rate (13.5%) has decreased to 0% within the last decade. No relapses were found in 21 re-examinations including CCT and EOG compared to a frequency of 9.7% in all 46 cases. Significantly less often than expected from other data we found: signs of possible hereditary influence (0%), multiple tumor localization combined with angiomatosis retinae (0%), polyglobulia (10.8%). Psychopathologically relevant signs (45.6%) were, in all cases, combined with signs of increased intracranial pressure. The results of our re-examination demonstrate that late postoperative deficits as well as possible relapses are earlier and more precisely evaluated by the combined use of clinical examination, CCT and EOG.

A case of anterior cleavage syndrome in a 27-year-old female patient is described. It is remarkable for the unusual completeness and prominence of the symptoms. In addition to medodermal anomalies of the anterior segment (e.g., prominent ring of Schwalbe, posterior embryotoxon, peripheral anterior synechiae, hypoplasia of the iris stroma) the case also manifested microcornea, cataract, glaucoma, excessive myopia, partial anodontia vera with maxillary hypoplasia and telecanthus. It is the first time that Rieger's syndrome has been described in association with endocrine orbitopathy, caused by hyperthyroidism with isolated elevation of T3 in the blood serum and a soft struma. Possible genetic correlations and the role of the secondary glaucoma in the two syndromes are discussed.

Botulinus poisoning generally ends fatally after an only short course, mild forms being rare. In four members of a family who had eaten deep-frozen grilled sausages symptoms of botulinus poisoning developed, predominantly marked by disturbances of the autonomic nervous system. The course was so mild that hospitalization was not necessary nor was specific antitoxin administration. All clinical symptoms had disappeared after nine weeks. But special clinical and neurophysiological studies (electromyography, pupillography, electroencephalography) demonstrated abnormalities for very much longer. Botulinus poisoning was proven in animal tests and neutralization tests with botulinus antitoxin. The epidemiology, source of infection, and clinical symptoms suggest botulinus type B poisoning.