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PubMed1990

Differentiation of ischemic from non-ischemic central retinal vein occlusion during the early acute phase.

We investigated prospectively in 128 patients (140 eyes) the role of six routine clinical tests in the differentiation of ischemic central retinal vein occlusion (CRVO) from non-ischemic CRVO during its early acute phase. There were four functional tests [visual acuity, visual fields, relative afferent pupillary defect (RAPD), electroretinography (ERG)] and two morphologic tests (ophthalmoscopy and fluorescein fundus angiography). We found that none of the six tests had 100% sensitivity and specificity in such a differentiation during the early, acute phase, so that no one test can be considered a "gold standard"; however, combined information from all six is almost always reliable. Overall, the four functional tests proved far superior to the two morphologic tests in differentiating ischemic from non-ischemic CRVO:RAPD was most reliable in uniocular CRVO (with a normal fellow eye), followed closely by ERG in all cases; combined information from RAPD and ERG differentiated 97% of cases; perimetry was the next most reliable, followed by visual acuity. The two morphologic tests performed worst; fluorescein angiography provided either no information at all on retinal capillary nonperfusion (in at least one-third of the eyes during the early, acute phase) because of multiple limitations, or sometimes provided misleading information. Ophthalmoscopic appearance is the least reliable, most misleading parameter.

Acute Disease↗

PubMed1990

Ocular toxicity of multiple intravitreal DHPG injections.

Intravitreal 9-[2-hydroxy-1-(hydroxymethyl) ethoxymethyl] guanine (DHPG) has been advocated as an alternative mode of therapy in cytomegalovirus (CMV) retinitis in the acquired immunodeficiency syndrome (AIDS) because of toxic neutropenia which is a complication of systemic intravenous DHPG. The recommended regimen requires injection of 200 micrograms DHPG intravitreally twice a week for a period of several weeks to months to control the progression of CMV retinitis. A previous study performed to determine the safe dose of intravitreal DHPG was based on a single intravitreal dose study; it does not consider the toxicity which may arise from multiple intravitreal injections of DHPG as it is utilized in the treatment of patients with CMV retinitis. In our study, intravitreal injections of 1000, 400, 200, 100, 50, and 25 micrograms DHPG were administered weekly for a period of 5 weeks in rabbit eyes. Ocular toxicity was monitored using slit-lamp biomicroscopy, indirect ophthalmoscopy, electroretinography, and light and electron microscopy. Electroretinographic evidence of retinal toxicity was found with doses as low as 100 micrograms. Electron-micrographic studies of retinal tissue from the eyes injected with even lower doses (as low as 25 micrograms) also showed evidence of toxic vacuolization in the inner segments of the photoreceptor.

Animals↗

PubMed1986

Development of traction retinal detachments following intravitreal injections of retinal Muller and pigment epithelial cells.

We injected varying numbers of retinal Muller glia into the rabbit vitreous in an established model of traction retinal detachment. We used indirect ophthalmoscopy to observe the changes elicited during the following 1 month. Although the severity of the tractional changes increased with increasing numbers of the glial cells, the pathology produced stabilized within the 1st week of injury. Muller glia were less effective at eliciting retinal detachments than retinal pigment epithelial cells (RPE) or mixtures of glia and RPE. Intravitreal tissue membranes derived from the glia differed morphologically from those derived from RPE. The glial membranes had fewer fibroblast-like cells, synthesized less extracellular matrix, and showed lower intravitreal cell proliferation, as determined by 3H-thymidine radioautography. Our findings indicate that membranes composed only of Muller glial cells promote less severe retinal pathology than those membranes composed of RPE or mixed cell types.

Animals↗

PubMed1993

Resident recognition of open-angle glaucoma: effects of an educational intervention.

To test an educational intervention's effect on improving detection of glaucoma by direct ophthalmoscopy, 14 medicine residents examined five patients, two with ophthalmoscopic changes of glaucoma and three with normal fundi. The residents observed a standardized slide/narrative educational intervention reviewing glaucomatous ophthalmoscopic changes and then re-examined the same patients eight to 12 weeks later. The intervention's odds of improving residents' diagnostic impression were significant (OR = 2.2; 95% CI = 1.3-3.6), with significant improvement in sensitivity (p = 0.02) and a trend toward improved specificity. These findings confirm that the diagnosis of glaucomatous ocular changes on eye examinations by medicine residents can be improved with a brief educational intervention.

Clinical Competence↗

PubMed2002

[Traction retinal detachment, optic atrophy, apallic syndrome after shaking trauma in an infant].

INTRODUCTION: Ophthalmological examinations are important in children with suspected shaken baby and/or battered child syndrome. Retinal and epiretinal haemorrhages can indicate non-accidental injuries. We observed a case of extensive retinal hemorrhages, edema of the optic disc followed by development of optic atrophy, neovascularisation and tractional retinal detachment over the course of months. CASE REPORT: A 6-week-old infant with no history of systemic disease or trauma was admitted to the children's hospital because of a disorder of consciousness, respiratory insufficiency, taut fontanel and dilated pupils with sluggish reaction to light. A subdural haematoma was diagnosed. Ophthalmological examination showed no signs of trauma in the anterior segment. Ophthalmoscopy revealed extensive retinal haemorrhages and swollen optic nerve heads. During the next months optic atrophy, subretinal fibrosis at the posterior pole, neovascularisation at the optic disc and non-rhegmatogenous retinal detachment developed. The child is in a persistent vegetative state. DISCUSSION: Non-accidental injuries can cause direct trauma and indirect traumatic sequelae. Retinal haemorrhages, especially in conjunction with unexplained trauma or changes of consciousness should arouse suspicion of shaken baby syndrome. The ophthalmologist should emphasize this and strongly recommend further investigation if not previously undertaken.

Battered Child Syndrome↗

PubMed2002

[Indocyanine green angiography in choroid metastases].

BACKGROUND: Up to now the diagnosis of choroidal tumors was mainly based on ophthalmoscopy and ultrasound examination. Indocyanine green angiography allows the identification of vascular patterns in these tumors, which could be helpful in the differential diagnosis. The aim of the study was to characterize the staining patterns of choroidal metastases. METHODS: In the years 1996-2000 we performed ICG-A of 15 choroidal metastasis using the scanning laser ophthalmoscope from Rodenstock. The mean tumor height was 3.7 mm (2.0-9.0). These angiographies were compared to the angiographies of 38 choroidal malignant melanomas with a mean height of 3.6 mm (1.4-6-6). RESULTS: All metastases showed a blockage of the background staining and a patchy staining of the tumor surface. Intratumoral vessels could be detected in 13% of all cases of metastases. The choroidal melanomas examined showed a blockage of the background staining in all cases and tumor vessels in 89%. CONCLUSION: The angiographic picture of the metastatic lesions was characteristic. Intratumoral vessels could not be detected using ICG-A. Most of the metastases showed a patchy staining of the tumor surface.

Angiography↗

PubMed2002

[Fundus autofluorescence after selective RPE laser treatment].

BACKGROUND: The selective RPE laser treatment is a new technique which selectively damages the RPE and avoids adverse effects to the neural retina. A problem is the ophthalmoscopically non-visibility of the laser lesions. The aim of the study was to investigate whether fundus autofluorescence (AF), which is derived from the lipofuscin contained by the RPE cells, is changed due to the RPE damage, and thus may be used for non-invasive treatment control. METHODS: A total of 26 patients with macular diseases, i.e. diabetic maculopathy (DMP), soft drusen maculopathy (AMD) and central serous retinopathy (CSR), were treated with repetitive short laser pulses (800 ns) from a green Nd:YAG laser (parameters: 532 nm, 100 and 50 pulses at 500 and 125 Hz, retinal spot diameter 200 micrometer, pulse energies 70-175 microJ). AF was excited by 488 nm and detected by a barrier filter at 500 nm (HRA, Heidelberg engineering). Patients were examined by ophthalmoscopy, fluorescein angiography and autofluorescence measurements at various times after treatment (i.e. 1 h, 1 and 6 weeks, 3, 6 and 12 months). RESULTS: None of the laser lesions was ophthalmoscopically visible during treatment although fluorescein angiography showed leakage of the irradiated areas. Identification of the lesions was possible by AF imaging showing an intensity decay in the irradiated area in 22 out of 26 patients, predominantly in patients with CSR and AMD. Lesions could be identified as hypoautofluorescent spots 1 h after treatment. During follow-up the laser spots became hyperautofluorescent. In patients with DMP some AF images were less helpful due to diffuse edema and larger retinal thickness. CONCLUSION: Imaging of non-visible selective RPE laser effects can be achieved by AF measurements predominantly in patients without retinal edema. Thus AF may replace invasive fluorescein angiography in many cases to verify therapeutic laser success.

Adult↗

PubMed2004

[Hereditary retinochoroidal dystrophies. Part 1: Pathogenesis, diagnosis, therapy and patient counselling].

Hereditary retinochoroidal dystrophies are a heterogeneous group of disorders characterised by progressive loss of visual acuity or visual field. They can manifest at every age of life. The basic knowledge of retinal physiology and pathophysiology, diagnostic approach, therapeutic limitations and patient counselling are summarised. Hereditary retinochoroidal dystrophies are usually monogenic disorders. The diagnosis is based on a combined assessment of patient history and the results of morphological, electrophysiological, psychophysical and molecular genetic evaluations. Patients should undergo measurement of refraction and visual acuity testing, perimetry, ophthalmoscopy, full-field and multifocal electroretinography. Additional methods, e.g. fluorescein angiography, electrooculography or laboratory testing are helpful in certain cases. For promising new methods like measurement of retinal pigment epithelium autofluorescence or optic coherence tomography further evaluation of their value for differential diagnosis is required. General molecular genetic testing is still limited due to technical and financial limitations. A detailed differential diagnosis and long-term follow-up are advisable for patient counselling and the development of new therapeutic options. To date, therapy is limited. Major tasks for the ophthalmologists are providing low vision aids and adequate patient counselling.

Adult↗

PubMed1997

[Intraocular involvement of Chagas disease (American trypanosomiasis). Studies in Paraguay/South America].

BACKGROUND: In Central and South America, Chagas' disease is of great epidemiologic importance. The epidemiologic agent is represented by Trypanosoma cruzi, a monocellular parasite, instrumental in human infection is the presence of vectors, which are various species of hematophagous bugs. The eye is one of the most important entrance sites of the parasite, and relatively little information about the relationship between Chagas' disease and eye complications is available. PATIENTS AND METHODS: We examined 79 chagasic patients in order to detect changes in the retina. As a control group, we examined 48 patients with negative serology within the same age range and from the same regions. For every patient we completed a routine ophthalmologic examination, with inspection of the retina using direct and indirect ophthalmoscopy. RESULTS: In most of the chagasic patients, the ocular fundus was unobtrusive; in only 6 out of 79 cases (7.6%) we did observe small parafoveolar retinal pigment epithelium defects and in 1 case (1.3%) distinct pigment epithelium atrophy of the posterior pole. No comparable findings were observed in the control group. CONCLUSION: Compared with the examination results of the control group, in the patients with intermediate and chronic Chagas' disease we observed an accumulation of retinal pigment epithelium defects, which, however, did not cause a significant loss of vision.

Adolescent↗

PubMed1997

[Prevalence of patients with diabetes mellitus without and with retinopathy in an ophthalmology practice].

OBJECTIVE: In a prospective study 10,000 consecutive patients were interviewed and examined in a German ophthalmology practice to evaluate the prevalence of diabetes mellitus and diabetic retinopathy. PATIENTS: Out of all patients 496 (4.96%) suffered from diabetes. In most patients (488:230 male, 258 female; mean age: 66 +/- 15 years) a clinical workup including demographic data and binocular ophthalmoscopy was performed. RESULTS: Diabetic retinopathy (DR) was present in 130 (26.6%) of the 488 diabetic patients. Subgroup analysis showed a higher prevalence of diabetic retinopathy in patients with insulin therapy (85 of 149; 57%) to those treated with oral antidiabetics (37 of 198; 19%) or diet only (8 of 141; 6%). The prevalence was significantly correlated with the duration of diabetes in the groups treated with insulin (P < 0.01) and with oral antidiabetic drugs (P < 0.001). Mild or moderate non-proliferative DR was found in 93 patients (19%), severe non-proliferative DR in 23 patients (4.7%) and proliferative DR in 14 of 488 patients (2.9%; 13 with insulin-dependent diabetes). Clinically significant diabetic macular edema was identified in 41 patients (8.4%). In 48 (9.8%) laser coagulation had already been performed: 13 cases with panretinal scatter, 18 with a focal coagulation, 17 cases with both. CONCLUSIONS: The prevalence of diabetes mellitus in a German ophthalmological referral practice is similar to the total prevalence in Germany (4.9%). Diabetic retinopathy was found in fewer patients than reported in the Wisconsin Epidemiologic Study and other recent studies in other countries. The data in this study showed that regular screening of all diabetic patients is mandatory.

Adolescent↗

PubMed1999

[Quantification of functional retinal damage in branch retinal vein thromboses].

PURPOSE: Branch retinal vein occlusion (BRVO) induces variable functional deficits depending on the grade of vascular occlusion and its localisation. Theses deficiences are not easily defined by visual acuity measurements. However, microperimetry offers topical mapping of retinal function, allowing precise documentation of the intensity and dimension of retinal functional loss in BRVO. METHODS: Retinal sensitivity was examined using a Rodenstock Scanning Laser Ophthalmoscope (SLO). A standardized grading system of stimuli ranging from 0 to 32 dB was used to document the retinal threshold in three different areas: regions presenting vascular occlusion, the collateral edematous zone and adjacent areas with intact perfusion. Absolute and relative scotomas as well as the fixation behavior were studied. RESULTS: Forty-two patients with isolated BRVO within the vascular arcades were examined with microperimetry and angiography. At initial presentation with BRVO the retinal sensitivity in the area of occlusion on average diminished to 4.1 dB. In the collateral edematous zone retinal threshold was reduced to 21.5 dB; area with intact perfusion demonstrated a threshold of 23.2 dB. Within the occluded area itself defects of significantly differing intensity were found which only partially correlated with the angiographic evidence. Intense scotomas (0 dB) were observed in 59% of the eyes examined: angiographically nonperfused areas or extended intraretinal hemorrhage were present. Relative scotomas (12.1 dB) were seen in 19.1% and minimal, non-significant defects (19.5 dB) were documented in 21.4% of the BRVO. The level of angiographically documented leakage did not correlate with the functional deficits present in these two groups. Measurements performed after 6-8 weeks revealed noticeable spontaneous recovery of retinal sensitivity, unless an additional progressive closure occurred. The average functional improvement in the area of leakage found after laser therapy was less than the results shown in spontaneous resolution of edema. CONCLUSIONS: BRVO may lead to significant reductions of central and paracentral retinal function. Angiographically observed leakage is not always directly correlated to the magnitude of retinal sensitivity loss. As spontenous remission is frequent in one group and intact retinal function can be shown in areas of angiographic leakage, therapeutic interventions, e.g., laser treatment, should be carefully considered. Scanning laser ophthalmoscopy provides additional information for precise evaluation and follow-up of the retinal damage in BRVO.

Adult↗

PubMed2000

[Ocular manifestation in dengue fever].

UNLABELLED: Dengue-Fever is a mosquito transmitted viral disease. It is endemic mainly in South-East Asia and Africa. The clinical manifestation is divided into different stages. Ocular manifestations in travellers have been rarely reported. PATIENTS: We present the cases of two patients, having just returned from a trip to Thailand. During their trip they had fallen ill with symptoms of classic dengue-fever. FINDINGS: On examination visual acuity had decreased in both patients. In one patient we detected a relative central scotoma in perimetry and reduced amplitudes in VEP. In indirect ophthalmoscopy we found intraretinal haemorrhages, foveal lesions in the pigment epithelium, cotton-wool spots and a maculopathy. The fluorescein angiographic findings included extravasation in the macular region and block fluorescence. The diagnosis was confirmed by a rise in Dengue-fever antibody titre and the detection of flavivirus IgM antibodies. CONCLUSION: Dengue-fever and its ocular manifestation in Europeans is a rare condition. Expanding tourism to tropical countries may lead to an increasing number of cases.

Adult↗

PubMed2001

[Autofluorescence imaging of the macula].

Visualization of the retinal pigment epithelium (RPE) in vivo has proven difficult for various reasons, including the optical properties of the eye and the small size of the cellular elements, forming a single layer between the neurosensory retina and Bruch's membrane. With the advent of scanning laser ophthalmoscopy it is now possible to image topographic distribution and intensity fundus autofluorescence derived from accumulations of lipofuscin granules in RPE cells. Excessive lipofuscin storage in the RPE cytoplasm occurs not only in association with age but also with many hereditary and degenerative retinal diseases including age-related macular degeneration, Stargardt disease, Best disease, and pattern dystrophies. Lipofuscin in the RPE derives mainly from incomplete degradation of phagocytosed distal segments of photoreceptor outer segments, and is composed of various biomolecules including lipids, protein, and retinoids. Some of its constituents have recently been shown to possess toxic properties in vitro and may play a pathophysiological role in diseases such as age-related macular degeneration.Visualizing lipofuscin in vivo may help to better understand the significance of these metabolic alterations in the pathogenesis of retinal disorders. In addition,fundus autofluorescence imaging can be useful in the preclinical diagnosis of hereditary retinal disease. Dynamic alterations of intrinsic RPE fluorescence change may be applicable for monitoring effects at the level of the RPE of novel therapeutic modalities. Furthermore, identification of high-risk characteristics in patients with age-related macular degeneration with this technique may be helpful for indicating and adjusting future therapies.

Fluorescence↗

PubMed2003

In vivo retinal vascular cannulation in rabbits.

PURPOSE: To perform in vivo cannulation of retinal vessels for local application of pharmacotherapy to treat central retinal vein occlusion (CRVO), a new method was tested using rabbits. Changes following cannulation were studied histologically. METHODS: The micropipette used for cannulation was constructed from a glass tube. The outer diameter of the tip was 30-40 microm. Rabbits for the experiment were anesthetized; each had its head stabilized with fixing equipment designed for that purpose. After preparing a port for infusion of balanced salt solution (BSS), the specially designed micropipette was inserted at the pars plana of the ciliary body to puncture the major retinal vein, through which BSS was injected. RESULTS: We were able to puncture the major retinal vein with the micropipette without causing any serious incident, after which we injected approximately 100 microl of BSS. A small amount of vitreous hemorrhage that appeared after removing the micropipette could be stopped by increasing intraocular pressure by elevating the infusion bottle. Postoperative observation by indirect ophthalmoscopy showed no obstruction in the vein at the puncture site. Light microscopy showed only a slight narrowing of the venous lumen at the site. CONCLUSION: Cannulation into the retinal vein of rabbits was possible, and invasion was not significant, as determined histologically. Our findings endorse a method of restoring blood flow that involves direct injection of tissue plasminogen activator into the retinal vein of patients with CRVO to dissolve a thrombus.

Animals↗

PubMed2003

Epimacular proliferative response following internal limiting membrane peeling for idiopathic macular holes.

PURPOSE: To present two patients who underwent surgery for an idiopathic macular hole (IMH) with internal limiting membrane (ILM) peeling and developed an epimacular proliferative response. METHODS: Observational case report. Two patients with an IMH underwent pars plana vitrectomy with ILM peeling. Ophthalmic examination including optical coherence tomography (OCT) was performed pre- and postoperatively. In both cases, scanning laser ophthalmoscopy (SLO) was performed postoperatively. RESULTS: In the first case, the closure of the macular hole (MH) was confirmed ophthalmoscopically and by OCT following the surgery. At 2 months postoperatively, a thin epiretinal membrane (ERM) developed over the nasal macula area where the ILM had been peeled. The patient's visual acuity had recovered to 1.0 but she complained of metamorphopsia. At 18 months postoperatively, the thin ERM around the nasal fovea remained and her visual acuity was still 1.0. In the second case, the MH was sealed after the surgery, and the patient's visual acuity had improved to 1.0 at 3 months, but an indistinct ERM developed in the macular region where the ILM had been peeled. Two years after the operation, her VA was still 1.0. One and two years postoperatively, a thin epimacular proliferation remained unchanged; in addition, the OCT and SLO images remained stable. CONCLUSION: Two patients who underwent IMH surgery with ILM peeling developed an epimacular proliferative response postoperatively. We suggest that the injury associated with the ILM peeling may have stimulated glial proliferation.

Adult↗

PubMed2004

Peripapillary atrophy in the unilateral exfoliation syndrome.

PURPOSE: To compare the areas of peripapillary atrophy between fellow eyes in patients with unilateral exfoliation syndrome. METHODS: Topographic measurements for peripapillary atrophy and the optic nerve head with confocal scanning laser ophthalmoscopy, using the Heidelberg Retina Tomograph were performed on 45 nonglaucomatous patients with unilateral exfoliation syndrome. The area of peripapillary atrophy was divided into an alpha and a beta zone. The areas of alpha and beta peripapillary atrophy and their angular extents around the disc were measured. The frequency distributions of the alpha and beta areas and their largest radial extents at different positions around the disc were calculated. RESULTS: An alpha area was detected in 84% of the exfoliative and 89% of the nonexfoliative fellow eyes, and a beta area in 31% and 42% of eyes, respectively. The exfoliative and the fellow nonexfoliative eyes did not differ in the sizes of the alpha (0.43+/-0.46 vs 0.33+/-0.18 mm(2), P=0.68) and beta (0.14+/-0.30 vs 0.17+/-0.34 mm(2), P=0.96) areas of peripapillary atrophy. The angular extents, the locations of the largest radial extent, and the frequency distributions of the alpha and beta peripapillary atrophy areas were similar in fellow eyes. CONCLUSION: Exfoliation syndrome itself is not a risk factor for peripapillary atrophy.

Aged↗

PubMed2004

Tomographic image and visual recovery of acute macula-off rhegmatogenous retinal detachment.

PURPOSE: To observe the macula of acute rhegmatogenous retinal detachment involving the macula with optical coherence tomography (OCT) after scleral buckling and to study the relation between pre- and postoperative visual acuity and the OCT image. METHODS: Prospective study of 15 eyes of 15 patients with macula-off rhegmatogenous retinal detachment. We selected cases with preoperative visual acuity worse than 0.5 to analyze the improvement in postoperative visual acuity. The time period between macula-off retinal detachment and surgery was less than 1 week. RESULTS: Indirect ophthalmoscopy indicated that all retinal detachments were reattached at 2 weeks postoperatively. Accumulation of subretinal fluid at the fovea was observed in nine (60%) cases with OCT. In four of these nine eyes, the accumulation of subretinal fluid persisted up to 6 months after the operation. The presence of residual subretinal fluid did not influence visual recovery during the 6 months' postsurgical follow-up. CONCLUSIONS: OCT revealed postoperative residual subretinal fluid at the macula in some acute macula-off retinal detachment cases. Residual subretinal fluid did not influence the recovery of visual acuity for at least 6 months after surgery.

Acute Disease↗

PubMed2004

Fundus autofluorescence in carriers of X-linked recessive retinitis pigmentosa associated with mutations in RPGR, and correlation with electrophysiological and psychophysical data.

PURPOSE: To describe fundus autofluorescence (AF) in carriers of X-linked retinitis pigmentosa (XLRP) associated with mutations in RPGR (RP3), and to compare the findings on AF with ophthalmoscopy and with electrophysiological and psychophysical data. METHODS: Eleven carriers from two families with XLRP and mutations in RPGR underwent clinical examination including fundus photography, AF, full-field electroretinography, Goldmann kinetic perimetry and two-colour threshold perimetry (2CT perimetry). RESULTS: An abnormal AF pattern was found in 9 of 11 carriers, with a radial pattern in 6 of 11. In 2CT perimetry patchy rod and cone sensitivity losses were seen in 7 of 8 carriers. Rods tended to be more affected than cones. The areas of sensitivity loss showed some correspondence with the abnormalities seen on AF. CONCLUSION: AF had a specific pattern in 9 of 11 carriers from two families with mutations in RPGR. The result was independent of the family investigated. The radial pattern may be explained by random X-inactivation early during embryogenesis subsequently preserved in all daughter cells and the centrifugal radial growth pattern of the developing neuroretina. AF may prove to be a rapid and easy clinical test to identify carriers of RP3.

Adolescent↗