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Biomedical subjects

R Sundmacher

Publications and source records attributed to R Sundmacher.

At least 109 records · Page 6Linked to original sources
PubMed1996

Central corneolimbal transplantation under systemic ciclosporin A cover for severe limbal stem cell insufficiency.

BACKGROUND: Severe stem cell deficiencies uniformly lead to superficial conjunctivalization of corneal grafts with subsequent functional failure. We sought better long-term results by transplanting central corneolimbal grafts and simultaneously protecting the graft and its stem cells from immunological destruction by means of systemic administration of ciclosporin A. PATIENTS AND METHODS: In an ongoing pilot study, up to April 1995 20 eyes with stem cell dysfunctions of various etiology (e.g. chemical burn, ocular pseudopemphigoid, congenital aniridia) received eccentrically trephined fresh corneal grafts of 7.7-10.0 mm diameter. About one third of the circumference of the grafts contained limbal area. The mean age of the patients was 46.2 years (range 9-84 years). All patients received systemic ciclosporin A for at least 12 months. At present, the mean follow-up period is 9.6 months (mean 1-20.6 months). RESULTS: Fourteen of 20 grafts (70%) have remained clear so far. Reasons for six graft failures were surface disorders in four eyes, immune reactions in one eye and surface disorders in combination with immune reactions in another eye. Ten of 20 grafts (50%) experienced severe surface disorders. In six eyes surface disorders were coincident with endothelial immune reactions, in four eyes they were not. In four of 20 grafts (20%) conjunctivalization was observed in front of the transplanted limbal area; in seven of 20 grafts (35%) conjunctivalization occurred only distant from the transplanted limbal stem cells. CONCLUSIONS: Our method of central corneolimbal transplantation with simultaneous protection of the transplanted stem cell population from immunological destruction by means of systemic ciclosporin A has been successful for 14 eyes with severe stem cell deficiencies up to 20.6 months postoperatively. This new treatment principle promises - for the first time - long-term rehabilitation for a majority of eyes with severe limbal stem cell deficiencies.

Adolescent↗
PubMed1996

[Combination therapy of circumscribed choroid hemangioma in contralateral Sturge-Weber syndrome with acetazolamide and laser coagulation].

BACKGROUND: In Sturge-Weber syndrome choroidal hemangiomas occur in up to 55%. With a few exceptions it is a diffuse hemangioma and it always affects the eye ipsilateral to the naevus flammeus. To the best of our knowledge, a contralateral circumscribed choroidal hemangioma has not yet been described. HISTORY AND CLINICAL FINDINGS: We present a 34-year-old male caucasian with a left-sided naevus flammeus and a right-sided circumscribed choroidal hemangioma. Ipsilateral to the naevus, the left eye showed typical vascular anomalies of the conjunctiva and episclera as well as in the anterior chamber angle with anterior synechia formation and circumscribed iris atrophy without secondary glaucoma. Retinal and choroidal vasculature was normal. In the contralateral eye the anterior segment was normal, but there was a juxtafoveolar circumscribed choroidal hemangioma of about 7.5 x 4.5 mm along the superior temporal vascular arcade. The tumor was detected when vision dropped to 0.4 due to an exsudative retinal detachment over the tumor involving the fovea. THERAPY AND CLINICAL COURSE: Complete regression of the exsudative detachment occurred under oral Acetazolamide (1000 mg/d), but after dose reduction to 500 mg/d the exsudation recurred. Thereafter, the surface of the tumor was treated with argongreen grid lasercoagulation in 3 sessions under Acetazolamide cover. Following scar formation the retina has stayed completely attached even after discontinuation of oral Acetazolamide therapy with a follow-up of now 7 months. CONCLUSIONS: Visual prognosis after exsudative macula detachment is depended on rapid retinal reattachment. Therefore, early and effective treatment is mandatory. Systemic application of Acetazolamid (1000 mg/d orally) led to a rapid reattachment of the retina with an excellent visual result. However, dose-reduction was followed by an immediate recurrency. We therefore suggest to perform an Argongreen grid lasercoagulation of the tumor surface while the patient is still under systemic Aceazolamid. This strategy has proven successful in this case.

Acetazolamide↗
PubMed1996

[Local cyclosporin A therapy in Thygeson superficial punctate keratitis--a pilot study].

PURPOSE: It was the purpose of this prospective study to evaluate the effect of topical Ciclosporin 2% on epithelial and subepithelial opacities in Thygeson's superficial punctate keratitis. PATIENTS AND METHODS: We administered Ciclosporin A 2% eye drops to 31 eyes of 17 patients with Thygeson's superficial punctate keratitis. The initial dose was 3 drops daily during the first month. It was reduced according to the following scheme: 2 drops in the second month, 1 drop in the third month, 1 drop every second day in the fourth to sixth months. Thereafter therapy was stopped. RESULTS: The opacities were suppressed completely in 21/31 eyes mostly after 4 weeks of therapy and incompletely in 8/31 eyes. Of the 21 eyes with complete suppression, 6/21 showed recurrent opacities when therapy was stopped after six months. 7/21 eyes had no recurrences after cessation of therapy. Follow-up of 8 eyes is currently less than 6 months and these eyes still receive Ciclosporin A 2% eye drops. All patients complained of a slight burning caused by the drops. CONCLUSIONS: In the majority of patients with Thygeson's superficial punctate keratitis topical Ciclosporin A 2% suppresses epithelial and subepithelial opacities as long as this non-steroid therapy is administered at a low dose. In a considerable percentage therapy seems to be curative.

Adolescent↗
PubMed1996

[Treatment of toxoplasmosis retinochoroiditis with atovaquone in an immunocompetent patient].

BACKGROUND: In Central Europe ocular toxoplasmosis is the leading cause of posterior uveitis. It is a major cause of severe visual loss and blindness in young people. Drugs for treatment of active lesions (tachyzoites) have been available for decades but are seen controversial especially because of sometimes serious side effects. These drugs don't seem to shorten the active inflammation nor the recurrence rate, in particular because of the poor effect on the cystic form (bradyzoites). Atovaquone (hydroxynaphthoquinone) is well tolerated systemically and is effective against tachyzoites and bradyzoites of Toxoplasma gondii so that we hope to reduce the recurrence rate. PATIENT HISTORY AND CLINICAL FINDINGS: Two immunocompetent patients with the first and respective second symptomatic recurrence of unilateral active toxoplasmic retinochorioiditis located within the major temporal vascular arcades were treated with Atovaquone and Fluorocortolone because of an impending loss of central visual function. THERAPY AND CLINICAL COURSE: Under the treatment with Atovaquone (3 x 750 mg/day) for three weeks and tapering of the Fluorocortolone the active lesions healed quickly. After a few weeks, atrophic and remarkably little pigmented scars remained. No side effects were observed. After a period of 7 and respective 11 months no recurrence occurred. CONCLUSIONS: Atovaquone is an effective and well tolerated drug for the treatment of active ocular toxoplasmosis in immunocompetent patients. Its efficacy against tachyzoites and cysts of Toxoplasma gondii relative to other drugs remains to be determined by further clinical trials.

Adult↗
PubMed1996

[Acute band-shaped keratopathy after intraocular fibrinolysis with recombinant tissue plasminogen activator (rt-PA)].

BACKGROUND: Intraocular fibrinolysis with recombinant tissue-plasminogen activator (rt-PA) in patients with severe fibrin reactions following anterior segment surgery is widely accepted because of the low complication rate. CASES: We present two eyes of two patients developing acute bandkeratopathy within the first week after intraocular rt-PA fibrinolysis (10 mg/100 ml). In the first patient, calcium deposition occurred inferiorly of the optic axis without visual impairment. In the second patient, a dense bandkeratopathy reaching from limbus to limbus developed, with a severe decrease of vision. A corneal abrasion together with the chelating agent disodium ethylene diamine tetra-acetate (EDTA) 0.5% in neutral solution led only to an incomplete resolution of the depositions. CONCLUSIONS: Acute development of a bandkeratopathy is very rare. Several risk factors are identified so far, e.g. the use of phosphate containing eye drops. Their interactions and the possible pathomechanism are discussed in detail. The close coincidence of intraocular rt-PA fibrinolysis and acute band-keratopathy in our two patients is in favor of an at least additive causative role of rt-PA fibrinolysis. Therefore, the indication should be limited to severe fibrin reactions and local application of phosphate containing drugs should be avoided.

Aged↗
PubMed1996

Keratoplasty in newborns with Peters' anomaly.

Severe Peters' anomaly with dense corneal opacities leads to blindness of the affected eye unless perforating keratoplasty is attempted. The optimal timing of this procedure has yet to be established. We performed keratoplasty early after birth in an attempt to optimally treat amblyopia. In eight eyes of five newborns with severe Peters' anomaly a first keratoplasty was performed at an average age of 54 days. A first control was done under general anesthesia 3 weeks thereafter, with subsequent controls being carried out according to the clinical course. Immunosuppressive therapy mostly consisted of topical steroid eye drops only. In two rekeratoplasty cases, systemic cyclosporin A was given in addition. Apart from the eight primary keratoplasties, three repeat keratoplasties, two lentectomies, and numerous glaucoma operations had to be performed. The average follow-up period was 46 months. As compared with the excellent results reported for penetrating keratoplasty in adults, the results obtained in this special group of newborns remain very poor. The observation of four eyes with a clear or partially clear graft and useful ambulatory vision might suggest a success rate of 50%. However, especially secondary glaucoma seems to be the limiting prognostic factor in the long run. At present, two of the four eyes continue to show uncontrolled intraocular pressure despite multiple surgical interventions, and their prognosis is poor. The performance of perforating keratoplasty in patients with Peters' anomaly early after birth is associated with a multitude of problems, especially glaucoma, and currently grafts can rarely be kept clear for an extended period. We would therefore conclude that it might be wise to postpone surgery until the patient is about 1 year old, in the hope that the overall chance for graft survival might be better at that point, even though persistent amblyopia might be quite severe and limit the functional success.

Corneal Opacity↗
PubMed1996

Characteristic distribution of deposits in recurrent granular corneal dystrophy.

Granular corneal dystrophy can recur after penetrating keratoplasty. In those cases as in the early primary manifestation of the disease, deposits are found predominantly in the superficial corneal layers. At a later stage, stromal deposits can also be seen. We describe an additional particular location of deposits and correlate clinical with histological findings in three corneas from two patients. Deposits were found mainly superficially within the graft and around the edge of the transplant along the scar between host and donor cornea. We suggest that the deposits are of epithelial origin, though their production by stromal cells cannot be excluded. Chemical interactions are discussed as an explanation for the characteristic distribution of the deposits.

Adult↗
PubMed1996

Cyclosporin-A and its metabolites in the anterior chamber after topical and systemic application as determined with high-performance liquid chromatography-electrospray mass spectrometry.

Penetration of cyclosporin A (CSA) into the anterior chamber through the intact cornea after topical application is difficult due to its hydrophobic structure. Following systemic application the anterior-chamber levels of CSA are reported to be higher. CSA metabolites are more hydrophilic than CSA. Only high-performance liquid chromatography-electrospray mass spectrometry allows exact quantification of the CSA level and the identification of all CSA metabolites. We studied the anterior-chamber levels of CSA and different CSA metabolites after topical and systemic application. CSA and CSA-metabolite anterior-chamber levels were measured in 49 patients after topical application of CSA 2% eye drops preceding routine cataract surgery with 2 different application schemes and in 7 patients receiving systemic CSA after high-risk penetrating keratoplasty. After topical application the average CSA level measured in the anterior chamber was 81 ng/ml. The CSA-metabolite levels were much higher, reaching an average of 378 ng/ml. After systemic therapy the anterior-chamber levels of CSA and of the metabolites were much more balanced at 256 and 317 ng/ml, respectively. CSA penetrates into the anterior chamber after topical eye-drop application, but these levels are much lower than those measured after systemic CSA therapy. After topical application the CSA metabolites might play an important role; they are found in the anterior chamber in much higher concentrations than is CSA, and the metabolite pattern differs from that seen after systemic therapy. The relevance of these findings to the immunosuppressive activity of the CSA metabolites, however, remains unclear.

Administration, Topical↗
PubMed1996

Rifabutin-associated anterior uveitis in patients infected with human immunodeficiency virus.

Iridocyclitis, arthralgia, and pseudojaundice have been identified as dose-dependent adverse effects in patients with acquired immunodeficiency syndrome (AIDS) who are treated orally with rifabutin for Mycobacterium avium intracellulare complex (MAC) infections. Nine episodes of acute anterior uveitis of varying severity ranging from mild iridocyclitis to anterior uveitis with fibrin or hypopyon, mimicking endogenous metastatic endophthalmitis, occurred in seven patients. At the time of presentation, all seven patients were receiving rifabutin at a dose ranging from 300 to 600 mg daily. Iridocyclitis was bilateral in four of seven patients, in two cases simultaneously and in two cases successively. Inflammation resolved rapidly on treatment with systemic and topical antibiotics, on corticosteroid therapy, and on discontinuation of rifabutin. In two cases of mild iridocyclitis, cessation of rifabutin alone led to resolution of the uveitis. The combination of rifabutin, clarithromycin, and fluconazole may increase the risk for anterior uveitis in patients with AIDS. All of our patients were treated with fluconazole, with clarithromycin, or with a combination of both substances in addition to rifabutin. Identification of rifabutin-induced uveitis is important because hypopyon uveitis in the immunocompromised patient generally evokes intensive and, sometimes, invasive ophthalmic and systemic workup and therapy. We suggest it to be sufficient for resolution of the inflammatory signs to discontinue rifabutin medication.

AIDS-Related Opportunistic Infections↗
PubMed1996

Endothelial precipitates and laser flare photometry in patients with acquired immunodeficiency syndrome: a screening test for cytomegalovirus retinitis?

Patients with acquired immunodeficiency syndrome (AIDS) who present with cytomegalovirus (CMV) retinitis show pathognomonic endothelial precipitates suggestive of primary anterior uveitis or secondary changes due to a spill-over from the posterior chamber. Laser flare photometry allows quantification of the intensity of anterior affection. We wanted to establish anterior-chamber flare values in AIDS patients with and without CMV retinitis and to find out whether CMV retinitis is preceded by an elevation of the flare value. In all, 25 men with AIDS who presented with CMV retinitis and 27 who did not have CMV retinitis but showed a CD4 count of < or = 200 cells/microliter blood were enrolled in a prospective study. Slit-lamp examination was performed, followed by indirect ophthalmoscopy and laser flare photometry after dilation of the pupil with tropicamide eye drops. Patients with CMV retinitis were followed every 10 days and the others, every 4 weeks. A group of 51 human immunodeficiency virus (HIV)-negative men served as a control group. AIDS patients with CMV retinitis showed a significantly higher flare count in the affected eye (12.4 photons/ms; n = 26) as compared with the unaffected partner eye (4.2 photons/ms; P < or = 0.0001; n = 18) and with eyes of AIDS patients without CMV retinitis (4.1 photons/ms; P < or = 0.0001; n = 50). The count in the latter eyes was also significantly higher than the control value (3.1 photons/ms; P < or = 0.0001; n = 102). Typical reticulate endothelial precipitates were found in 92% of AIDS patients with CMV retinitis. During the study, five eyes of three patients developed a fresh CMV retinitis, but a preceding rise in the flare count was not observed. Laser flare photometry follows the occurrence of pathognomonic reticulate endothelial precipitates. It lags behind the development and the extension of CMV retinitis. Therefore, it cannot be used as a screening test for early detection of CMV retinitis.

AIDS-Related Opportunistic Infections↗
PubMed1996

Postoperative ultrasound biomicroscopic evaluation of the haptic position in transsclerally sutured posterior-chamber lenses as compared with the intraoperative endoscopic position.

Our objective was to evaluate the long-term stability of transsclerally sutured posterior-chamber lens (PCL) haptics. A total of 22 patients (26 eyes) were examined 29-50 months postoperatively by ultrasound biomicroscopy (UBM) to determine the exact haptic position in relation to the iris base, ciliary sulcus, pars plicata, and pars plana. In all eyes, endoscopy had been performed intraoperatively immediately after PCL insertion and suture fixation of the haptic. We could locate all 52 haptics by UBM. Intraoperative haptic localization was compared with the postoperative position. UBM confirmed the endoscopic position in 81% of cases; 19% of the haptics showed a clinically undetectable dislocation. Secondary dislocations were analyzed in correlation with the intraoperative endoscopic transscleral suture penetration site and the primary position of the two haptics of one PCL. Loosening of the fixation suture together with primary asymmetry of the two haptics of one PCL apparently contributes to a slight dislocation.

Ciliary Body↗
PubMed1995

[Treatment of toxoplasmosis retinochoroiditis with atovaquone in an AIDS patient].

BACKGROUND: Treatment of ocular toxoplasmosis in HIV-infected patients with standard drug regimens (Pyrimethamine, Clindamycine, Sulfonamides) is very often complicated by side-effects and adverse reactions. On the other hand, maintenance therapy must be continued life long, because of the high recurrence rates. Atovaquone (Hydroxynaphthoquinon) is tolerated excellently and is very effective against tachyzoits of toxoplasma gondii and its cysts. PATIENT HISTORY AND CLINICAL FINDINGS: A 49-year-old homosexual man with AIDS developed an allergic rash after being treated with a course of Pyrimethamine and Clindamycine for unilateral, bifocal ocular toxoplasmosis for 13 days. Therapy with Atovaquone 3 x 750 mg/d was instituted and within 8 days the infiltrates healed leaving retinochorioidal scars. THERAPY AND CLINICAL COURSE: During maintenance therapy with Atovaquone (3 x 750 mg/d) two relapses occurred, the first after 2 months and the second after 8 months. The recurrences were successfully treated by increasing the dosage of Atovaquone to 4 x 750 mg/d and the addition of Trimethoprime/Sulfamethoxazol and Clindamycine/Pyrimethamine respectively. Reexposition was tolerated without an allergic reaction. Under maintenance therapy with Pyrimethamine the patient was free of recurrences for another 4 months until he died. CONCLUSIONS: Atovaquone is an effective and well tolerated substance for the treatment of ocular toxoplasmosis. In contrast to earlier reports, two recurrences occurred under maintenance therapy. It cannot be excluded that the patient was incomplient and did not take the tablets according to our prescription. Future clinical investigations have to control the efficacy of Atovaquone in the therapy of ocular toxoplasmosis.

AIDS-Related Opportunistic Infections↗
PubMed1995

Cyclosporin A in perforating keratoplasty.

Systemically administered cyclosporin A offers three advantages for the management of high risk keratoplasties. First, its immunomodulating action reduces the risk of immune complications. Second, it can be used in cases where no topical steroids can be applied. Third, it may exert an extra beneficial effect on underlying disadvantageous immune disorders like endogenous eczema. We present some of the currently available core data on 12/1986 through 2/1993.

Cyclosporine↗
PubMed1994

[Iris black diaphragm intraocular lenses in traumatic Aniridia].

PURPOSE: In this study we wanted to gain experiences with a new black diaphragm IOL concerning surgical postoperative difficulties in traumatic aniridia. PATIENTS: Since June 1991 we have implanted the IOL prototype and the modifications into 13 eyes with traumatic aniridia. The IOL was transsclerally sutured in 11 eyes without capsular support and it was positioned in front of capsular remnants in two eyes. In eight eyes penetrating keratoplasty was necessary. The mean follow-up period was 17 (1-34) months. RESULTS: The seventh IOL modification can be implanted safely now. Persistent intraocular inflammation (Tyndall +) has been observed in all eyes postoperatively but it seems to disappear slowly. Its effect upon the corneal endothelium and the development of cystoid macula edema is still under investigation. Secondary glaucoma has been the greatest postoperative problem: It could be controlled medically in five eyes, surgically in two eyes, but remained uncontrolled in one eye. Implantation of the IOL improved visual acuity in 11/13 eyes. CONCLUSION: Rehabilitation of eyes with traumatic aniridia by implanting the new black diaphragm IOL still presents some unsolved problems, especially uncontrolled secondary glaucoma and prolonged intraocular inflammation. In spite of many encouraging aspects we advise to be rather cautious and self-restrictive in this group of patients.

Adolescent↗
PubMed1994

[Lamellar horseshoe sclerokeratoplasty and thermoplasty in keratoconus with peripheral ectasia of the cornea].

PURPOSE: Peripheral ectasia of the cornea is a rare, but rather complicated form of keratoconus, which in its severest form cannot be corrected by glasses or contact lenses. Penetrating corneal grafts must be positioned directly at the limbus. Such transplants mostly fail because of a high risk of immune reactions which can only be circumvented by systemic Ciclosporin A. To avoid the potential risks of such a systemic immunomodulation we performed instead of a penetrating keratoplasty a special lamellar procedure which restored the normal configuration of the cornea. PATIENT: The 35-year-old man presented with best corrected visual acuity of 0.1 in both eyes. Contact lenses were not tolerated any longer. RESULT: After lamellar dissection, thermoplasty and lamellar horse-shoe sclerokeratoplasty the patient now wears well-fitting contact lenses and has a visual acuity of 0.8 with his right and 0.5 with his left eye after a follow-up period of 25 and 14 months respectively. There were no postoperative complications. CONCLUSION: Lamellar horse-shoe sclerokeratoplasty preceded by lamellar corneal dissection and thermoplasty is a technically difficult, but efficient surgical measure to restore the normal corneal curvature in patients with advanced peripheral ectasia of the cornea.

Corneal Transplantation↗