Ординатура / Офтальмология / Английские материалы / Applied Pathology for Ophthalmic Microsurgeons_Naumann, Holbach, Kruse_2008
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Gottfried O.H. Naumann, Leonard M. Holbach, Friedrich E. Kruse (Eds.) Applied Pathology for Ophthalmic Microsurgeons
G.O.H. Naumann, L.M. Holbach, F.E. Kruse (Eds.)
Additional main authors: Claus Cursiefen, Ludwig M. Heindl, Antonia M. Joussen, Anselm Jünemann, Christian Y. Mardin, and Ursula Schlötzer-Schrehardt
Applied Pathology for Ophthalmic Microsurgeons
With 317 figures in 1063 parts mostly in color and 108 tables
Gottfried O.H. Naumann, Prof. (emer.) Dr. med. Dr. hc. (mult.)
Department of Ophthalmology, University of Erlangen-Nürnberg Schwabachanlage 6, D-91054 Erlangen, Germany
Leonard M. Holbach, Prof. Dr. med.
Department of Ophthalmology, University of Erlangen-Nürnberg Schwabachanlage 6, D-91054 Erlangen, Germany
Friedrich E. Kruse, Prof. Dr. med.
Department of Ophthalmology, University of Erlangen-Nürnberg Schwabachanlage 6, D-91054 Erlangen, Germany
ISBN 978-3-540-24189-8 Springer-Verlag Berlin Heidelberg New York
Library of Congress Control Number: 2007941808
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Editor: Marion Philipp, Heidelberg
Desk Editor: Martina Himberger, Heidelberg
Copy-editing: WS Editorial Ltd, Shrewsbury, UK
Illustrations: Jörg Kühn, Heidelberg
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To competent and compassionate ophthalmic microsurgeons committed to the preservation and restoration of sight – everywhere
Preface
Interaction of Pathology and Ophthalmic Microsurgery
Ophthalmic pathology means the study of the symptoms and morphologic signs of diseases of the eye and ocular adnexae both biomicroscopically and in the laboratory. Precise definition of the phenotype is a prerequisite for correlation to the genotype, helping to design clinical studies. Spectacular progress is considered a hallmark of both conservative medicine and surgery today. This is driven by the application of both the methods of molecular biology and the new approaches in biotechnology.
Microsurgical magnification and miniaturization of instruments and non-me- chanical tools, e.g., lasers, have made possible procedures beyond our imagination a few years ago. They are characterized by small-access wounds into the eye and only minimal threshold trauma beyond the targeted intraocular tissue. In view of all the glittering advances of biotechnology, the details of critical anatomy morphology are too often neglected or forgotten although they are essential for the success of our microsurgical manipulations.
This book is intended for ophthalmologists in training and also for mature eye physicians. Hopefully, this should help them to avoid pre-, intraand postoperative complications and make them more alert to explaining the risks to their patients before surgery. It attempts to remind the ophthalmic microsurgeon that knowledge of the minutiae of structures is a prerequisite to achieving the intended outcome. Microsurgical landmarks need to be defined more precisely than in conventional ophthalmic surgery without microscopic magnification. Awareness of the specific pathology is crucial for the appropriate indications and suitability of instrumentation to overcome the specific tissue resistance.
Finally, while biotechnology is always changing, the morphologic elements of the eye and ocular adnexae in health and disease remain essentially the same. However, wound healing, scars and complications are also modified by new microsurgical approaches.
Our intention is not to compile a complete list of references but instead to give the reader a selection of textbooks and review articles that may be helpful for further study.
We have not concentrated on the details of instrumentation and surgical techniques. Both are developing continuously. As an exception the reader is referred to sections on non-mechanical trephination penetrating keratoplasty with the excimer laser along metal masks and direct surgery of the ciliary body (see Chapters 5.1 and 5.4).
Clinical findings including imaging by biomicroscopy, “biocytology”, ultrasound, OCT, CT, MRI etc. of the phenotype – supported by knowledge of the “third dimension” supplied by ophthalmic pathology – therefore are essential for patient care. They present in vivo and in the laboratory the foundation for solving diagnostic and therapeutic challenges for the clinician and microsurgeon: Ophthalmic pathology is also a clinical subspecialty.
We want to emphasize that demanding and complex “ophthalmic microsurgery is applied ophthalmic pathology.” This is particularly true if intraor postoperative complications need to be corrected or minimized.
VIII Preface
Therefore we have tried to do the following:
1.Alert the ophthalmic microsurgeon to the critical surgical anatomy and pathology, landmarks and potential complications before he or she plans and starts to discuss the indications with the patient and then the procedure itself.
2.Emphasize respect for the structure of the eye and ocular adnexae and point out the most vulnerable cell populations in the various microsurgical interventions.
3.Point out the peculiar and unique features of intraocular microsurgery in the “closed system” and “open eye,” focusing on acute ocular hypotony-paracentesis effects and the influence on blood-ocular barriers.
4.Illustrate the consequences of the movement of the iris-lens diaphragm (“vis a tergo”) in relation to the systemic arterial pressure in the open eye; also the significance of maintaining or restoring the anterior chamber at the end of all intraocular procedures involving the anterior segment.
5.Show how knowledge of the specific pathology modifies microsurgical interventions. We mention here only a few examples and refer the reader to the relevant chapters.
) Loss of Bowman’s layer – focal or diffuse – recognized before corneal incisions
or grafting makes a surplus of interrupted sutures advisable: because suture loosening is more likely. Running sutures can then be particularly annoying, because if one loop becomes loose the entire suture and wound will be unstable. Single loose interrupted sutures can be easily removed at the slit lamp – the architecture of the wound beyond one loose suture is usually not endangered.
)Calcifications within Bowman’s layer in band degeneration of the cornea can usually be chemically dissolved and do not justify sacrifice of this structure, e.g., by excimer laser.
) Limbal stem cell insufficiency alerts one to serious ocular surface problems.
) Avascular corneal lesions after herpes corneae may more likely harbor herpes simplex-virus in the stroma, which may lead to recurrence after keratoplasty. In contrast vascularized herpetic scars indicate an increased risk for postoperative immune reactions following corneal transplantation.
)Granulomatous reaction against Descemet’s membrane in herpes corneae leads to defects and signals imminent corneal perforation. This may be an argument for urgent curative perforating keratoplasty.
)Tumors of the “iris root” de facto involve the anterior face of the ciliary body and need to be treated by block excision of iris and ciliary body.
)Cystic and diffuse epithelial ingrowth into the anterior chamber usually reach the angle and cover the anterior surface of the ciliary body. Therefore “block excisions” are necessary including removal of the adjacent pars plicata of the ciliary body, iris, cornea and sclera – acting as a “shell.” Only small epithelial implantations in the central iris region can be cured by iridectomy if the angle
is not involved.
)Fibrous pseudo-metaplasia of the anterior subcapsular lens epithelium results in mechanical properties such as sclera; it may divert the standard capsulorr-
hexis around the anterior subcapsular cataract.
)Pseudoexfoliation syndrome (PEX) is a generalized disease of the extracellular matrix. It affects all tissues of the anterior segment of the eye. Although common, it may very often be overlooked and may manifest asymmetrically but in fact is always present bilaterally. It is not a harmless anomaly but a disease leading in its advanced stages to potentially catastrophic complications.
We need to consider not only the risk of secondary open angle and angle closure glaucomas, but also the zonular instability, blood-aqueous barrier breakdown, anterior segment hypoxia, poor mydriasis, and reduced mobility of the iris. The vulnerability of the directly involved corneal endothelium contributes to the increased risk of corneal decompensation. To miss the diagnosis of PEX or disregard it may imply many unpleasant surprises or “recklessly running into a trap.”
Interaction of Pathology and Ophthalmic Microsurgery |
IX |
)Intraocular neovascularization commonly develops in the end stages of many ocular and systemic diseases. Until recently medical and laser therapy attempted to eliminate angiogenic factors originating from hypoxic retina. The new capillaries did not disappear but were less recognizable because of decreased blood flow in the persisting vascular scaffold. A spectacular advance currently is evolving by new local application of specific inhibitors of vascular endothelial growth factors (VEGFs) in the therapy of these entities. The endothelial capillary sprouts can actually regress as long as a capillary basement membrane
has not yet been formed.
)Defining structures (“Leitstrukturen”) of the retina help to better interpret optical coherence tomography (OCT), retinal thickness analysis (RTA) and fluorescence angiography to outline indications for microsurgery.
)Uveal malignant melanomas almost always invade the sclera, although their degree often is not detectable clinically – particularly if they are unpigmented.
6.Not to forget: All cataract surgeons exert some tension on the lens capsule and thus exert traction on the vitreous base via Wieger’s ligaments – but many are not really aware of this in their daily routine. The peripheral retina also should be inspected before and after cataract surgery.
7.Features of normal and pathologic wound healing (“scar wars”) deserve attention in the various tissues following mechanical or non-mechanical (laser, cryo-, diathermia coagulation) interventions in the closed and open eye constellations.
Beyond the practical implications these pages might also encourage our colleagues to study the living eye and ocular adnexae – with a conscious knowledge of the third dimension – and with enlightened curiosity and magnified attention.
We sincerely hope that our book might be helpful in the clinical care of patients.
Erlangen, Summer 2007 |
Gottfried O.H. Naumann |
|
Leonard Holbach |
|
Friedrich E. Kruse |
XAcknowledgements
Acknowledgements
We would like to thank our numerous coworkers at the Departments of Ophthalmology of the Universities of Hamburg (1961–74), Tübingen (1975–80) and Erlangen (since 1980), who have made such a large contribution to this book. It is impossible to mention them all.
Our colleagues from the European Ophthalmic Pathology Society (EOPS), the Verhoeff-Zimmerman Society and the German Speaking Ophthalmic Pathologists (DOP) and many ophthalmologists from around the world were a great source of inspiration in the preparation of the book.
Frau Carmen Rummelt of the Ophthalmic Pathology Laboratory in Erlangen made expert technical contributions to the cutting and staining of specimens for the figures and helped with the digital microphotographs and SEM. The excellent work of our photographers, particularly H. Strahwald and M. Vogler in Erlangen, is evident from their clinical pictures, and Jörg Kühn, Heidelberg, created some fine graphical work by modifying sketches mainly from previous publications by the authors, unless mentioned otherwise.
Most of the schematic drawings and tables are based on drafts by the First Editor/ Author, who also supplied numerous microphotographs.
We are very grateful to Frau Marion Philipp and Frau Martina Himberger, Spring- er-Verlag, Heidelberg, for their encouragement and tolerance with unforeseeable delays; Mr. W. Shufflebotham, who with great patience transferred our teutonic version of the manuscript into correct English; and Herr Joachim W. Schmidt, Munich, who combined the text, figures, tables and references very efficiently into the book in its present form.
Frau Iris Schmitt not only typed many of the chapters but was essential in maintaining orderly communications during the long process of preparing the text and arranging tables, figures and literature of the manuscript. Her experience in preparing books and publications since 1975 proved invaluable. Without her untiring support this book would not yet be finished.
Finally, we are very grateful for the support of our partners and families for their understanding and patience during the completion of this project.
Condensed Table of Contents
1Introduction
G.O.H. Naumann, Friedrich E. Kruse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2General Ophthalmic Pathology: Principal Indications and Complications, Comparing
Intraand Extraocular Surgery
G.O.H. Naumann, F.E. Kruse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3Special Anatomy and Pathology in Surgery of the Eyelids, Lacrimal System, Orbit and Conjunctiva
L.M. Holbach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
29 |
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3.1 |
Eyelids |
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L.M. Heindl, L.M. Holbach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
30 |
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3.2 |
Lacrimal Drainage System |
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L.M. Heindl, A. Jünemann, L.M. Holbach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
45 |
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3.3 |
Orbit |
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L.M. Holbach, L.M. Heindl, R.F. Guthoff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
49 |
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3.4 |
Conjunctiva and Limbus Corneae |
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C. Cursiefen, F.E. Kruse, G.O.H. Naumann . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
67 |
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4General Pathology for Intraocular Microsurgery: Direct Wounds and Indirect Distant Effects
G.O.H. Naumann, F.E. Kruse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
76 |
5Special Anatomy and Pathology in Intraocular Microsurgery
5.1 Cornea and Limbus
C. Cursiefen, F.E. Kruse, G.O.H. Naumann . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
5.2 |
Glaucoma Surgery |
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A. Jünemann, G.O.H. Naumann . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
131 |
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5.3 |
Iris |
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G.O.H. Naumann . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
152 |
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5.4 |
Ciliary Body |
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G.O.H. Naumann . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
176 |
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5.5 |
Lens and Zonular Fibers |
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U. Schlötzer-Schrehardt, G.O.H. Naumann . . . . . . . . . . . . . . . . . . . . . . . . . . |
217 |
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