Indikation und Prognose der Dakryozystorhinostomie im Kindesalter Eine klinische Studie 1970–2000

Background. Dacryocystitis in infants is a serious complication of congenital, but seldom of acquired nasolacrimal duct obstructions. If conservative treatment fails, dacryocystorhinostomy (DCR) appears to be effective. The indications, special clinical history and results will be reviewed. Patients and methods. From 1/1970 to 2/2000, a total of 72 children (56 male, 16 female) with persistent dacryocystitis (18 bilateral) were treated surgically by DCR and were continuously documented. The patients ranged in age from 10 months to 14 years old (mean age 4.9 years). Included in our study were 66 children (52 male, 14 female) with 84 surgically treated lacrimal ducts (46 right eyes, 38 left eyes) who underwent control examinations. Results. The cause of dacryocystitis was congenital obstruction in 63 children and trauma (maxillary fracture) in 3 children, respectively. Of these, 20 children (30.3%) had additional anomalies of the lacrimal system, 21 (31.8%) systemic malformations and 8 out of the 66 children (12.1%) had a family history of nasolacrimal duct obstruction. Since 1985 the surgical procedures have been performed under microsurgery conditions and since 1998 sometimes with a transcanalicular laser-assisted technique. We found a functional success rate (with complete resolution of symptoms) of 90.4% (76 out of 84 lacrimal ducts) over follow-up periods ranging from 1 month to 12 years (average 1.6 years). Conclusion. Patients with persistent dacryocystitis due to congenital nasolacrimal duct obstruction have a prevalence of further nasolacrimal abnormalities and a family history. The dacryocystorhinostomy of infants requires minimal invasive (sometimes laser-assisted) techniques. In the case of persistent dacryocystitis, DCR is indicated after the age of 1 year and has the same success rate in infants as in adults (90–95%).     

20-MHz-Ultraschall der präsakkalen Tränenwege

Background. In clinical practice, ultrasound examination of the lacrimal drainage system is not able to represent the lacrimal canaliculi with a high quality but the high-resolution ultrasound with 20 MHz transducer is a better possibility to get images of the lacrimal canaliculi. Patients and methods. A total of 20 patients suffering from diseases of the lacrimal drainage system were examined ultrasonographically. Detection and localisation of the lacrimal canaliculi was made by a 20 MHz sector scanner in combination with the ultrasound diagnostic system I³. After patient positioning, the high-resolution ultrasound investigation was done via immersion connection (methylcellulose). Instillation of viscoelastic substances (e.g. Healon) was necessary to detect the lacrimal canaliculi. Results. In all investigated patients, the high-resolution ultrasound (transducer frequency of 20 MHz) allowed reproducible images of the lacrimal drainage system. Without viscoelastic substances, a good echographic visualisation of canaliculi structures was obtained from patients with chronic canaliculitis or dislocated punctum plugs. In chronic canaliculitis the ultrasonic images showed an ectatic canaliculus (diverticulum) and high-reflective structures (concrements). Conclusion. The high-resolution ultrasound (transducer frequency of 20 MHz) seems to be well suited for investigations of the lacrimal drainage system. In comparison with ultrasound biomicroscopy the resolution is lower but the depth of penetration is higher. The use of 20 MHz ultrasonic examination can be helpful in the clinical diagnostic of chronic canaliculitis.     

Darstellung der Mikroarchitektur und Dynamik der Aufreißphänomene des präkornealen Tränenfilms mit Hilfe der Laser-Rastermikroskopie

Background. Sufficient and regular wetting of the cornea with a normal preocular tear film is an essential requirement for the accurate visual functioning of the eye. Multiple factors may cause tear film instability. Measuring the break-up time of the preocular tear film is a necessary, clinically reliable means for evaluating tear film stability. We designed a new instrument to observe the preocular tear film at high magnification which can contribute to the in vivo imaging of the physiological and pathophysiological dynamics of the tear film and its break-up phenomena. Materials and methods. To image the tear film phenomena at sufficient magnification (×200) we used a confocal laser scanning microscope. Modification of an additional adaptor allows the tear film to be imaged at high magnification. This study evaluated the dynamics and microarchitecture of the break-up phenomena in the preocular tear film of normal patients and patients with “dry eye”. Results. Laser scanning microscopy allows high magnification imaging of the preocular tear film and evaluation of a number of break-up mechanisms. The dynamics and structure of the tear film was analyzed and documented. Based on our observations we formulate a new hypothesis on the break-up mechanism of the preocular tear film caused by alteration in the epithelial surface, for example, an elevation or tear film microparticle. By evaluating video sequences in the fluorescence and reflection modus of the laser scanning ophthalmoscope we also found early thinning of the aqueous layer simultaneously with an intact lipid layer covering the aqueous layer. Conclusions. Additional criteria result from using high-magnification microscopy, for example, laser scanning microscopy. This method reveals more microstructures of the corneal surface and the preocular tear film. The morphological representation of break-up phenomena leads to a better understanding of the underlying mechanisms and can be used for further investigations. Confocal laser scanning microscopy supplements the examination facilities and can be used in addition to slit lamp microscopy and to diagnose “dry eye”.     

Prognose der Konjunktivodakryozystorhinostomie Modifikationen mit unterschiedlichen Implantatmaterialien

Zusammenfassung Hintergrund. Bei ausgedehnten Verschlüssen der pr?sakkalen bzw. der gesamten Tr?nennasenwege erfordert die funktionelle Rehabilitation den Neuaufbau der tr?nenableitenden Strukturen. Die operativ geschaffene Tr?nenableitung aus dem Bindehautsack wird durch ein Kunststoffimplantat sichergestellt. Neben anderen Kriterien soll der Einfluss der verwendeten Materialien Polyethylen und Silikonkautschuk auf das funktionelle Ergebnis überprüft werden. Patienten und Methode: Zwischen 9/1978 und 2/1999 erfolgten an der Augenklinik Halle insgesamt 37 fortlaufend dokumentierte Konjunktivodakryozystorhinostomien sowie modifizierte Operationen (1mal beidseits) an 36 Patienten (22 M?nner und 14 Frauen) im Alter von 9–76 Jahren (durchschnittlich 35,2 Jahre). Die bis 1990 mit Polyethylenr?hrchen durchgeführten Operationen (Gruppe I: n=23) wurden denen seit 1991 mit Silikonr?hrchen (Gruppe II: n=14) gegenübergestellt. In dieser retrospektiven Studie wurden die Krankenakten ausgewertet und die Patienten nachuntersucht. Ergebnisse: Ursache dieser schwerstgesch?digten Tr?nenwege waren Unf?lle (n=21), Fehlbildungen (n=8), chronische Entzündungen (n=5) sowie Tumoren (n=2). Es kamen die Konjunktivodakryozystorhinostomie (KDR, n=23), die Konjunktivodakryozystostomie (KD, n=10) und die Konjunktivorhinostomie (KR, n=4), 21mal am rechten und 16mal am linken Auge zur Anwendung. In der Gruppe I wurde nach 14 von 23 Operationen (61%) eine funktionelle Heilung erzielt, in der Gruppe II nach 10 von 14 Operationen (72%). Die Polyethylenr?hrchen wurden durchschnittlich 15 Monate belassen (4mal Spontanabsto?ung), die Silikonr?hrchen 12 Monate (4mal Spontanabsto?ung). Schlussfolgerungen: Zerst?rung oder angeborenes Fehlen der Tr?nenr?hrchen sowie angrenzender Strukturen machen bei entsprechenden Beschwerden die operative Rekonstruktion der ableitenden Tr?nenwege erforderlich. Mit Einführung der Silikonr?hrchen konnte die Prognose dieser Operationsverfahren weiter verbessert werden.      

Transnasaler Ankerfaden zur Erleichterung der Silikonschlauchintubation bei tiefer kongenitaler Tränenwegsstenose

Background. In silicone intubation of the nasolacrimal duct for congenital obstruction, retrieval of the guide thread behind the inferior turbinate can be difficult and time consuming. To facilitate this maneuver a modification of the conventional technique has been developed. Patients and method. In the conventional technique, a hollow probe was inserted into both lacrimal puncti and pushed downward into the nasal cavity. A guide thread was forwarded into the pharynx. Using the same hollow probe, a third guide thread was inserted transnasally and also forwarded into the pharynx. These three threads were pulled out of the pharynx transorally and tied together. Pulling on the nasal aspect of the transnasal guide brought all guides back into the pharynx and out of the nose. The intubation was completed in the conventional way. Results. The new method was evaluated in 13 children. With the conventional technique the mean duration of the operation was 35 min, but the time required varied greatly among individuals due to retrieval of the guides. In contrast, no guide retrieval problem occurred using the new technique, and the average duration was reduced to 25 min. No adverse effect was observed. Conclusion. Using a simple modification, difficulties with the retrieval of the guide thread could be avoided, thus facilitating the procedure of nasolacrimal duct intubation and reducing its duration.     

Comparison of Rinkel injection therapy with standard immunotherapy

We compared the results of a controlled, double blind study of standard immunotherapy (SIT) in subjects with ragweed hay fever during 1980 with the results of our study of Rinkel injection therapy (RIT) in a group of subjects with ragweed hay fever in 1979. Both groups were of comparable sensitivity. During the 1980 hay fever season in Milwaukee, 20 subjects with atopic rhinitis due to ragweed pollen (eight from the 1979 group treated with RIT) were given SIT (Tr), while 14 matched subjects (eight from the 1979 placebo group) were treated with a histamine placebo (Pl). The same glycerinated aqueous ragweed extract and glycerinated histamine placebo were used in both studies. The mean cumulative dose of ragweed extract in the 1980 study was 5391 PNU (20.1 μg of antigen E [AgE]) as compared with 41.5 PNU (0.16 μg of AgE) in 1979. Results indicated a significantly lower weekly mean symptom score (SxSc) in the Tr group compared with that of the Pl group in 5 of the 6 wk that ragweed pollen was counted in 1980. Weekly mean medication score (MxSc) and physical exanination score (PESc) showed similar but less striking differences. The mean seasonal SxScs, MxScs, and PEScs of the SIT Tr group were significantly lower than those of the Pl group in 1980 as well as those of the RIT Tr group in 1979. The same indices were also significantly lower in 1980 by paired analyses in the subset of eight subjects treated in both years. RAST scores showed a significant decrease in the “after season” means in the Tr group as compared with the Pl group in 1980 but not in 1979 (analysis of covariance). We conclude that SIT is more effective than a placebo or RIT in reducing SxSc, MxSc, and PESc as well as in diminishing postseason RAST values. We cannot recommend therapy as proposed by Dr. H. J. Rinkel for clinical use at this time.     

Interleukin‐10‐secreting type 1 regulatory T cells in rodents and humans

Summary: Interleukin‐10 (IL‐10)‐secreting T regulatory type 1 (Tr1) cells are defined by their specific cytokine production profile, which includes the secretion of high levels of IL‐10 and transforming growth factor‐β(TGF‐β), and by their ability to suppress antigen‐specific effector T‐cell responses via a cytokine‐dependent mechanism. In contrast to the naturally occurring CD4⁺CD25⁺ T regulatory cells (Tregs) that emerge directly from the thymus, Tr1 cells are induced by antigen stimulation via an IL‐10‐dependent process in vitro and in vivo. Specialized IL‐10‐producing dendritic cells, such as those in an immature state or those modulated by tolerogenic stimuli, play a key role in this process. We propose to use the term Tr1 cells for all IL‐10‐producing T‐cell populations that are induced by IL‐10 and have regulatory activity. The full biological characterization of Tr1 cells has been hampered by the difficulty in generating these cells in vitro and by the lack of specific marker molecules. However, it is clear that Tr1 cells play a key role in regulating adaptive immune responses both in mice and in humans. Further work to delineate the specific molecular signature of Tr1 cells, to determine their relationship with CD4⁺CD25⁺ Tregs, and to elucidate their respective role in maintaining peripheral tolerance is crucial to advance our knowledge on this Treg subset. Furthermore, results from clinical protocols using Tr1 cells to modulate immune responses in vivo in autoimmunity, transplantation, and chronic inflammatory diseases will undoubtedly prove the biological relevance of these cells in immunotolerance.