Table Of ContentGottfriedO.H.Naumann,LeonardM.Holbach,FriedrichE.Kruse(Eds.)
AppliedPathologyforOphthalmicMicrosurgeons
G.O.H. Naumann, L.M. Holbach, F.E. Kruse (Eds.)
Additionalmain authors: ClausCursiefen, Ludwig M.Heindl,
Antonia M. Joussen, AnselmJünemann,Christian Y. Mardin,
andUrsula Schlötzer-Schrehardt
Applied Pathology for
Ophthalmic Microsurgeons
With317figuresin1063partsmostlyincolorand108tables
GottfriedO.H.Naumann,Prof.(emer.)Dr.med.Dr.hc.(mult.)
DepartmentofOphthalmology,UniversityofErlangen-Nürnberg
Schwabachanlage6,D-91054Erlangen,Germany
LeonardM.Holbach,Prof.Dr.med.
DepartmentofOphthalmology,UniversityofErlangen-Nürnberg
Schwabachanlage6,D-91054Erlangen,Germany
FriedrichE.Kruse,Prof.Dr.med.
DepartmentofOphthalmology,UniversityofErlangen-Nürnberg
Schwabachanlage6,D-91054Erlangen,Germany
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To competent and compassionate ophthalmic
microsurgeons committed to the preservation
and restoration of sight – everywhere
Preface
InteractionofPathologyandOphthalmicMicrosurgery
Ophthalmicpathologymeansthestudyofthesymptomsandmorphologicsignsof
diseasesoftheeyeandocularadnexaebothbiomicroscopicallyandinthelaboratory.
Precisedefinitionofthephenotypeisaprerequisiteforcorrelationtothegenotype,
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
boththemethodsofmolecularbiologyandthenewapproachesinbiotechnology.
Microsurgical magnification and miniaturization of instruments and non-me-
chanicaltools,e.g.,lasers,havemadepossibleproceduresbeyondourimaginationa
fewyearsago.Theyarecharacterizedbysmall-accesswoundsintotheeyeandonly
minimalthresholdtraumabeyondthetargetedintraoculartissue.Inviewofallthe
glitteringadvancesofbiotechnology,thedetailsofcriticalanatomymorphologyare
toooftenneglectedorforgottenalthoughtheyareessentialforthesuccessofourmi-
crosurgicalmanipulations.
Thisbookisintendedforophthalmologistsintrainingandalsoformatureeye
physicians.Hopefully,thisshouldhelpthemtoavoidpre-,intra-andpostoperative
complications and make them more alert to explaining the risks to their patients
beforesurgery.Itattemptstoremindtheophthalmicmicrosurgeonthatknowledge
oftheminutiaeofstructuresisaprerequisitetoachievingtheintendedoutcome.Mi-
crosurgicallandmarksneedtobedefinedmorepreciselythaninconventionaloph-
thalmic surgerywithoutmicroscopicmagnification.Awarenessofthe specificpa-
thologyiscrucialfortheappropriateindicationsandsuitabilityofinstrumentation
toovercomethespecifictissueresistance.
Finally,whilebiotechnologyisalwayschanging,themorphologicelementsofthe
eyeandocularadnexaeinhealthanddiseaseremainessentiallythesame.However,
woundhealing,scarsandcomplicationsarealsomodifiedbynewmicrosurgicalap-
proaches.
Ourintentionisnottocompileacompletelistofreferencesbutinsteadtogivethe
readeraselectionoftextbooksandreviewarticlesthatmaybehelpfulforfurther
study.
We have not concentrated on the details of instrumentation and surgical tech-
niques.Botharedevelopingcontinuously.Asanexceptionthereaderisreferredtosec-
tionsonnon-mechanicaltrephinationpenetratingkeratoplastywiththeexcimerlaser
alongmetalmasksanddirectsurgeryoftheciliarybody(seeChapters5.1and5.4).
Clinical findings including imaging by biomicroscopy, “biocytology”, ultra-
sound,OCT,CT,MRIetc.ofthephenotype–supportedbyknowledgeofthe“third
dimension”suppliedbyophthalmicpathology–thereforeareessentialforpatient
care.Theypresentinvivoandinthelaboratorythefoundationforsolvingdiagnostic
andtherapeuticchallengesfortheclinicianandmicrosurgeon:Ophthalmicpatholo-
gyisalsoaclinicalsubspecialty.
Wewanttoemphasizethatdemandingandcomplex“ophthalmicmicrosurgeryis
applied ophthalmic pathology.” This is particularly true if intra- or postoperative
complicationsneedtobecorrectedorminimized.
VIII Preface
Thereforewehavetriedtodothefollowing:
1. Alerttheophthalmicmicrosurgeontothecriticalsurgicalanatomyandpatholo-
gy,landmarksandpotentialcomplicationsbeforeheorsheplansandstartstodis-
cusstheindicationswiththepatientandthentheprocedureitself.
2. Emphasizerespectforthestructureoftheeyeandocularadnexaeandpointout
themostvulnerablecellpopulationsinthevariousmicrosurgicalinterventions.
3. Point out the peculiar and unique features of intraocular microsurgery in the
“closedsystem”and“openeye,”focusingonacuteocularhypotony-paracentesis
effectsandtheinfluenceonblood-ocularbarriers.
4. Illustratetheconsequencesofthemovementoftheiris-lensdiaphragm(“visater-
go”)inrelationtothesystemicarterialpressureintheopeneye;alsothesignifi-
canceofmaintainingorrestoringtheanteriorchamberattheendofallintraocular
proceduresinvolvingtheanteriorsegment.
5. Showhowknowledgeofthespecificpathologymodifiesmicrosurgicalinterven-
tions.Wementionhereonlyafewexamplesandreferthereadertotherelevant
chapters.
)
LossofBowman’slayer–focalordiffuse–recognizedbeforecornealincisions
orgraftingmakesasurplusofinterruptedsuturesadvisable:becausesuture
looseningismorelikely.Runningsuturescanthenbeparticularlyannoying,
becauseifoneloopbecomesloosetheentiresutureandwoundwillbeunsta-
ble.Singlelooseinterruptedsuturescanbeeasilyremovedattheslitlamp–the
architectureofthewoundbeyondoneloosesutureisusuallynotendangered.
)
CalcificationswithinBowman’slayerinbanddegenerationofthecorneacan
usuallybechemicallydissolvedanddonotjustifysacrificeofthisstructure,
e.g.,byexcimerlaser.
)
Limbalstemcellinsufficiencyalertsonetoseriousocularsurfaceproblems.
)
Avascular corneal lesions after herpes corneae may more likely harbor herpes
simplex-virusinthestroma,whichmayleadtorecurrenceafterkeratoplasty.In
contrastvascularizedherpeticscarsindicateanincreasedriskforpostoperative
immunereactionsfollowingcornealtransplantation.
)
GranulomatousreactionagainstDescemet’smembraneinherpescorneaeleads
todefectsandsignalsimminentcornealperforation.Thismaybeanargument
forurgentcurativeperforatingkeratoplasty.
)
Tumorsofthe“irisroot”defactoinvolvetheanteriorfaceoftheciliarybody
andneedtobetreatedbyblockexcisionofirisandciliarybody.
)
Cysticanddiffuseepithelialingrowthintotheanteriorchamberusuallyreach
theangleandcovertheanteriorsurfaceoftheciliarybody.Therefore“block
excisions”arenecessaryincludingremovaloftheadjacentparsplicataofthe
ciliarybody,iris,corneaandsclera–actingasa“shell.”Onlysmallepithelial
implantationsinthecentralirisregioncanbecuredbyiridectomyiftheangle
isnotinvolved.
)
Fibrouspseudo-metaplasiaoftheanteriorsubcapsularlensepitheliumresults
inmechanicalpropertiessuchassclera;itmaydivertthestandardcapsulorr-
hexisaroundtheanteriorsubcapsularcataract.
)
Pseudoexfoliationsyndrome(PEX)isageneralizeddiseaseoftheextracellular
matrix.Itaffectsalltissuesoftheanteriorsegmentoftheeye.Althoughcom-
mon,itmayveryoftenbeoverlookedandmaymanifestasymmetricallybutin
factisalwayspresentbilaterally.Itisnotaharmlessanomalybutadiseaselead-
inginitsadvancedstagestopotentiallycatastrophiccomplications.
Weneedtoconsidernotonlytheriskofsecondaryopenangleandangleclosure
glaucomas,butalsothezonularinstability,blood-aqueousbarrierbreakdown,
anteriorsegmenthypoxia,poormydriasis,andreducedmobilityoftheiris.The
vulnerabilityofthedirectlyinvolvedcornealendotheliumcontributestothein-
creasedriskofcornealdecompensation.TomissthediagnosisofPEXordisre-
garditmayimplymanyunpleasantsurprisesor“recklesslyrunningintoatrap.”
InteractionofPathologyandOphthalmicMicrosurgery IX
)
Intraocularneovascularizationcommonlydevelopsintheendstagesofmany
ocularandsystemicdiseases.Untilrecentlymedicalandlasertherapyattempt-
edtoeliminateangiogenicfactorsoriginatingfromhypoxicretina.Thenew
capillariesdidnotdisappearbutwerelessrecognizablebecauseofdecreased
bloodflowinthepersistingvascularscaffold.Aspectacularadvancecurrently
isevolvingbynewlocalapplicationofspecificinhibitorsofvascularendotheli-
algrowthfactors(VEGFs)inthetherapyoftheseentities.Theendothelialcap-
illarysproutscanactuallyregressaslongasacapillarybasementmembrane
hasnotyetbeenformed.
)
Defining structures (“Leitstrukturen”) of the retina help to better interpret
optical coherence tomography (OCT), retinal thickness analysis (RTA) and
fluorescenceangiographytooutlineindicationsformicrosurgery.
)
Uvealmalignant melanomasalmost always invade the sclera, although their
degreeoftenisnotdetectableclinically–particularlyiftheyareunpigmented.
6. Nottoforget:Allcataractsurgeonsexertsometensiononthelenscapsuleand
thusexerttractiononthevitreousbaseviaWieger’sligaments–butmanyarenot
really aware of this in their daily routine. The peripheral retina also should be
inspectedbeforeandaftercataractsurgery.
7. Featuresofnormalandpathologicwoundhealing(“scarwars”)deserveattention
inthevarioustissuesfollowingmechanicalornon-mechanical(laser,cryo-,dia-
thermiacoagulation)interventionsintheclosedandopeneyeconstellations.
Beyondthepracticalimplicationsthesepagesmightalsoencourageourcolleagues
tostudythelivingeyeandocularadnexae–withaconsciousknowledgeofthethird
dimension–andwithenlightenedcuriosityandmagnifiedattention.
Wesincerelyhopethatourbookmightbehelpfulintheclinicalcareofpatients.
Erlangen,Summer2007 GottfriedO.H.Naumann
LeonardHolbach
FriedrichE.Kruse
X Acknowledgements
Acknowledgements
WewouldliketothankournumerouscoworkersattheDepartmentsofOphthalmol-
ogy of the Universities of Hamburg (1961–74), Tübingen (1975–80) and Erlangen
(since1980),whohavemadesuchalargecontributiontothisbook.Itisimpossible
tomentionthemall.
Our colleagues from the European Ophthalmic Pathology Society (EOPS), the
Verhoeff-ZimmermanSocietyandthe GermanSpeakingOphthalmic Pathologists
(DOP)andmanyophthalmologistsfromaroundtheworldwereagreatsourceofin-
spirationinthepreparationofthebook.
Frau Carmen Rummelt of the Ophthalmic Pathology Laboratory in Erlangen
madeexperttechnicalcontributionstothecuttingandstainingofspecimensforthe
figuresandhelpedwiththedigitalmicrophotographsandSEM.Theexcellentwork
ofourphotographers,particularlyH.StrahwaldandM.VoglerinErlangen,isevi-
dent from their clinical pictures, and Jörg Kühn, Heidelberg, created some fine
graphicalworkbymodifyingsketchesmainlyfrompreviouspublicationsbytheau-
thors,unlessmentionedotherwise.
MostoftheschematicdrawingsandtablesarebasedondraftsbytheFirstEditor/
Author,whoalsosuppliednumerousmicrophotographs.
WeareverygratefultoFrauMarionPhilippandFrauMartinaHimberger,Spring-
er-Verlag,Heidelberg,fortheirencouragementandtolerancewithunforeseeablede-
lays;Mr.W.Shufflebotham,whowithgreatpatiencetransferredourteutonicversion
ofthemanuscriptintocorrectEnglish;andHerrJoachimW.Schmidt,Munich,who
combinedthetext,figures,tablesandreferencesveryefficientlyintothebookinits
presentform.
FrauIrisSchmittnotonlytypedmanyofthechaptersbutwasessentialinmain-
tainingorderlycommunicationsduringthelongprocessofpreparingthetextand
arrangingtables,figuresandliteratureofthemanuscript.Herexperienceinprepar-
ingbooksandpublicationssince1975provedinvaluable.Withoutheruntiringsup-
portthisbookwouldnotyetbefinished.
Finally,weareverygratefulforthesupportofourpartnersandfamiliesfortheir
understandingandpatienceduringthecompletionofthisproject.
Condensed Table of Contents
1 Introduction
G.O.H.Naumann,FriedrichE.Kruse................................... 1
2 GeneralOphthalmicPathology:PrincipalIndicationsandComplications,Comparing
Intra-andExtraocularSurgery
G.O.H.Naumann,F.E.Kruse ........................................... 7
3 SpecialAnatomyandPathologyinSurgeryoftheEyelids,LacrimalSystem,
OrbitandConjunctiva
L.M.Holbach ....................................................... 29
3.1 Eyelids
L.M.Heindl,L.M.Holbach ........................................... 30
3.2 LacrimalDrainageSystem
L.M.Heindl,A.Jünemann,L.M.Holbach .............................. 45
3.3 Orbit
L.M.Holbach,L.M.Heindl,R.F.Guthoff .............................. 49
3.4 ConjunctivaandLimbusCorneae
C.Cursiefen,F.E.Kruse,G.O.H.Naumann ............................. 67
4 GeneralPathologyforIntraocularMicrosurgery:DirectWounds
andIndirectDistantEffects
G.O.H.Naumann,F.E.Kruse .......................................... 76
5 SpecialAnatomyandPathologyinIntraocularMicrosurgery
5.1 CorneaandLimbus
C.Cursiefen,F.E.Kruse,G.O.H.Naumann ............................. 97
5.2 GlaucomaSurgery
A.Jünemann,G.O.H.Naumann....................................... 131
5.3 Iris
G.O.H.Naumann.................................................... 152
5.4 CiliaryBody
G.O.H.Naumann.................................................... 176
5.5 LensandZonularFibers
U.Schlötzer-Schrehardt,G.O.H.Naumann .......................... 217
