[Intraoperative floppy iris syndrom (IFIS) associated with tamsulosin]

BACKGROUND

Tamsulosin is one of the most commonly prescribed alpha-1A antagonists for the treatment of benign prostatic syndrome (BPS). Patients treated with tamsulosin often develop intraoperative floppy iris syndrome (IFIS) during cataract surgery. This leads to increasing miosis and an undulating iris, which increases the risk of complications significantly and can cause permanent damage.

AIM OF THE WORK

The aim is to raise awareness for the effects of tamsulosin intake before cataract surgery.

MATERIAL AND METHODS

We conducted a critical review of publications on the association of IFIS in cataract surgery with alpha-receptor blockers.

RESULTS AND DISCUSSION

Tamsulosin has a risk of complications of up to 80 %, whereas doxazosin and alfuzosin only have a 15-20 % chance of complications. Tamsulosin therefore represents a significant risk factor for permanent secondary damage after cataract surgery. Even after discontinuing tamsulosin, IFIS was still observed after up to 3 years. Nevertheless, pausing of tamsulosin intake is recommended. An alternative preparation should therefore be preferred in patients who have not yet had cataract surgery. If patients are already pseudophakic, tamsulosin can be given without concern.

Partial monovision achieved by unilateral implantation of a multifocal add-on lens with bilateral pseudophakia: evaluation and results

Purpose

To assess the results of partial monovision (PMV) in comparison to a bilateral monofocal implantation (MMV).

Methods

The PMV group was treated bilaterally with a monofocal intraocular lens (IOL) implantation, followed 3 months later by the implantation of a multifocal AddOn® lens (+ 3.00 D) into the non-dominant eye. The MMV group received a bilateral monofocal IOL implantation intending to achieve a slight anisometropia (0.0 D/ − 0.50 D). The near visual acuity (UNVA), intermediate visual acuity (UIVA), distance visual acuity (UDVA), defocus curve, and Lang-Stereotest II were conducted uncorrected, binocular, and minimum 3 months after the last operation. For the contrast sensitivity test, the patients were refractively corrected. The Quality of Vision Questionnaire (QoV), Visual Function Questionnaire (VF-14), spectacle independence, and general satisfaction were also assessed.

Results

A total of 27 PMV patients and 28 MMV patients without ocular diseases relevant to visual acuity were examined. The PMV group was significantly better at UNVA (0.11 ± 0.08 logMAR vs 0.56 ± 0.16 logMAR) and between − 2.00 and − 4.00 D in the defocus curve (p < 0.001). At the UIVA, the PMV group was slightly better (0.11 ± 0.10 logMAR vs 0.20 ± 0.18 logMAR) but not significant (p = 0.054). The UDVA (− 0.13 ± 0.09 logMAR vs − 0.09 ± 0.14 logMAR) (p = 0.315) and contrast sensitivity (p = 0.667) revealed no differences between the groups. The stereo vision was in favor of PMV (p = 0.008). Spectacle independence was statistically better for PMV at distance, intermediate, and near (distance p = 0.012; intermediate p < 0.001; near p < 0.001). In the VF-14 Questionnaire, the PMV was statistically superior (p < 0.001). The QoV Questionnaire showed no differences regarding frequency and severity of visual disturbances. Both groups were highly satisfied (p = 0.509).

Conclusion

Patients with PMV are more independent of glasses and are able to read without disadvantages in distance vision, due to halos and glare. The concept of PMV is well suited for the desire of eyeglass independence, without optical side effects.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00417-022-05584-y.

Silent Brain Infarctions and Leukoaraiosis in Patients With Retinal Ischemia: A Prospective Single-Center Observational Study

BACKGROUND AND PURPOSE

We aimed to determine the incidence of co-occurring cerebral ischemia, extent of cerebral small vessel disease, and vascular risk profile of patients with acute retinal ischemia.

METHODS

RETIS (Frequency of Acute Silent Brain Infarction and Systematic Evaluation of Stroke Risk in Retinal Ischemia) was a single-center, prospective, observational study comprising ophthalmologic examination, brain magnetic resonance imaging, and extensive diagnostic work-up of vascular risk factors and stroke cause. Silent brain infarctions were identified on diffusion-weighted imaging, leukoaraiosis was quantified on fluid-attenuated inversion recovery sequences, and carotid artery stenosis was assessed by carotid ultrasound.

RESULTS

Of 112 patients with retinal ischemia, 77 (68.8%) had retinal arterial occlusion, and 35 (31.3%) presented with amaurosis fugax. Silent brain infarctions were found in 17 (15.1%) patients. Internal carotid artery stenosis was present in 19 (17.0%) and severe leukoaraiosis in 29 (25.9%) patients. Atrial fibrillation was detected in 14 (12.5%) patients. Patients with silent brain infarctions had higher rates of internal carotid artery stenosis (35.3% versus 13.7%; P=0.029) than those without, whereas leukoaraiosis and vascular risk factors were comparable between groups. Internal carotid artery stenosis was the only significant predictor of silent brain infarctions in multivariate analysis (odds ratio, 4.27; 95% confidence interval, 1.06-17.23).

CONCLUSIONS

Silent cerebral ischemia is present in about 1 in 7 patients with retinal ischemia. The high rate of symptomatic internal carotid artery stenosis suggests that large artery atherosclerosis plays a major role in the pathogenesis of acute retinal ischemia.

Pattern of gray matter volumes related to retinal thickness and its association with cognitive function in relapsing-remitting MS

BACKGROUND

Neurodegeneration in multiple sclerosis (MS) may be investigated in the visual system as optical coherence tomography (OCT) and magnetic resonance imaging (MRI) allows examining structural integrity in detail. The association between thickness of retinal layers and focal cortical volumes beyond the primary visual system has not been thoroughly investigated.

OBJECTIVE

To investigate the association between focal cortical volume and thickness of retinal layers.

METHODS

Fifty-four patients (relapsing-remitting MS, mean age 40.5 years, mean disease duration 7.6 years, median EDSS 2) underwent OCT and MRI. The association between focal cortical volume and OCT measurements was investigated with voxel-based morphometry (VBM). Patterns of association were determined with Yeo's functional network atlas and the Harvard-Oxford cortical atlas. We used GEE models with cortical volumes from the FreeSurfer parcellation to confirm VBM results. Post hoc, we analyzed the association between OCT, focal cortical volumes, and an extended neuropsychological assessment in a subgroup of 14 patients.

RESULTS

Macular retinal nerve fiber layer (mRNFL) and ganglion cell /inner plexiform layer (GCIPL) showed a robust association with mainly the insular cortex and the cingulate cortex. VBM findings were confirmed with FreeSurfer volumes. The post hoc analysis detected significant correlations between both OCT outcomes and cognition.

CONCLUSION

Besides the primary visual system, OCT outcomes show a correlation pattern with cortical regions that are known to be important for cognitive performance, predominantly the insula in both hemispheres. Thus, OCT should be further investigated as a marker for neurodegeneration in MS.

Evaluation of Retinal Vessel Morphology in Patients with Parkinson's Disease Using Optical Coherence Tomography

PURPOSE

The retina has been found affected in Parkinson's disease (PD). It is unclear if this is due to neurodegeneration of local dopamine-dependent retinal cells, a result of central nervous degeneration including the optic nerve or retinal small vessel disease. This study aimed to detect changes of the retinal vasculature in PD patients compared to controls.

METHODS

We examined 49 PD patients and 49 age- and sex-matched healthy controls by spectral domain optical coherence tomography (SD-OCT) with a circular scan centred at the optic disc. Vessels within the retinal nerve fibre layer were identified by an automated algorithm and thereafter manually labelled as artery or vein. Layer segmentation, vessel lumen and direct surrounding tissue were marked automatically with a grey value and the contrast between both values in relation to the surrounding tissue was calculated. The differences in these grey value ratios among subjects were determined and used as an indicator for differences in vessel morphology. Furthermore, the diameters of the veins and arteries were measured and then compared between the groups.

RESULTS

The contrast of retinal veins was significantly lower in PD patients compared to controls, which indicates changes in vessel morphology in PD. The contrast of arteries was not significantly different. Disease duration, disease stage according to Hoehn and Yahr or age did not influence the grey value ratios in PD patients. Vessel diameter in either veins or arteries did not differ between subject groups. The contrast of retinal veins contralateral to the clinically predominant and first affected side was significantly lower compared to the ipsilateral side.

CONCLUSION

Our data show a potential difference of the retinal vasculature in PD patients compared to controls. Vascular changes in the retina of PD patients might contribute to vision-related complaints in PD.

Treatment of optic neuritis with erythropoietin (TONE): a randomised, double-blind, placebo-controlled trial-study protocol

INTRODUCTION

Optic neuritis leads to degeneration of retinal ganglion cells whose axons form the optic nerve. The standard treatment is a methylprednisolone pulse therapy. This treatment slightly shortens the time of recovery but does not prevent neurodegeneration and persistent visual impairment. In a phase II trial performed in preparation of this study, we have shown that erythropoietin protects global retinal nerve fibre layer thickness (RNFLT-G) in acute optic neuritis; however, the preparatory trial was not powered to show effects on visual function.

METHODS AND ANALYSIS

Treatment of Optic Neuritis with Erythropoietin (TONE) is a national, randomised, double-blind, placebo-controlled, multicentre trial with two parallel arms. The primary objective is to determine the efficacy of erythropoietin compared to placebo given add-on to methylprednisolone as assessed by measurements of RNFLT-G and low-contrast visual acuity in the affected eye 6 months after randomisation. Inclusion criteria are a first episode of optic neuritis with decreased visual acuity to ≤ 0.5 (decimal system) and an onset of symptoms within 10 days prior to inclusion. The most important exclusion criteria are history of optic neuritis or multiple sclerosis or any ocular disease (affected or non-affected eye), significant hyperopia, myopia or astigmatism, elevated blood pressure, thrombotic events or malignancy. After randomisation, patients either receive 33,000 international units human recombinant erythropoietin intravenously for 3 consecutive days or placebo (0.9% saline) administered intravenously. With an estimated power of 80%, the calculated sample size is 100 patients. The trial started in September 2014 with a planned recruitment period of 30 months.

ETHICS AND DISSEMINATION

TONE has been approved by the Central Ethics Commission in Freiburg (194/14) and the German Federal Institute for Drugs and Medical Devices (61-3910-4039831). It complies with the Declaration of Helsinki, local laws and ICH-GCP.

TRIAL REGISTRATION NUMBER

NCT01962571.

Scanning laser polarimetry and spectral domain optical coherence tomography for the detection of retinal changes in Parkinson's disease

PURPOSE

Whether retinal degeneration is part of the degenerative processes in patients with Parkinson's disease (PD) is still unclear. This cross-sectional study was undertaken to compare the retinal morphology of patients with PD and healthy controls using spectral domain optical coherence tomography (SD-OCT) and scanning laser polarimetry (SLP).

METHODS

Both eyes of patients with PD (n = 108) and healthy controls (n = 165) were examined using SD-OCT and SLP on the same day. Data on the thickness of the retinal nerve fibre layer (RNFL) of all quadrants and the macular area were acquired by OCT (Cirrus, Zeiss). The SLP device (Glaucoma diagnostics (GDx), Zeiss) measured the RNFL and calculated the nerve fibre index (NFI). All patients and probands were checked for concomitant ocular disorders by an ophthalmologist. Visual acuity, intraocular pressure (IOP), objective refraction and the anterior and posterior segment were assessed.

RESULTS

Patients with PD showed a reduced macular volume and a reduced central subfield thickness in OCT examinations. The RNFL in the different quadrants did not differ significantly from that of controls. SLP data showed a reduced average RNFL thickness, a decreased thickness of the inferior quadrant and an increase of the NFI in patients with PD.

CONCLUSION

PD may be associated with reduced thickness and volume of the macula and a reduced thickness of the RNFL in the inferior quadrant of the retina. Investigations using SD-OCT and SLP revealed distinct but significant differences between patients with PD and healthy controls.

Detection of retinal changes in idiopathic Parkinson's disease using high-resolution optical coherence tomography and heidelberg retina tomography

PURPOSE

The study was performed to analyse the retina of patients with Parkinson's disease (PD) for morphological changes compared to healthy controls (HC) using spectral-domain optical coherence tomography (SD-OCT) and confocal scanning laser ophthalmoscopy.

METHODS

We enrolled 108 patients with idiopathic PD and 165 HC. All study participants underwent an ophthalmological examination to exclude ophthalmological disorder potentially interfering with the retinal analyses. Peripapillary retinal nerve fibre layer (RNFL) thickness and macular thickness and volume were measured by a SD-OCT device (Heidelberg Spectralis(®) ). Stereometric parameters of the optic disc were acquired by Heidelberg Retina Tomograph (HRT III).

RESULTS

The RNFL thickness did not significantly differ between patients with PD and HC. The thickness of the central minimum and the centre of the macular area were significantly reduced in patients with PD, while the total macular volume did not significantly differ between the groups. Furthermore, we noted an inverse correlation between the central minimum thickness and the disease severity (assessed by the Hoehn and Yahr scale). HRT data showed no significant differences.

CONCLUSION

The HRT device and the RNFL measurements of the SD-OCT did not prove to be a clinically valid diagnostic tool to distinguish eyes of patients with PD and HC. However, the macular region and especially the foveola (central minimum) with the highest density of photoreceptor cells seem to be more sensitive and might be potential biomarkers.

[Intraoperative Measurement of Refraction with a Hand-Held Autorefractometer]

PURPOSE

The aim of this study was to evaluate an intraoperative measurement of objective refraction with a hand-held retinomax instrument.

METHODS

At the end of cataract surgery objective refraction in a lying position was measured with a retinomax instrument. On the first postoperative day the same measurement was performed with a retinomax and a standard autorefractometer. To evaluate the differences between measurements, the spherical equivalent (SE) and Jackson's cross cylinder at 0° (J0) and 45° (J45) was used.

RESULTS

103 eyes were included. 95 of them had normal cataract surgery. Differences between retinomax at the operative day and the standard autorefractometer were 0.68 ± 2.58 D in SE, 0.05 ± 1.4D in J0 and 0.05 ± 1.4D in J45. There were no statistically significant differences between the groups.

CONCLUSION

Intraoperative measurement of the refraction with a retinomax can predict the postoperative refraction. Nevertheless, in a few patients great differences may occur.

Thirty years of cornea cultivation: long-term experience in a single eye bank

PURPOSE

To evaluate donor demographics, trends in donor tissue procurement and tissue storage over a long period.

METHODS

A retrospective, longitudinal, descriptive analysis was undertaken of data from the Hamburg Eye Bank Data Base (HEB-DB) that had been collected between 1981 and 2010. Data on 54 parameters of cornea donors [including clinical history, age, death cause, gender and death-to-explantation interval (DEI)] and of cultivated corneas (endothelial quality and development in culture, cultivation period, microbiological contamination) were retrieved. These data were analysed statistically, focusing on the historical development of the eye bank.

RESULTS

At the time of retrieval (June 2010), the HEB-DB contained data on 10 943 corneas (5503 donors). Most donors were men (65%) and had died from cardiopulmonary (n = 801)/cerebral (n = 261) failure or as the result of a polytraumatic accident/suicide (n = 602). Within these years, donor age, DEI and storage time increased. The percentage of stored corneas suitable for transplantation displayed a variable but increasing trend; in 2007, almost 75% of the stored corneas were transplanted. Between 1995 and June 2010, the median microbiological contamination rate was 5.3%. A change in the procurement procedure from enucleation to corneoscleral explantation in 2008 led to a briefly increased contamination rate.

CONCLUSION

  Donor demographic data run parallel to the general demographic development. Our analysis indicates a dynamic development of the eye bank over the last 30 years and emphasizes the need for an active quality management in coping with the challenges of modern eye banking.

[The new OCT generation offers deep insights: imaging of the choroid using the Cirrus OCT]

BACKGROUND

Until now depiction of the choroid using time domain optical coherence tomography (OCT) (Stratus III) was barely possible. Visualization of choroidal perfusion was carried out using indocyanine green angiography (ICGA). The spectral-domain OCT, such as Cirrus OCT (C-OCT) is able to image the choroid better because it offers higher resolution, increased penetration depth of the scan beam and faster acquisition of A-scan data. The aim of the study was to evaluate the potential of choroidal imaging in patients suffering from macular disease.

METHODS

The advanced visualization tool of C-OCT was primarily used and converted to a z-axis topography. Because of a special algorithm developed by our team, targeted imaging of the choroidal vessels was possible through the scanned two dimensional retinal areas. This image offers an extended image of choroidal vessels (large and small vessels) in several levels. In total 20 patients eyes (n = 15 with various macular diseases and n = 5 normal conditions) who underwent C-OCT and ICG angiography (HRA 2) were chosen to participate in this special algorithm. A precise correlation of ICG and choroid OCT in a semitransparent manner was carried out.

RESULTS

The first prototype of the recognition software prototype produced clear imaging of the choroid in 100% of cases but only in 55% in the macular region depending on the extent of macular disease. Limitations were low signal intensity and penetration depth as well as a poorly defined retinal pigment epithelium (RPE) and choriocapillaris especially in macular diseases of the RPE layer. After a black and white conversion in OCT using the software it was possible in all cases to integrate the choroidal OCT with the ICG angiogram in a semitransparent manner. This confirms that the choroidal vessels in C-OCT correlated identically with the ICG angiography. In contrast to the ICG where the contrast agent in the vessel emits a signal, the choroidal vessels are visible due to different reflectivity in the merging tissue.

CONCLUSIONS

These investigations showed that non-invasive topographic imaging of the choroid using spectral domain OCT, such as Cirrus OCT is now possible. Distinguishability of smaller vessels was excellent. The ICG (perfusion) and C-OCT (morphology) methods are two very different vessel imaging techniques. The integration of both methods is possible. The clinical relevance of the new image information still has to be researched.

A randomized, double-blind, phase 2 study of erythropoietin in optic neuritis

OBJECTIVE

Based on findings in animal models of autoimmune optic nerve inflammation, we have assessed the safety and efficacy of erythropoietin in patients presenting with a first episode of optic neuritis.

METHODS

Patients with optic neuritis who attended the University Hospitals of Homburg/Saar, Göttingen, or Hamburg (Germany) were included in this double-blind, placebo-controlled, phase 2 study (ClinicalTrials.gov, NCT00355095). They were randomly assigned to groups receiving either 33,000IU recombinant human erythropoietin intravenously daily for 3 days or placebo as an add-on therapy to methylprednisolone. The primary outcome parameter was change in retinal nerve fiber layer (RNFL) thickness after 16 weeks. Secondary outcome parameters included optic nerve atrophy as assessed by magnetic resonance imaging, and changes in visual acuity, visual field, and visual evoked potentials (VEPs).

RESULTS

Forty patients were assigned to the treatment groups (21/19 erythropoietin/placebo). Safety monitoring revealed no relevant issues. Thirty-seven patients (20/17 erythropoietin/placebo) were analyzed for the primary endpoint according to the intention-to-treat protocol. RNFL thinning was less apparent after erythropoietin treatment. Thickness of the RNFL decreased by a median of 7.5μm by week 16 (mean ± standard deviation, 10.55 ± 17.54μm) compared to a median of 16.0μm (22.65 ± 29.18μm) in the placebo group (p = 0.0357). Decrease in retrobulbar diameter of the optic nerve was smaller in the erythropoietin group (p = 0.0112). VEP latencies at week 16 were shorter in erythropoietin-treated patients than in the placebo group (p = 0.0011). Testing of visual functions revealed trends toward an improved outcome after erythropoietin treatment.

INTERPRETATION

These results give the first indications that erythropoietin might be neuroprotective in optic neuritis.

[Severe contact lens-associated fungal keratitis]

A 23-year-old man presented with severe contact lens-associated keratitis and descemetocele with pre-existing drug therapy. After 1 week of intensive antibiotic treatment Aspergillus fumigatus was identified. Despite adjusted antimycotic treatment a corneal perforation occurred. Due to peripheral scleral infiltration the cornea was primarily closed with a double layer amniotic membrane in order to avoid a sclerokeratoplasty with a bad prognosis. After 2 weeks the peripheral corneal situation stabilized and a simple keratoplasty á chaud could be performed. After surgery and adjusted drug therapy, no adequate signs of recovery occured. In repeated microbiological testing an additional Candida albicans infection was diagnosed and therapy was readjusted. This resulted in a cure of the corneal infection. After 5 years and a re-keratoplasty the patient presented with a clear corneal transplant and a corrected visual acuity of 20/25.

[EYECUBE as 3D multimedia imaging in macular diagnostics]

BACKGROUND

In the new generation of EYECUBE devices, the angiography image and the OCT are included in a 3D illustration as an integration. Other diagnostic procedures such as autofluorescence and ICG can also be correlated to the OCT. The aim was to precisely classify various two-dimensional findings in relation to each other.

METHOD

The new generation of OCT devices enables imaging with a low incidence of motion artefacts with very good fundus image quality - and with that, permits a largely automatic classification. The feature enabling the integration of the EYECUBE was further developed with new software, so that not only the topographic image (red-free, autofluorescence) can be correlated to the Cirrus OCT, but also all other findings gathered within the same time frame can be correlated to each other. These were brightened and projected onto the cube surface in a defined interval. The imaging procedures can be selected in a menu toolbar. Topographic volumetry OCT images can be overlayed. The practical application of the new method was tested on patients with macular disorders.

RESULTS

By lightening up the results from various diagnostic procedures, it is possible of late to directly compare pathologies to each other and to the OCT results. In all patients (n = 45 eyes) with good single-image quality, the automated integration into the EYECUBE was possible (to a great extent). The application is not dependent on a certain type of device used in the procedures performed.

CONCLUSIONS

The increasing level of precision in imaging procedures and the handling of large data volumes has led to the possibility of examining each macular diagnostics procedure from the comparative perspective: imaging (photo) with perfusion (FLA, ICG) and morphology (OCT). The exclusion of motion artefacts and the reliable scan position in the course of the imaging process increases the informative value of OCT.

[Paediatric pseudophakia - refractive changes after primary and secondary intraocular lens implantation]

BACKGROUND

A so-called myopic shift after cataract extraction and IOL implantation is known to occur in children. How much is difficult to predict. In this study we report the refractive development in pseudophakic children after primary and secondary IOL implantation.

METHODS

The refractive change in all patients receiving an IOL-implantation between 2000 and 2008 with a follow-up of a minimum of 6 months was reviewed (6 - 107 months). Rigid or foldable lenses were implanted by the same technique. Refraction postoperatively and at last follow-up was measured. 62 eyes of 41 patients were reviewed. Patients were divided into three groups based on age at time of surgery: 3 - 4 years, 5 - 6 years and 7 - 12 years.

RESULTS

The mean myopic shift was 2.5 D in both study groups, patients with primary and secondary IOL implantation. In the group with 3 - 4-year-old children mean myopic shift was 1.5 D in primary and 1.0 D in secondary implantations, in the group with 5 - 6-year-old children 2.75 D in primary and 3.25 D in secondary implantations and in the group with 7 - 12-year-old children 2.0 D in both primary and secondary implanted IOLs.

CONCLUSIONS

We have shown that there are no differences in refractive changes between primary and secondary IOL implantations in our study group. In contrast to other findings we found the lowest myopic shift in the group of 3 - 4-year-old patients. Our results show that a prediction of expected myopic shift in children after IOL implantations remains difficult.

[Optical coherence tomography for macula diagnostics. Review of methods and standardized application concentrating on diagnostic and therapy control of age-related macula degeneration]

BACKGROUND

Optical coherence tomography (OCT) has gained increasing relevance for follow-up after the treatment of macular diseases especially after anti-VEGF therapy. Therefore it seemed reasonable to develop standardized evaluation strategies and OCT examination guidelines for Stratus OCT III.

MATERIALS AND METHODS

Basic guidelines for the Stratus OCT III examination of macular diseases were developed. The first part contains basic advice for the OCT examination with respect to the examiner, patients, image quality, movement artefacts, algorithms, archiving and interpretation of OCT images. The second part consists of the relevance and indications for OCT examination especially in age-related macular degeneration (AMD), subgroups of AMD and follow-up after treatment. The third part demonstrates a brief outlook on future developments, such as the digital integration method (DIM), which provides identical scan localization in follow-up and eliminates any movement artefacts.

CONCLUSION

The application of standardized routine scanning and analysis protocols in Stratus OCT III for macular diseases and follow-up examinations provides an optimized, time-saving and comparable use of OCT. Therefore, the relevance and quality of OCT is increased for routine use in outpatient departments, hospitals and also for clinical studies.

Clinical use and research applications of Heidelberg retinal angiography and spectral-domain optical coherence tomography - a review

Fluorescein angiography (FA) was discovered by Nowotny and Alvis in the 1960s of the 20th century and has evolved to become the 'Gold standard' for macular diagnostics. Scanning laser imaging technology achieved enhancement of contrast and resolution. The combined Heidelberg retina angiograph (HRA2) adds novel innovative features to established fundus cameras. The principle of confocal scanning laser imaging provides a high resolution of retinal and choroidal vasculature with low light exposure providing comfort and safety for the patient. Enhanced contrast, details and image sharpness image are generated using confocality. For the visualization of the choroid an indocyanine green angiography (ICGA) is the most suitable application. The main indications for ICGA are age-related macular degeneration, choroidal polypoidal vasculopathy and choroidal haemangiomas. Simultaneous digital FA and ICGA images with three-dimensional resolution offer improved diagnosis of retinal and choroidal pathologies. High-speed ICGA dynamic imaging can identify feeder vessels and retinal choroidal anastomoses, ensuring safer treatment of choroidal neovascularization. Autofluorescence imaging and fundus reflectance imaging with blue and infrared light offer new follow-up parameters for retinal diseases. Finally, the real-time optical coherence tomography provides a new level of accuracy for assessment of the angiographic and morphological correlation. The combination of various macular diagnostic tools, such as infrared, blue reflectance, fundus autofluorescence, FA, ICGA and also spectral domain optical coherence tomography, lead to a better understanding and improved knowledge of macular diseases.

[OCT in epiretinal gliosis]

Biomorphometric studies using optical coherence tomography (OCT) in patients with epiretinal membranes reveal a highly reflective membrane, a significant foveal thickening, loss of the foveal depression, and the presence of intraretinal cysts. Epiretinal membranes are more frequently totally adherent than separated with focal points of adherence. Visual acuity correlates with foveal thickness prior to and 6 months after vitrectomy and surgical removal of epiretinal membranes. Foveal thickening regresses postoperatively, but normal values are seldom reached. Marked foveal thickening, nonexistent foveal depression, and extensive cyst formation are supposed to correlate with a rather poor visual outcome. OCT plays a pivotal role in the differential diagnosis of pseudomacular hole in epiretinal membranes and of full-thickness macular hole. In addition to biomicroscopy and fluorescein angiography, OCT images provide valuable information for a structural assessment of the macula, especially in evaluating the postoperative course of macular surgery.

[OCT in macular holes]

The traditional Gass classification of macular holes can now be supplemented by additional and more detailed morphologic information obtained with optical coherence tomography (OCT). The perifoveal vitreous detachment and subsequent anterior foveal traction is considered to be the primary pathomechanism of macular hole formation. In cases of persistent traction on the fovea it may lead to foveal dehiscence. A possible explanation for intraretinal cyst formation may be secondary vitreous body fluid accumulation within the retina. A classification of macular holes based on additional information from OCT images is possible. Thus, OCT is a valuable tool for differential diagnosis of a pseudo macular hole versus macular hole, precise stage classification, therapy decision making process, outcome control after macular surgery, and prognosis prediction.

Optische Koh�renztomographie bei Grubenpapille und ser�ser Makulopathie

BACKGROUND

Of patients with an optic pit 30% develop an associated maculopathy of unknown origin. We report on 8 patients with an optic pit and associated maculopathy evaluated by optical coherence tomography (OCT) for detection of structural retinal changes and indications for the pathogenesis.

PATIENTS AND METHODS

A total of 8 patients (mean age 25 years) suffering from an optic pit and associated maculopathy were evaluated by biomicroscopy, fluorescein angiography (FLA) and OCT and the results were compared.

RESULTS

Visual acuity was on average 0.5 (0.05-0.8). Funduscopy revealed a macular elevation. In clinically suspected 'pseudo' macular hole, OCT revealed foveal schisis. OCT demonstrated a retinal detachment with a typical convex schisis of the outer retinal layer (n=6), and three patients showed a neurosensory detachment with (n=2) and without (n=1) intraretinal cystoid formation.

CONCLUSION

The typical macular schisis pattern in OCT in optic pit with serous maculopathy helps to differentiate this condition from other macular elevations.

[Choroidal neovascularisation in type II membranoproliferative glomerulonephritis, photodynamic therapy as a treatment option--a case report]

BACKGROUND

Photodynamic therapy (PDT) is an established treatment in predominantly classic choroidal neovascularisation (CNV) in exudative age-related macular degeneration (AMD). Membranoproliferative glomerulonephritis (MPGN) type II leads to AMD-similar changes ("pseudo-AMD") of the fundus with CNV as a late complication. We report on a patient suffering from MPGN II and a classic CNV who was treated with PDT.

PATIENT AND METHOD

A 31-year old male patient suffering from MPGN II from the age of 8 presented with visual deterioration and metamorphopsies on his left eye (VA OD 1.0, OS 0.25). Funduscopy revealed a "Pseudo"-AMD on both eyes and the left eye showed a 100 % classic CNV in fluorescein angiography (FLA). The left eye has treated with PDT. Visual acuity after PDT remained stable with 0.25 OS and metamorphopsies were reduced. 3 months later FLA showed a small residual leakage, therefore a second PDT was performed. 4 months after the 2 nd PDT the patient suffered again from metamorphopsies with a stable VA of 0.25 OS following a 3 rd PDT.

RESULTS

Visual acuity of the left eye remained stable at 0.25 and metamorphopsies reduced due to the treatment of 3 PDT's. Even in "pseudo-AMD" in MPGN II the PDT is able to reduce leakage and stops progression consistent to the results in exudative AMD.

CONCLUSION

In MPGN II associated "pseudo"-AMD with classic CNV the PDT was also successful. The origin of the CNV does not appear to play a role for the success of the PDT.

[Incidence of ocular manifestations in patients with histologically confirmed systemic sarcoidosis]

BACKGROUND

Intraocular findings in sarcoidosis were described by US studies with 35 % anterior uveitis, 25 % posterior uveitis and 20 - 30 % for late complications in case of first presentation. We report on the spectrum and diagnostic possibilities in 38 German patients.

PATIENTS AND METHODS

38 patients (68 eyes) aged 11 - 58 years (average 42.7 y), who suffered of intraocular manifestations in histological confirmed systemic sarcoidosis (1987 - 1997), were completely evaluated retrospectively. For additional diagnostic tools fluorescein angiography, optical coherence tomography, nuclear magnetic resonance tomography and measurements of angiotensin-converting enzyme, lysozyme and calcium in serum were performed.

RESULTS

15 patients (22 eyes = 32.4 %) had anterior uveitis: granulomatous keratouveitis (10 eyes), granulomas of the iris (6), granulomas of the trabecular meshwork (3) and 22 patients (42 eyes = 61.8 %) an intermediate and posterior uveitis: granulomatous perivasculitis (18 eyes), cystoid maculopathy (8), pars planitis (6), neuroretinitis (4), optic neuritis (3), choroiditis (3). Late complications in case of first presentation were found in 22 patients (39 eyes = 57.4 %): posterior synechiae 14 x, secondary glaucoma 10 x, cataracta complicata 8 x, optic atrophy 6 x, intraocular calcification 1 x.

CONCLUSION

Compared to previous studies with heterogeneous ethnic composition, intraocular inflammations with confirmed sarcoidosis in German patients show more than 60 % involvement of the posterior segment. We may speculate on the reasons for these discrepancies as being due to ethnic reasons, age and long-term follow-up. In case of typical ocular signs of sarcoidosis, treatment should be started immediately even without histological confirmation. In some cases histological confirmation is successful 8 years after first presentation.

[Testing central retinal function with multifocal electroretinography before and after photodynamic therapy]

BACKGROUND

Photodynamic therapy (PDT) is applied for certain forms of choroidal neovascular membrane (CNV). The aim of this study was to investigate the effect of PDT on central retinal function as assessed by multifocal electroretinography (ERG).

METHODS

24 patients (25 eyes) with CNV (>50% classic 12 eyes) or occult (9 eyes) in age related macular degeneration (AMD) and CNV with pathological myopia (4 eyes) were treated by PDT using Verteporfin((R)). Before and a median of 6 weeks after therapy, central retinal function was examined using multifocal ERG (RetiScan, 61 hexagons, first-order response).

RESULTS

In the area of treatment,we found a tendency of the amplitude of the first positive deflection (P1) to decrease and of the implicit time to increase, but both effects were not statistically significant. These alterations were more pronounced in eyes with occult CNV and in myopia-related CNV. Amplitude reduction and implicit time prolongation could also be found in the areas represented by the multifocal ERG but not treated. There was no significant correlation between change in visual acuity after PDT and amplitude of the multifocal ERG.

CONCLUSION

The effects of PDT on retinal function seem to be moderate as assessed by multifocal ERG. An inherent problem of this investigation was the recruitment of nontreated patients as controls. Future goals are investigations of patients with repeated PDT and of long-term alterations in multifocal ERG after PDT.

[Subretinal granuloma, retinal vasculitis and keratouveitis with secondary open-angle glaucoma in schistosomiasis]

BACKGROUND

More than 250 million people in Africa and Asia currently suffer from schistosomiasis, however, ocular manifestations of this disease are rare in Germany. PATIENT AND FOLLOW-UP: We present the case of a 32-year-old patient from Gambia who had been resident in Germany for 3 years and suffered from a painful persistent diarrhoea, fever and a reduction of visual acuity (R > L). On admission, the patient reported a schistosomiasis in 1994, which was diagnosed by a skin test and was not adequately treated because of the side-effects of praziquantel. Vision was OD-0.75 sph 0.8, OS sc 1.0, IOD OD 31, OS 18 mmHg. Biomicroscopy: R > L fatty retrocorneal precipitates, especially in the lower circumference (ARLT), large inflammatory cells and Tyndall ++, vitreous with large inflammatory cells, Fundus: OD at 11 o'clock large subretinal granuloma in the periphery. Serum lysozyme was elevated (22.2 mg/l, normal range 10-17 mg/l), a syphilis stage II-III (TPHA 1:5000, VDRL neg.) and an IgG-antibody titre for Schistosoma mansoni of > 30 micrograms/ml was detected by enzyme immunoassay. In the faeces and urine no schistosoma eggs were found. Before the specific treatment for schistosomiasis could be initiated, the patient left the hospital because of reduced ocular pain due to the corticosteroids and fear of the side-effects of the treatment.

DISCUSSION

In patients who present a subretinal granuloma and report a painful persistent diarrhoea, schistosomiasis, which is one of the most frequent tropical diseases should be considered, even if they have been living in central Europe for several years. Although the disease cannot become established due to the lack of specific hosts in this area, a curative treatment should be enforced in order to prevent late manifestations of chronic inflammatory organ manifestations.

[Optical coherence tomography in geographic atrophy--a clinicopathologic correlation]

BACKGROUND

Optical coherence tomography was used for the examination of patients with geographic atrophy in different stages of age-related macular degeneration. Always compared with biomicroscopy and fluorescein angiography [4,7,8,10].

PATIENTS AND METHODS

37 patients with geographic atrophy (n = 55 eyes) out of 150 with AMD (n = 169 eyes) were examined. The results of biomicroscopy, fluorescein angiography, optical coherence tomography and histological knowledge in age-related macular degeneration were studied.

RESULTS

Fluorescein angiography always identified geographic atrophy and in 13.5% the findings additionally were similar to an occult choroidal neovascularisation with circular hyperpigmentation. Geographic atrophy shows a significant thinning of the neurosensory retina of 135 microns as an average in optical coherence tomography (p < 0.0005) which did not correlate to visual acuity. Typically an enhanced vertically sharp demarcated reflectivity of the choroid is found because of the lacking pigment epithelium. 43% of the geographic atrophies were identified by optical coherence tomography. 3 out of 55 eyes (5%) in optical coherence tomography only show macular holes additionally to geographic atrophy.

CONCLUSION

A typical pattern of reflectivity is found by optical coherence tomography with enhanced reflectivity of the choroid because of lacking pigment epithelium and significant thinning of the fovea. Atypical macular holes moreover are found in 5% neither appearing in biomicroscopy nor in fluorescein angiography. An occult choroidal neovascularisation can be differentiated by optical coherence tomography from geographic atrophy because there is no spindle-like thickening of the pigment epithelium and no enhanced choroidal reflectivity. In borderline cases optical coherence tomography may be helpful and therapeutically decisive in differentiating geographic atrophy and occult choroidal neovascularisation and in detecting atypical macular holes.

Optical coherence tomography in uveitis patients

PURPOSE

To evaluate optical coherence tomography in allergy-prone uveitis patients.

METHODS

Thirty-four patients (43 eyes) with posterior uveitis (31 eyes) and intermediate uveitis (12 eyes) were evaluated by fluorescein angiography, indocyanine green angiography, and optical coherence tomography. Follow-up examinations used optical coherence tomography in allergy-prone patients.

RESULTS

Optical coherence tomography identified epiretinal membranes, which were removed surgically (three eyes); persistent cystoid macular edema, which resolved with cytotoxic treatment (12 eyes); and juxtafoveolar membranes, which were treated by diode laser (six eyes) and excision (two eyes).

CONCLUSION

Optical coherence tomography may provide useful information on complications developing in uveitis patients.

[r-tPA in keratoplasty à chaud. Report of 50 patients]

BACKGROUND

Fibrinolytic treatment using recombinant plasminogen activator (r-tPA) has been reported in cataract surgery; however, reports are lacking with respect to complex surgical interventions including keratoplasty because of anterior segment infections.

PATIENTS AND METHODS

This report deals with a prospective study comprising 50 patients (50 eyes) suffering from a serpent ulcer treated by keratoplasty à chaud. r-tPA (25 micrograms) was instilled intracamerally at the end of surgery in 25 eyes.

RESULTS

The 25 eyes treated with r-tPA were subsequently less inflamed than the control population (decrease in inflammatory cells 1.5 days vs 7 days, fibrin reaction 1x vs 12x), had highly significantly better visual acuity and there was significantly reduced inpatient hospitalization (median 9.9 vs 19.3 days). No hemorrhages were observed in either population; medically treated infection recurrences (S. aureus, C. tropicalis, acanthameba) were observed in 3 and primary graft failure or rejection in both populations 3x.

CONCLUSIONS

This study showed that perioperative application of r-tPA had a beneficial effect. This therapeutic avenue should be further evaluated in a randomized, double-masked multicenter study.

Tapioca melanomas of the iris: immunohistology and report on two cases

BACKGROUND

Tapioca-like tumors are rare, and their benign or malignant nature is obscure without histological work-up. We report on the clinical and histological features of different types of tumors in two patients.

CASE REPORT

Two patients aged 17 and 45 years presented with brownish iris masses increasing in size. Full-thickness en bloc excision of melanocytic tumors (5.5 mm and 7.0 mm in diameter) was carried out. Histological work-up revealed a nevus cell nevus in the young patient and an epithelioid malignant melanoma in the middle-aged patient evolving from the ciliary body. Staining for HMB-45 was marked in both tumors, for S-100 low in the nevus and marked in the melanoma, and for p53 negative in the nevus and positive in the melanoma. Ki67 stains were negative.

CONCLUSION

We propose that excision of anteriorly located pigmented tumors that increase in size is indicated in order to determine whether they are benign or malignant. In these case reports, tapioca-like tumors include a benign and a malignant entity. To our knowledge, a nevus cell nevus presenting as a tapioca-like tumor has not previously been described. Curative surgery and histological and immunohistological evaluation are required to characterize the malignant potential of these tumors and the prognosis.

Limitations of imaging choroidal tumors in vivo by optical coherence tomography

BACKGROUND

Optical coherence tomography (OCT) produces two-dimensional cross-sectional images with a longitudinal resolution of 10 microns. Its capacity for imaging retinal structure has been shown in a variety of diseases. There are no reports on its capacity and limitations in imaging choriocapillary and choroidal structures.

METHODS

Twenty-two patients with the diagnosis of malignant melanoma of the choroid were submitted to OCT. We used a prototype and a commercial device, both with an 850-nm superluminescent diode with a band-width of 30 nm (reported longitudinal resolution 10 microns). The images were evaluated for retinal thickness, changes in retinal pigment epithelium, subretinal fluid accumulation and changes in choriocapillary or choroidal reflectivity.

RESULTS

Retinal edema and detachment found on biomicroscopic examination for fluorescein angiography was detected by OCT in all such cases. In 2 of 22 cases small retinal detachments were detected only by OCT. Tumor extension through the retinal pigment epithelium was not seen in this series, either by biomicroscopy or by OCT. The pattern of choroidal or choriocapillary reflectivity was nonspecifically lower than that of normal choroid, but did not yield any additional information about tumor histology. When normal retina was present, the OCT appearance of a malignant melanoma resembled that of normal choroid.

CONCLUSION

OCT may provide information about the retinal structure overlying prominent tumors and the extent of adjacent retinal detachment. In its present state of development, OCT is of little value in the differential diagnosis of choroidal tumors. Its potential value for the follow-up of shallow tumors needs further investigation.

[Intraocular pseudotumor in an AIDS patient. Block excision, differential diagnosis, histology]

BACKGROUND

Intraocular pseudotumors are a rare event in Aids patients and often pose diagnostic problems.

CASE REPORT

A 37-year-old patient who had had HIV seroconversion for 7 years was seen to developed progressively growing, multiple, disseminated, subretinal lesions OD > OS, accompanied by exudative retinal detachment and iritis. Since all etiological laboratory diagnostic efforts to detect an infectious, noninfectious and neoplastic systemic lesion failed, a diagnostic and curative therapeutic chorioretinal excisional biopsy specimen of the largest of the tumors (3 x 3 x 2 mm) was taken. The histological work-up demonstrated granulation tissue similar to an intraocular pseudotumor without signs of infection, malignancy or reactive lymphoid hyperplasia. This finding resulted in systemic corticosteroid treatment with complete resolution of the lesions in both eyes and no recurrences.

CONCLUSIONS

An invasive diagnostic procedure in patients suffering from lesions of unknown cause resulting in the institution of an appropriate medical treatment may be beneficial for the integrity and vision of the respective eye.