[Effect of low-dose PDT on perfusion of the choriocapillaris in cCSCR : An OCT-angiography-based study]

BACKGROUND

In patients with chronic central serous chorioretinopathy (cCSCR) it is assumed that low-dose photodynamic therapy (PDT) induces short-term hypoperfusion of the choriocapillaris, which leads to long-term choroidal vascular remodeling and subsequent reduction of vascular hyperpermeability and leakage; however, it remains unclear whether the hypoperfusion completely returns to normal. The main aim of the retrospective study was to analyze the choroidal flow signal after treatment with low-dose PDT by optical coherence tomography-angiography (OCT‑A).

PATIENTS AND METHODS

In this study 16 eyes with a total of 19 treated areas were included. Aside from visual acuity and metamorphopsia checks, all patients underwent enhanced depth imaging-OCT (EDI-OCT) and OCT‑A in the areas treated with low-dose PDT. In the present study, the flow signal in the choriocapillaris and choroidal thickness were measured retrospectively both in the PDT-treated area and in a non-treated reference area located in close proximity with similar eccentricity to the center of the fovea.

RESULTS

The study found a mean reduction of 33% (p < 0.001) of the choroidal flow signal in the treated area compared to the reference area and an average decrease in choroidal thickness of 71 µm (p = 0.001). In the long term 7 out of 10 patients suffered from metamorphopsia despite the low-dose PDT; however, visual acuity was improved in almost half of the patients by the treatment.

CONCLUSION

Using OCT‑A it could be shown that at the choriocapillaris level, hypoperfusion persists in spite of low-dose PDT. Thus, the choroidal vascular remodeling is not able to completely compensate for the hypoperfusion induced by thrombosis.

[MEK inhibitor-associated retinopathy under binimetinib treatment for cutaneous malignant melanoma]

Die Behandlungsmöglichkeiten für Patienten mit metastasierendem Melanom (MM) wurden in den letzten Jahren mit der Zulassung von neuen Medikamenten dramatisch erweitert. Die MEK(mitogen-aktivierte Proteinkinase-Kinasen)- und BRAF(Serin/Threonin-Kinase B-Raf kodierendes Gen)-Hemmer-Kombinationstherapie gehört aktuell zum Versorgungsstandard für das Stadium IIIC/IV des BRAF-mutierten Melanoms. MEKAR (MEK-Inhibitor-assoziierte Retinopathie) werden bei Patienten mit metastasierendem Melanom beobachtet, die mit einer solchen Kombinationstherapie behandelt werden bzw. wurden. Wir berichten über den Fall eines 72-jährigen Patienten, der eine solche Pathologie unter der Therapie mit Binimetinib in Kombination mit Nivolumab erlitt. Diese Kasuistik verdeutlicht die Wichtigkeit einer interdisziplinären Zusammenarbeit bei der Behandlung von MM-Patienten.

[Vitrectomy and iOCT-assisted inverted ILM flap technique in patients with full thickness macular holes]

BACKGROUND

In large full thickness macular holes (FTMH) the closure rate after vitrectomy and conventional internal limiting membrane (ILM) peeling is less than 90%. The aim of this study was to examine the visual acuity and anatomical success rate with high-resolution optical coherence tomography (OCT) after transconjunctival sutureless 23-gauge pars plana vitrectomy as well as intraoperative OCT (iOCT) and Brilliant Peel (BP)-assisted ILM peeling using the inverted ILM flap technique in patients with large FTMHs.

METHOD

In this retrospective study 25 eyes of 25 consecutive patients with large FTMH were treated by 23-G vitrectomy with BP and iOCT-assisted ILM peeling using the inverted ILM flap technique followed by gas tamponade. In all patients best corrected visual acuity (BCVA) and the maximum diameter, base and height of the FTMH as well as intraretinal alterations were measured preoperatively using high-resolution spectral domain OCT (SD-OCT, Spectralis, Heidelberg Engineering, Germany). The BCVA was measured after 1, 3, and 6 months. Additionally, the closure rate and the microstructural integrity of the outer retinal layers, e.g. external limiting membrane (ELM), ellipsoid zone und photoreceptor outer segment (OS) were registered in the SD-OCT and correlated with the results of BCVA after macular hole surgery.

RESULTS

In all surgical procedures with the inverted ILM flap technique the application of iOCT enabled a good visualization and a controlled positioning of the ILM flaps. At baseline mean BCVA was 0.2 (0.7 logMAR) and improved significantly after 1, 3 und 6 months to 0.4 (0.4 logMAR), 0.5 (0.3 logMAR) and 0.63 (0.2 logMAR), respectively. The closure rate of the FTMHs was 100%. Microstructural integrity of the outer retinal layers was evaluated semiquantitatively and showed good correlation with BCVA.

CONCLUSION

Vitrectomy with BP and iOCT-assisted ILM peeling using the inverted ILM flap technique in patients with large FTMH is a very controlled and safe microsurgical strategy and shows good functional and anatomical results. The morphology of the FTMH, the ILM flap and the position of the inverted ILM flap under air was well visualized by IOCT. The microstructural integrity of the outer retinal layers is displayed in detail on SD-OCT and represents an important predictive parameter for BCVA after macular hole surgery.

[Morphology of the vitreoretinal interface in fellow eyes of patients with full thickness macular holes]

PURPOSE

We performed a retrospective, observational clinical study to evaluate the vitreoretinal interface (VRI) in fellow eyes of patients with full thickness macular holes (FTMH) based on spectral domain optical coherence tomography (SD-OCT) examinations.

METHODS

The VRI in fellow eyes of 38 patients with idiopathic FTMH, 6 of which had concomitant vitreomacular traction (VMT) and the VRI of 32 patients with FTMH with complete resolution of VMT were examined by SD-OCT for the presence of vitreomacular adhesion (VMA), VMT and the formation of FTMH, lamellar macular holes (LMH), macular pseudoholes (MPH) or epiretinal membranes (ERM). Patients underwent complete ophthalmic evaluation, including SD-OCT at baseline and follow-up visits. To classify the morphology of the VRI, we used the international vitreomacular traction study classification system by Duker et al. (Ophthalmology 2013), evaluating the baseline SD-OCT data for significant classification parameters, including size of VMA, macular thickness and volume and structural changes of retinal layers.

RESULTS

Of the 38 eyes with FTMH, 2 (5.3%) fellow eyes also showed evidence of FTMH, 5 (13.2%) had isolated VMT while 5 (13.2%) showed formation of ERM, of which 2 demonstrated MPH. In 5 patients (13.2%) showing evidence of VMA and 17 patients (44.7%) with an unremarkable VRI, 22 fellow eyes (57.9%) showed no pathological morphology. Altogether, 16 fellow eyes (42.1%) of patients with FTMH showed pathological changes of the vitreoretinal interface.

CONCLUSION

This high-resolution SD-OCT-based retrospective study showed that fellow eyes of patients with VMT or FTMH were at increased risk of demonstrating pathological changes in the morphology of the VRI.

[A young patient with full visual acuity, small visual field defects, and normal fluorescence angiogram]

A 28-year-old female patient came to our clinic complaining of small central visual field defects in both eyes, without any impairments of visual acuity. She reported recent flu-like symptoms and work-related stress associated with high caffeine intake. Dark reddish cloverleaf-shaped lesions were noted in the macular region with red-free fundoscopy, and alterations of the external retinal layers were observed in spectral domain optical coherence tomography (SD-OCT). The visual field test (Octopus, program 32) revealed small central scotoma on both eyes. The fluorescein angiograms were normal. A suspected diagnosis of acute macular neuroretinopathy (AMNR) was made and the patient was scheduled for follow-up 4 weeks later. The follow-up examination showed persisting central scotoma as well as persistence of the lesions in the external retinal layers in OCT. The best-corrected visual acuity was still 20/20. In OCT angiography (OCT-A), a reduced correlation signal and therefore perfusion was detected in the outer retinal capillary plexus within the area of the fundoscopic macular lesions. Multimodal imaging, including SD-OCT and A‑OCT, plays a pivotal role in the diagnosis of acute macular neuroretinopathy. Even though no serious impairments of visual acuity are reported, patients should be informed about the possibility of permanent central scotoma.

Corneal Haze after Excimer Laser Refractive Surgery: Objective Measurements and Functional Implications

Postoperative changes in corneal transparency is a major concern after PRK. Data were obtained from 69 human eyes treated with excimer laser photorefractive keratectomy in order to evaluate a relationship between objective measurements of corneal transparency and visual performance. A CCD-camera device was employed and by using polarizing filters the system could discriminate between reflected and scattered light. We observed two groups of postoperative behaviour in corneal transparency. Each group showed an increase in both scattered and reflected light signals with a maximum at around two months postoperatively. In the majority group (70%) this was followed by a subsequent decline of the scattered light signal, whereas the combined signal generated by reflected and scattered light showed a biphasic curve with a second peak at around 4 to 5 months postoperatively. In the minority patient group (30%) the timebase variations in pattern of both signals were indistinguishable throughout the period of observation. In all patients we observed a good correlation between the signal generated by scattered light alone and the reduction in the 5% contrast visual acuity performance, whereas correlation was poor when the combined signal of reflected and scattered light was considered. These disturbances in low contrast visual performance were only significant during the first three to four months postoperatively and thereafter most patients returned to their preoperative value. Eighteen percent of our patients discontinued topical steroids postoperatively. No differences in either corneal transparency or final refraction was observed. We consider that PRK is an effective form of refractive surgery and the marginal loss of corneal transparency should only be a problem during the first three or four months postoperatively.

Regression and wound Healing after Excimer Laser Prk: A Histopathological Study on Human Corneas

BACKGROUND

The results of excimer laser PRK are promising as more than 80% of eyes with up to -6.0 diopters of attempted correction have refractive results within 1.0 diopter of emmetropia. However, throughout the dioptric range some unexpected results have been observed with individual patients showing an aggressive wound healing response with excessive myopic regression and severe corneal haze. Unfortunately, only limited data are available about the cellular and extracellular responses in human corneas after PRK and this information is important to establish adequate postoperative pharmaceutical treatment.

METHODS

We made a histopathological and immunohistochemical study on 20 human corneal samples from patients with severe corneal haze and myopic regression. The indirect immunofluorescence method was used for demonstration of collagen types I, III, IV laminin, chondroitin sulphate, dermatan sulphate, and keratin.

RESULTS

All corneal specimens showed a hyperplastic epithelium. Histologically, most samples (16/20) showed mainly a loose lamination of extracellular material which could be identified as collagen type IV. The remaining four samples had newly synthesised collagen type III.

CONCLUSIONS

Our histopathological results indicate that corneal wound healing after excimer laser PRK varies among individuals. In some people epithelial basement proteins, such as collagen type IV, are the main wound healing products, whereas in others mainly collagen type III is found postoperatively, which does not effect the synthesis of collagen type IV. This suggests the need for individually-tailored postoperative pharmaceutical treatment regimens.

Night Vision after Excimer Laser Photorefractive Keratectomy: Haze and Halos

A series of 85 patients with myopia, up to −6.00D, was treated by photorefractive keratectomy (PRK), using a 5 mm diameter ablation zone. At six months, 38 patients (45%) reported slight disturbances of night vision, nine (11%) of whom had significant problems. Perturbations of night vision after PRK are seen as starbursts and halos around lights. Corneal haze produces the starbursts, which are usually transient. In contrast, halos are myopic blur circles and may be persistent. Using a computer program, halos after PRK were found to be significantly larger than those in emmetropes and myopes corrected with spectacles (p < 0.01). The halos were diminished by using either artificial pupils or negative lens over-correction. In patients with identical bilateral PRK corrections, except for the ablation zone size, the magnitude of the halo was less with 5 mm than 4 mm zones (p < 0.01). Patients treated with 5 mm reported fewer problems attributable to halo than with the 4 mm ablation diameters (p < 0.01). Halos and pupil diameters were measured in nine patients with significant impairment of night vision haze. Those with starbursts had small hyperopic shifts, minimal halos and high haze and light scatter measurements, whilst patients with halos had large hyperopic shifts, little haze and large pupil diameters. Patients with persistent halo problems benefited from either negative lens over-correction or miotics at night.

A targeted drug delivery platform for assisting retinal surgeons for treating Age-related Macular Degeneration (AMD)

In this paper we present our latest robotic setup, which has been modified for sub-retinal interventions. The setup consists of: 1) sub-retinal micro cannula with automatic pump; 2) Micromanipulator; 3) patient fixation mechanism and 4) clinically compatible workstation. The primary objective of this work is to allow ophthalmologists to improve administration of substances such as drugs, stem-cells and gene cargos to their desired targets in the sub-retinal microstructures. Such a delivery method will enable effective treatment of Age-related Macular Degeneration (AMD). AMD is the leading cause of blindness in developed countries and as yet there is no efficient treatment. To validate the precision of the system a successful targeted delivery scenario with the proposed setup and using an intra-operative OCT integrated microscope in a clinical environment is presented in this paper.

Haptic interface for robot-assisted ophthalmic surgery

Vitreo-retinal surgery is challenging, as delicate structures have to be manipulated. Eliminating tremor caused by human motions when doing micromanipulation can therefore improve the outcome of such an intervention. An eye surgery robot has been built to overcome this problem. The contribution of this paper is the design of a telemanipulation setup for the robotic system. A telemanipulation setup using a haptic device featuring force feedback as a user interface for controlling a hybrid parallel-serial micromanipulator is designed and developed. The position error control scheme is chosen and different control modes are provided. The output forces of the haptic device are analyzed. The system allows the surgeon to perform precise and comfortable micromanipulation. Nevertheless a way to provide more meaningful force feedback still has to be found.

Graphical user interface for a robotic workstation in a surgical environment

Surgery using a robotic system has proven to have significant potential but is still a highly challenging task for the surgeon. An eye surgery assistant has been developed to eliminate the problem of tremor caused by human motions endangering the outcome of ophthalmic surgery. In order to exploit the full potential of the robot and improve the workflow of the surgeon, providing the ability to change control parameters live in the system as well as the ability to connect additional ancillary systems is necessary. Additionally the surgeon should always be able to get an overview over the status of all systems with a quick glance. Therefore a workstation has been built. The contribution of this paper is the design and the implementation of an intuitive graphical user interface for this workstation. The interface has been designed with feedback from surgeons and technical staff in order to ensure its usability in a surgical environment. Furthermore, the system was designed with the intent of supporting additional systems with minimal additional effort.

[Ocriplasmin as a treatment option for symptomatic vitreomacular traction with and without macular hole. First clinical experiences]

PURPOSE

To evaluate the resolution rate in patients with symptomatic vitreomacular traction (≤ 1500 μm) with or without macular holes (≤ 400 μm) after therapy with intravitreal ocriplasmin (Jetrea®) injection in a clinical setting.

METHODS

Until now we have prospectively examined 21 eyes of 21 consecutive patients with symptomatic vitreomacular traction with or without macular holes who underwent intravitreal operative injection of 0.1 ml ocriplasmin. The best corrected visual acuity and high-resolution optical coherence tomography (SD-OCT) ultrastructural parameters were measured before injection and again 1, 3 and 4 months after treatment. The numbers of resolved vitreomacular traction and closed macular holes were documented.

RESULTS

Vitreomacular traction was resolved in 15 out of 21 (71 %) eyes. Of the five eyes which initially presented with vitreomacular traction with macular holes, all showed resolution of vitreomacular traction but only two of the macular holes were closed. The average best corrected visual acuity was 0.38 logMAR (± 0.23) at baseline and 0.43 logMAR (± 0.28), 0.38 logMAR (± 0.27) and 0.36 logMAR (± 0.24) 1, 3 and 4 months after injection, respectively. The average foveal thickness was 355.95 μm (± 114.53 μm) at baseline, reducing to 304.61 μm (± 100.91 μm), 308.00 μm (±76.17 μm) and 277.50 μm (± 26.24 μm) after 1, 3 and 4 months, respectively.

CONCLUSION

In this ongoing study there was a high percentage of resolution of vitreomacular traction (71 %) 1 month after intravitreal operative injection of Jetrea® and closure of two out of five macular holes. This was further associated with stabilization of visual acuity and reduction of foveal thickness. Further investigations are necessary to document the effectiveness of the pharmacological vitreolysis in a clinical setting.

[Functional and Morphological Microstructural Changes in SD-OCT in Long-Term Treatment for Neovascular AMD with Ranibizumab - Monotherapy Versus Combination Therapy with PDT]

Background: Intravitreal anti-VEGF therapy is the gold standard in the treatment of neovascular age-related macular degeneration (nAMD). In recent literature, the benefit of additional photodynamic therapy (PDT) has been debated. The aim of our study was to compare the functional and structural effects of long-term combination therapy with PDT plus ranibizumab with monotherapy with ranibizumab. Material and Methods: In a retrospective study, patients suffering from nAMD were followed up for at least 42 months. Patients were assigned to group A (monotherapy with ranibizumab according to pro re nata [PRN]) or group B (combination therapy with one-time PDT plus ranibizumab according to PRN). The best-corrected visual acuity (BVCA) was evaluated at the starting and end points, together with central retinal thickness (CRT), maximal retinal thickness (MRT) and the maximal diameter of the base of the subretinal plaque in spectral-domain optical coherence tomography (SD-OCT), at the first measurement and at the end point. Results: Group A consisted of 21 eyes (17 patients) and group B consisted of 12 eyes (11 patients). The average follow-up from starting to end point was 64 months and 47 months, from the first measurement of SD-OCT to the end point. Within this period, patients in group A received 19 ± 14 intravitreal injections, and patients in group B received 22 ± 10 intravitreal injections. BCVA at the starting point was 0.31 ± 0.26 in group A and 0.31 ± 0.17 in group B. At the end point, BCVA in group A was 0.29 ± 0.25 (p = 0.405), and in group B 0.25 ± 0.20 (p = 0.142). CRT decreased in group A by 72 ± 178 µm (p = 0.024) and group B by 28 ± 98 (p = 0.1335). MRT decreased in group A by 25 ± 135 µm (p = 0.166) and in group B by 2 ± 118 µm (p = 0.421). The base of the subretinal plaque increased in group A by 32 ± 1468 µm (p = 0.242) and in group B by 748 ± 1024 (p = 0.025). Conclusion: In a long-term follow-up of 5.3 years, patients with nAMD in both groups exhibited good stabilisation of visual acuity. In both groups, retinal thickness decreased and the base of the subretinal plaque increased. With respect to SD-OCT morphological criteria, patients in group A (monotherapy) responded slightly better to therapy than patients in group B (combination group).

[Therapeutic Options in Vitreomacular Traction With or Without a Macular Hole]

Treatment is usually indicated for symptomatic vitreomacular traction (VMT) with or without a full thickness macular hole (FTMH) and without spontaneous resolution. Ultrastructural parameters are evaluated by SD-OCT, in order to classify the vitreoretinal interface and to estimate the success rate of treatment. The resolution rate after therapy with intravitreal Jetrea® (Ocriplasmin) is high (up to 70 %) in patients with symptomatic focal vitreomacular traction (≤ 1500 µm) with or without a macular hole (≤ 250 µm) and with no epiretinal membrane (ERM), but depends on the exact baseline analysis. All other patients with idiopathic traction retinopathy should be treated by minimal invasive pars plana vitrectomy (MIVI). Vitreoretinal surgery effectively removes traction and gives a high closure rate of a full thickness macular hole (FTMH, 90 to 100 %). It is now a very safe procedure with few side effects. Despite a low risk profile (cataract, retinal tear etc.) the indication for surgery needs to take the safety profile into account. Therefore vitrectomy is only indicated in symptomatic patients complaining of blurred vision, VA reduction and metamorphopsia. Vitrectomy is also indicated in patients whose treatment by pharmacologic vitreolysis has failed.

[Sympathetic ophthalmia : Therapy with steroid-free immunosuppressant azathioprine]

This article describes the case of a 48-year-old male patient who presented with persistent inflammation and deterioration of vision to a best corrected visual acuity (BCVA) of 0.6 in the only functioning left eye. The right eye had suffered a severe penetrating ocular trauma 6 months prior to presentation. After diagnosis of a sympathetic ophthalmia a high dosage corticosteroid therapy was initiated. Due to intolerance with decompensating diabetes an immunosuppressive therapy with azathioprine was initiated. This therapy resulted in stable clinical findings with an increase in BCVA to 0.9.

[Morphologic Patterns on Spectral-Domain Optical Coherence Tomography (SD-OCT) as a Prognostic Indicator in Treatment of Macular Edema Due to Retinal Vein Occlusion]

BACKGROUND

SD-OCT is an important tool in the diagnosis of macular oedema (ME) due to retinal vein occlusion (RVO). Its high resolution makes it possible to distinguish various morphological characteristics and differences. The aim of this study is to evaluate the correlation between morphological patterns and the development of visual acuity (VA) after intravitreal treatment of ME due to RVO.

METHODS

81 patients on intravitreal treatment (dexamethasone: n = 53/ranibizumab: n = 28) due to ME associated with branch and central retinal vein occlusion (

BRVO

n = 38/CRVO: n = 43) were retrospectively reviewed. Preoperative SD-OCT images were analysed by vitreous adhesion, epiretinal membranes, foveal contour, height of intraretinal cystoid spaces, inner and outer segment integrity and presence of subretinal fluid. The influence of these patterns on VA improvement was analysed.

RESULTS

In almost every morphological pattern, the data were highly variable. Therapy was effective, with a medium gain in VA of 9.51 letters ETDRS (dexamethasone: 9.62 letters/ranibizumab: 9.29 letters). The improvement in VA in patients with small intraretinal cystoid spaces (thickness ≤ 250 µm) was 19.44 letters ETDRS, compared to 7.23 letters ETDRS in patients with confluent cystoid spaces (p = 0.009). Patients with a convex fovea exhibited more pronounced reduction in central retinal thickness (CRT) (p = 0.004).

CONCLUSION

Analysis of OCT has concentrated on demonstrating oedema and CRT. Our data indicate that detailed OCT morphology and the size of intraretinal cystoid spaces offer important information about VA prognosis after intravitreal therapy in ME due to RVO.

The introduction of a new robot for assistance in ophthalmic surgery

This paper introduces the design and development of a new robotic system to assist surgeons performing ophthalmic surgeries. The robot itself is very compact and similar to an average human hand in size. Its primary application is intraocular micromanipulation in order to overcome the existing challenges in treatment of diseases like Retinal Vein Occlusion (RVO). The novel hybrid mechanism designed for this robot allows microscale motions and is stable in the presence of vibrations common in operation room (OR). The robotic system can be easily integrated into standard operation rooms and does not require modification of conventional surgical tools. This compact microsurgical system is suitable for mounting on the patient's head and thereby, solves the problem of patient motion. The compatibility of the robotic system with a real world surgical setup was evaluated and confirmed in this work.

[Morphological Characteristics in SD-OCT and Fundus Autofluorescence in Different Ischaemic Retinopathies - Characterisation of a New, Temporary Hyperreflective Band]

BACKGROUND

The aim of this study was to investigate alterations in the neurosensory retinal morphology secondary to acute retinal ischaemic conditions. The observations were documented by spectral domain optical coherence tomography (SD-OCT, Heidelberg Engineering) and fundus autofluorescence (FAF) imaging. In addition, the occurrence of an additional hyperrefelctive band in the outer corneal layers is described. This observation was made during the evaluation of OCT images of patients with an acute loss of vision due to retinal ischaemia.

PATIENTS/METHOD

SD-OCT images and FAF were used to observe the retinal structure of 26 subjects (36 to 96 years) with acute monocular visual impairment due to central retinal artery occlusion (CRAO), branch retinal artery occlusion (BRAO), anterior ischaemic optic neuropathy (AION) or impending central retinal vein occlusion were included. The main focus of attention was set on the transition of the outer nuclear layer (ONL) to outer plexiform layer (OPL). Furthermore measurements of the retinal thickness at the fovea, parafoveal and within the retinal layers were acquired and compared to corresponding points of the non-affected eyes. SD-OCT images were acquired with a combined SD-OCT and scanning laser ophthalmoscope (cSLO) imaging system using a linear cross hair scan and a 6 line radial scan of 6 mm length (ART mode on; average of 20 frames).

RESULTS

SD-OCT revealed an additional highly reflective band located within the OPL. Morphological characteristics of this hyperdense band were a decreasing intensity with distance from the fovea, partially segmental occurrence and manifestation limited in time. FAF showed areas of increased and decreased signal intensity within the vessel arcade at the posterior pole. The regions of decreased FAF corresponded to perivenous regions and resemble the "frosted branches" sign seen in fluorescein angiography in patients with ocular ischaemia.

CONCLUSIONS

The additional hyperreflective band observed in SD-OCT could represent a marker for retinal ischaemia in subjects without the presence of a complete vascular occlusion. The mid retinal localisation of the band within the OPL is situated at the locus of transition from retinal to choroidal oxygen supply where oxygen diffusion is weakest. Histopathologically the observed structure could represent activated microglial tissue induced by the hypoxia driven upregulation of inflammatory molecules aimed at ischaemia repair.

[Bilateral papilledema, unilateral loss of vision and abducens nerve palsy]

A 35-year-old woman complained of headache, reduced visual acuity, restricted visual field in the right eye and blindness in the left eye. The examination of the retina showed papilledema and peripapillary hemorrhages in both eyes. Magnetic resonance imaging (MRI) revealed a sinus thrombosis. Despite modern imaging technologies sinus thrombosis is an often overlooked, life-threatening disease and needs immediate treatment in order to avoid long-term consequences. An ophthalmological examination can be pioneering as it leads to further imaging.

[Vitreomacular Traction Syndrome (VMTS)]

In vitreomacular traction syndrome (VMTS) an anomalous posterior vitreous detachment (APVD) with persistant symptomatic vitreoretinal adhesion is seen. The adhesion leads to a thickened macula, to macular oedema and a reduction of BCVA. Modern imaging techniques like spectral domain OCT (SD-OCT) allow a detailed imaging of the retinal microstructure and the vitreoretinal interface. Vitreomacular adhesions and their effect on the retina can be visualised. Until now, the treatment option for VMTS was and is vitreoretinal surgery. In studies pharmacological vitreolysis has shown a therapeutic effect in patients with symptomatic adhesion and traction. The results of these studies represent an important step towards a pharmacological treatment of VMTS.

[Transconjunctival sutureless pars plana vitrectomy and Brilliant Peel (BP)-assisted ILM peeling in patients with macular holes]

PURPOSE

The aim of this study was to evaluate the visual and anatomic outcome after 23-gauge transconjunctival sutureless pars plana vitrectomy and Brilliant Peel (BP)-assisted ILM peeling in patients with macular holes.

METHODS

In a consecutive retrospective study in 41 eyes of 41 patients with macular holes a standardised 23-G transconjunctival sutureless pars plana vitrectomy with ILM-peeling and gas tamponade was performed. All patients underwent preoperative measurements of visual acuity (VA), the maximum hole diameter, basis, height, and intraretinal changes using high resolution optical coherence tomography (SD-OCT; Spectralis; Heidelberg Engineering). Main outcome measures included visual acuity 1, 3, and 6 months after surgery and the closure rate. We also evaluated photoreceptor inner/outer segment (IS/OS) integrity as seen in SD-OCT for correlation with visual outcomes after macular hole surgery.

RESULTS

At baseline the mean best corrected visual acuity (BCVA) was 0.2 (0.77 logMAR). BCVA improved significantly to 0.4 (0.46 logMAR) after 1 month, to 0.44 (0.41 logMAR) after 3 months and to 0.58 (0.28 logMAR) after 6 months, respectively. A closure rate of 95.1 % was achieved. The morphological parameter photoreceptor IS/OS integrity was measured semiquantitatively and showed a positive correlation to BCVA.

CONCLUSION

Transconjunctival sutureless pars plana vitrectomy and Brilliant Peel (BP)-assisted ILM peeling in patients with macular holes is a very safe procedure and leads to good functional and anatomic results. The integrity of the IS/OS segment is a good predictive parameter for BCVA improvement after macular hole surgery.

[Vitreomacular interface and posterior vitreomacular adhesion in exudative age-related macular degeneration (AMD): an OCT-based comparative study]

PURPOSE

The aim of this study was to evaluate posterior vitreomacular adhesion as a risk factor for choroidal neovascularisation (CNV) in age-related macular degeneration (AMD). The vitreoretinal interface was examined using spectralis optical coherence tomography (Spectralis-OCT, Heidelberg Engineering).

PATIENTS AND METHODS

In a retrospective observational case series 375 consecutive eyes of 375 patients (age 51-90 years) were examined with spectralis OCT and fluorescein angiography (Spectralis-HRA, Heidelberg Engineering). Vitreomacular adhesion was defined when a posterior hyaloid line attached to the inner retinal surface was seen in OCT. In 202 patients with exudative AMD the incidence of posterior vitreomacular adhesion was compared to 173 control eyes (72 with non-exudative AMD and 101 eyes without retinal alterations).

RESULTS

We found posterior vitreomacular adhesions in 151 patients (40.27 %). In the control group 53 patients (30.6 %) showed vitreomacular adhesions compared to 98 patients (48.5 %) with exudative AMD. The difference was statistically significant (p = 0.001). The location of vitreomacular adhesion was observed over the area of the CNV in 87 patients (88 %) with exudative AMD.

CONCLUSIONS

Spectralis OCT allows a detailed examination of the vitreomacular interface. The frequency of posterior vitreomacular adhesion is significantly increased in eyes with CNV in AMD. Chronic vitreomacular traction may be a risk factor for the development of exudative AMD.

[Acute loss of vision during therapy of chronic hepatitis C]

A patient undergoing combined therapy of chronic hepatitis C with pegylated interferon-α-2a (PEG-IFN-α-2a) and ribavirin suddenly developed severe loss of visual acuity. A central vein occlusion with macular edema was found and intravitreal injections of bevacizumab were initiated. Retinal occlusion is a known complication of therapy with pegylated interferon-α-2a and ribavirin. An interdisciplinary assessment of patients treated for a chronic hepatitis C as well as an early anti-VEGF administration can be helpful in the therapy of this complication of chronic hepatitis C.

[Comparison of the aesthetic outcome and complication rate of reconstructive surgical procedures of the eyelid after basalioma excision]

BACKGROUND

The therapy of choice of the basalcellcarcinoma is the surgical removal often combined with soft-tissue reconstruction. Aim of this study was to evaluate the subjective aesthetic outcome and the complication rate in consequence of the chosen surgical procedure.

METHOD

57 patients formerly treated by surgery enclosing free grafts, Hughes flaps, interpolated flaps or primary wound closures were included. The patients were examined to evaluate possible surgery derived complications. Furthermore the aesthetic outcome was assessed by a questionnaire.

RESULTS

After an interpolated flap nearly 30% of the patients were without any complications and after a Hughes flap 21.4%. In contrast 43.8% of the patients after primary wound closure showed any complications and even 57% of the patients treated with a free graft. Concerning the aesthetic outcome 92.3% of the patients undergoing an interpolated flap were subjective satisfied or even very satisfied with their aesthetic outcome.

CONCLUSION

Regarding the complication rate the free graft and the primary wound closure seem to be superior. On the contrary the interpolated flap demonstrated a considerable better estimated aesthetic outcome.

[Sutureless encircling band - clinical experience]

PURPOSE

In cases with multiple retinal breaks and in combination with vitrectomy in eyes with proliferative vitreoretinopathy (PVR) often an encircling band is used for retinal detachment surgery. Usually the encircling band is fixed with non-resorbable sutures.

METHODS

A fixation method for an encircling band in retinal detachment surgery with one scleral tunnel in each of the 4 quadrants is reported. After 50 consecutive operations on 50 patients, we describe our experience and biomechanical calculations of this fixation technique.

RESULTS

In comparison to conventional fixation technique we found the following advantages. No suture is necessary, this means that no additional foreign body can produce irritations. The scleral tunnel is safe and the preparation under the microscope can be performed rapidly and under good control. According to our biomechanical calculations, the same tension of the encircling band produces less myopic shift with this technique. Scleral tunnel fixation is very comfortable in combination with a vitrectomy.

CONCLUSIONS

After a short learning curve, the operating time is as short as with conventional suture fixation of the encircling band. There is less perforating risk, less irritation and less patient discomfort postoperatively. A sutureless encircling band with scleral tunnel fixation is a very useful operative technique in clinical routine.

[Spontaneous closure of traumatic macular holes. Two cases]

The optimal treatment approach for traumatic macular holes (TMH) is still controversial. We report two cases of spontaneous closure of TMH. In the first patient, closure resulted in an increase in visual acuity from 0.2 to 0.8. In the second case, no increase in visual acuity was detectable despite spontaneous closure of the TMH within a few days after the trauma. This may be explained by an irreversible damage of the photoreceptors and retinal pigment epithelium. In patients with TMH, a waiting approach should be considered because of the possibility of spontaneous closure of TMHs.

Macular function and morphology after peeling of idiopathic epiretinal membrane with and without the assistance of indocyanine green

AIM

To investigate macular function and morphology after surgical removal of idiopathic epiretinal membrane (IEM) with and without assistance of indocyanine green (ICG).

METHODS

A retrospective study as a consecutive case series, of 39 patients with IEM. 39 patients, 23 female, 16 male, mean age 67 years, underwent standard three port pars plana vitrectomy with removal of epiretinal membrane. Two groups of patients were consecutively operated: in 20 patients ICG 0.1% in glucose 5% was used to stain the epiretinal membrane. 19 patients underwent the identical procedure but without use of ICG. Postoperative follow up was 1-92 months (mean 15.5 months). Functional outcome was assessed with subjective improvement, best corrected visual acuity (BCVA), Amsler grid test, 10 degrees and 30 degrees automated perimetry (Heidelberg visual field analyser) (HFA), and Goldmann kinetic perimetry. Macular morphology was assessed with stereoscopic biomicroscopy and optical coherence tomography (OCT). The main outcome measures were macular function as determined by BCVA, presence of visual field defects, and metamorphopsia as determined by Amsler grid test, macular morphology as determined by slit lamp biomicroscopy, and OCT.

RESULTS

BCVA improved in 28 patients, remained unchanged in eight patients, and decreased in three patients. Improvement of BCVA was statistically significant in both groups (p = 0.003). Mean BCVA in patients operated with ICG improved from 0.33 preoperatively to 0.53 postoperatively. Mean BCVA in patients operated without ICG improved from 0.32 preoperatively to 0.54 postoperatively. Reduction of macular oedema as measured by OCT was statistically significant in both groups (p<0.01). There was no statistically significant difference in postoperative BCVA, macular oedema as measured by OCT, postoperative Amsler grid test, and subjective improvement between the two groups. The incidence of residual or recurrent epiretinal membrane was greater in the group operated without ICG (p = 0.014). Visual field defects were detected in one patient operated with ICG and in three patients operated without ICG.

CONCLUSIONS

Removal of epiretinal tissue with or without assistance of ICG improved visual function and reduced macular oedema in most patients. Adverse effects clearly attributable to the use of ICG were not observed but further investigation is warranted.

[Tolerance of a new calcium-alginate-insert for controlled medication therapy of the eye]

PURPOSE

For an effective pharmaceutical treatment it is necessary in some cases to maintain a constant drug level over a certain period. This cannot be achieved by conventional eye drop application. Therefore, a new insert basically consisting of alginates with a different hydroxyethylcellulose (HEC) content was developed. The aim of this study was to evaluate the tolerance of these inserts applied to the conjunctival cul de sac.

METHODS

24 healthy volunteers received the insert containing different concentrations of hydroxyethylcellulose (0%, 5%, 30%) for 1 up to 5 days. The eyes have been examined several times (including visual acuity, ocular surface morphology, break-up-time, Schirmer-Tear-Test). Subjective parameters were pain sensations or daily life disturbance.

RESULTS

After an initial conjunctival hyperemia and a mild foreign body sensation, the insert was well tolerated. No variations concerning the tolerance between the different concentrations of hydroxyethylcellulose were observed.

CONCLUSION

This study showed good tolerance of the new calcium-alginate-insert applied to the ocular surface for controlled drug release.

Laser-epitheliale Keratomileusis (LASEK) zur Behandlung von Myopien bis -6,0 dpt

BACKGROUND

Laser epithelial keratomileusis (LASEK) is a new keratorefractive procedure for the correction of myopia and myopic astigmatism, which may combine advantages and eliminate disadvantages of photorefractive keratectomy (e.g. pain, corneal haze) and laser in situ keratomileusis (e.g. flap and interface complications, dry eye, keratectasia). We present the results of 108 consecutively LASEK-treated eyes with a follow-up period of 12 months.

PATIENTS AND METHODS

LASEK was performed on 108 consecutive eyes with myopia or myopic astigmatism using a keracor 117 excimer laser. The mean preoperative refraction was -4.12+/-1.30 diopters (D) spherical equivalent range: -1.75 to -6.0 D and maximal cylinder was 3.25 D. Results of the 12 months visit are available for 101 eyes (93.5%).

RESULTS

No serious complications were observed. After 12 months, SE was within +/-1.0 D of emmetropia in 96% and within +/-0.5 D in 86% of the eyes; 6 eyes had to be retreated. None of the eyes showed haze worse than grade 1 or lost more than one line of best-corrected visual acuity. Uncorrected visual acuity (UCVA) was > or =20/20 in 80% and > or =20/40 in 98%.

CONCLUSIONS

Laser epithelial keratomileusis (LASEK) seems to be safe and effective in treatment of myopia and myopic astigmatism of up to -6.0 D. Preliminary results compare favourably with those after photorefractive keratectomy and laser in situ keratomileusis. Haze formation after LASEK seems to be low. Coverage of the stromal wound with a vital epithelial flap could positively influence postoperative wound healing reactions.

Optical biometry before and after excimer laser epithelial keratomileusis (LASEK) for myopia

PURPOSE

In order to select the correct intraocular lens (IOL) for implantation, it is important to measure the eye length (biometry). The IOL Master from Zeiss-Humphry is frequently used for such measurements. Because this instrument employs an optical method, any irregularities on the corneal surface or any disturbances in corneal transparency could lead to mistakes in the measurements. The aim of this study was to determine whether eye length measurements obtained at the University Eye Clinic Regensburg, Germany with the IOL Master before and after excimer laser epithelial keratomileusis (LASEK) show any changes.

METHODS

Axial length was measured on 20 myopic eyes (-2.75 to -8.00 diopters) before and one month after LASEK using the IOL Master.

RESULTS

The mean pre-operative eye length was 25.46 mm (SD +/- 1.03) and the post-operative mean length was 25.38 mm (SD +/- 0.99). There was a strong correlation between the pre- and post-operative eye lengths (Pearson correlation coefficient 0.998).

CONCLUSIONS

Although LASEK can lead to increased light scattering due to irregularities of the corneal surface and changes in corneal transparency, there is no difference in biometry pre- and post-operatively.

[Corneal haze after photorefractive keratectomy. Role of individual collagen type IV synthesis on postoperative corneal opacity]

PURPOSE

Histological studies on human corneas have shown that collagen type IV plays a major role in the development of haze after photoreactive keratectomy (PRK). Currently, there is no clinically available pharmaceutical agent which can inhibit the synthesis of collagen IV. The aim of this study was to determine if there are individual differences in the expression of collagen IV and if there is a correlation between the amount of collagen IV and haze. This would give new options to prevent haze after PRK.

PATIENTS AND METHODS

PRK was carried out on 26 eyes (26 patients) with a myopia ranging between -1.50 to -6.00 D. Prior to the surgery a small sample of epithelium was taken from the cornea and the individual concentration of collagen IV alpha 3 mRNA was quantitatively determined by a newly developed PCR test.

RESULTS

In all samples collagen IV alpha 3 mRNA was measured with levels between 0.11 and 6.42 (mean: 1.68; SD: 1.64). There was a correlation between haze and the amount of collagen IV alpha 3 mRNA. (r = 0.92).

CONCLUSIONS

With this quantitative PCR-based test we were able to measure the individual collagen IV mRNA concentration in corneal epithelial cells. Further development of this test could establish a screening test which identifies patients with a pronounced synthesis of collagen IV as high risk individuals in terms of haze.