Semi-automated quantification of vitreal hyperreflective foci in SD-OCT and their relevance in patients with peripheral retinal breaks.

BACKGROUND: Retinal breaks (RB) are emergencies that require treatment to prevent progression of rhegmatogenous retinal detachment. Vitreal hyperreflective foci (VHF) representing migration of RPE cell clusters or interphotoreceptor matrix from the RB are potential biomarkers. The aim of this study is to investigate VHF in RB-patients using SD-OCT. METHODS: The retrospective cross-sectional study included RB patients from our Department of Ophthalmology, HSK Wiesbaden who underwent macular SD-OCT (SPECTRALIS®, Heidelberg Engineering, Germany) on both eyes. VHF, defined and quantified as foci that differ markedly in size and reflectivity from the background speckle pattern, were assessed for presence and frequency. The RB-affected eyes were the study group (G1), the partner eyes the control group (G2). RESULTS: 160 consecutive patients with RB were included. Age was 60 ± 10.2 years (52% female). 89.4% of G1 and 87.5% of G2 were phakic (p = 0.73). 94.4% (n = 151) were symptomatic. Symptom duration was 8.0 ± 10.1 days in G1, 94.4% (n = 151) showed VHF versus 5.6% (p < 0.0001) in G2, of which 75% (n = 6) showed asymptomatic lattice degenerations. Detectable VHF showed a strong association of OR = 320 (95% CI, 110-788, p < 0.0001)) with respect to symptomatic RB. Sensitivity and specificity were 94.7% and 94.7%, respectively. CONCLUSIONS: Most eyes with symptomatic RB show vitreal VHF in SD-OCT. Detected VHF are strongly associated with RB, and our semi-automated greyscale reflectivity analysis indicates that VHF likely originate from photoreceptor complexes torn out of the RB area that migrate into the vitreous cavity. The presence of VHF may indicate RB and should lead to a thorough fundus examination in both symptomatic and asymptomatic cases.

[Endogenous Candida lens abscess in a premature infant]. / Endogener Candida-Linsenabszess bei Frühgeborenem.

BACKGROUND: This case report describes an extremely rare Candida lens abscess in a premature infant (gestational age 24 weeks at birth). CASE REPORT: After birth the infant suffered from Candida sepsis which was successfully treated with an antifungal medication. The patient was referred at the age of 6 months because of greyish alterations in the pupils but an absence of other symptoms. The examination with the patient under general anesthesia revealed a grey pupillary membrane and behind it a whitish swollen lens. A lensectomy was performed. The vitreous body was inconspicuous. Candida albicans was identified microbiologically. CONCLUSIONS: In preterm infants dissemination of pathogens into the lens through the vascular coat of the lens is possible, which after regression of the coat is no longer accessible to systemic treatment and may thus be manifested as delayed abscess formation.

[Retinal bleeding and venous stasis in a 10-month-old infant after a fall?]. / Retinale Blutungen und venöse Stase bei einem 10 Monate alten Säugling nach Sturz?

This report describes the case of a 10-month-old infant, who was delivered to our hospital by the emergency physician intubated and in an unclear unconscious state. The father reported that the child had fallen from the couch to the ground. The consulted ophthalmologist reported venous stasis in both eyes including intraretinal and preretinal bleeding in all four quadrants, a diffuse vitreous hemorrhage in the right eye and temporal retinal wrinkling in both eyes. Based on these particular clinical findings a shaken baby syndrome was suspected. This report demonstrates the importance of recognizing and correctly interpreting the typical ophthalmological signs of physical child abuse in order to detect and prevent further mistreatment of children; moreover, the increasing importance of photographic documentation and histological work-up of the findings for forensic reasons are emphasized.

[Are there diurnal variations in choroidal thickness?]. / Unterliegt die Aderhautdicke zirkadianen Schwankungen?

PURPOSE: Measurement of diurnal choroidal thickness in healthy eyes to investigate thickness variations. METHODS: A total of 30 healthy eyes in 30 subjects were examined at 6 predefined times within 24 h. Choroidal thickness was visualized using the 7-line scan of spectral domain optical coherence tomography (OCT) with enhanced depth imaging (Spectralis, Heidelberg Engineering) and manually measured by two independent observers. For statistical analyses the mean value was calculated. RESULTS: The mean choroidal thickness was 270 ± 87 µm. Choroidal thickness changes from baseline ranged between - 47 µm and + 41 µm. There was a statistically significant negative correlation between baseline choroidal thickness and the thickness in examinations at 10:30 am, 1:30 pm and 4:30 pm with the Spearman correlation test. Due to the large diversity in the individual diurnal fluctuations, a significant diurnal variation of choroidal thickness was not observed. There was a significant negative correlation between age and choroidal thickness. CONCLUSIONS: In this study a significant diurnal variation of choroidal thickness was not observed. Patient age correlated negatively with choroidal thickness.

[Full depth imaging: a new imaging technique using optical coherence tomography (OCT)]. / Full Depth Imaging: neue Aufnahmetechnik mittels optischer Kohärenztomografie (OCT).

PURPOSE: The aim of this study was to evaluate the full depth imaging (FDI) mode as a new acquisition technique with spectral domain (SD) optical coherence tomography (OCT) from Heidelberg Engineering for illustrating vitreoretinal and choroidal structures with high contrast. METHODS: Patients with different diseases such as age-related macular degeneration, chorioretinopathia centralis serosa, diabetic retinopathy and epiretinal gliosis were examined with the FDI mode. For comparison, we also examined healthy probands with conventional OCT and the enhanced depth imaging (EDI) mode. FDI images were obtained with a manual acquisition technique. First, 100 conventional OCT scans of the vitreoretinal interface were averaged. After manual switching to the EDI mode the previous averaged image was overlayed with EDI images until vitreous, retina and choroid were projected in one comparably sharp image. RESULTS: The FDI mode enables SD-OCT images showing the vitreoretinal interface and deep choroid structures with a high contrast. The new acquisition mode has a few limitations: it is only possible to perform a single linear scan, a raster scan is not possible. The FDI mode is a manual acquisition technique and not automated yet. CONCLUSION: By a combination of averaged images of the vitreoretinal interface with the help of conventional SD-OCT scans with EDI OCT scans the FDI mode exhibits a simultaneous contrast image of the posterior vitreous, the retina and the choroid. Whereas the application of OCT was focused to evaluate the retina-retinal pigment epithel complex, the routine reinforcement of FDI scans could additionally show potential vitreous and choroidal pathologies. As the FDI mode is not an automated application yet it may be too complex to use for routine diagnostics at the moment.

[Bilateral diffuse uveal melanocytic proliferation in a patient with metastatic breast cancer]. / Bilaterale diffuse uveale melanozytäre Proliferation bei metastasierendem Mammakarzinom.

A 64-year-old female patient with a history of metastatic breast cancer presented with bilateral deterioration of visual acuity over a period of several weeks. Examination revealed patchy fundus pigmentation, serous retinal detachment and cataract in both eyes. After diagnosis of a bilateral diffuse uveal melanocytic proliferation (BDUMP) and due to disease progression, a course of plasmapheresis three times a week over a period of 2 weeks was initiated. Apart from the occurrence of peripheral edemas the therapy was well-tolerated by the patient. Treatment success could not be evaluated because the patient died a short time later. This is the first reported case of BDUMP due to breast cancer.

[Adjuvant stereotactic low energy radiation therapy of exudative age-dependent macular degeneration (Oraya system)]. / Adjuvante stereotaktische niederenergetische Strahlentherapie bei exsudativer altersabhängiger Makuladegeneration (Oraya System).

With respect to the increasing number of patients and the risk and burden for patients caused by injections, a reduction in the number and frequency of injections with vascular endothelial growth factor (VEGF) inhibitors in exudative age-related macular degeneration (ARMD) is desirable. Stereotactic low-voltage x-ray irradiation seems to be a promising approach. For this purpose the Oraya system is available and has shown positive results in initial studies. Pending presentation of phase II and III study data this adjuvant irradiation should only be used in clinical trials.

[Acute bilateral impaired vision with central scotoma in an 11-year-old boy]. / Akute bilaterale Visusminderung mit Zentralskotom bei einem 11-jährigen Jungen.

This article presents a case of acute bilateral impaired vision and central scotoma in an 11-year-old boy. Looking directly into a laser beam of a laser pointer for only a few seconds can cause retinal damage in the form of lesions of the retinal pigment epithelium and the photoreceptor layer, up to retinal hemorrhage. Patients often complain about impaired vision and a central scotoma of the affected eye.

[Is choroidal thickness of importance in idiopathic macular hole?]. / Spielt die Aderhautdicke beim idiopathischen Makulaforamen eine Rolle?

BACKGROUND: The pathogenesis of idiopathic macular hole (MH) formation is not fully understood and the choroid might be involved in its etiology. Recently published data reported choroidal thickness (CT) to be significantly thinner in eyes with idiopathic MH and in fellow eyes compared to age-matched healthy controls [24]. METHODS: The enhanced depth imaging (EDI) modus of the Spectralis OCT (Heidelberg Engineering, Heidelberg) was used to measure subfoveal CT in 12 patients with MH of which 2 suffered from bilateral MH. Measurements were manually acquired preoperatively using the horizontal foveal scan of the 7-line scan (5 × 30  perifoveal) with 100 averaged scans per scan, between the outer border of the retinal pigment epithelium and the inner scleral border. Additional CT measurements were obtained 8 weeks and 6 months postoperatively. RESULTS: Subfoveal CT of the 12 patients with MH (10 ♀, 2 ♂; 68 ± 7 years) was 274 ± 65 µm. The CT of the 10 patients with healthy fellow eyes measured 268 ± 75 µm and CT of the 2 patients with bilateral MH measured 309 ± 34 µm in the non-operated eye. The mean axial length (AL) in eyes with MH was 23.64 ± 0.59 mm and in healthy fellow eyes 23.68 ± 0.54 mm. After surgery MH closure was obvious in all eyes, the postoperative CT at 8 weeks measured 284 ± 77 µm and at 6 months 276 ± 73 µm. CONCLUSIONS: The EDI-OCT procedure enables measurements of CT. In the patients studied a reduced CT could not be found neither in patients with macular holes nor in the fellow eyes. There was no significant change in CT comparing preoperative with postoperative measurements. In contrast to recently published data [24] no reduction in CT in idiopathic macular hole could be demonstrated.

[Infrared imaging of outer lamellar macular holes]. / Infrarot-Imaging bei äußeren Makulaschichtforamen.

BACKGROUND: Outer lamellar macular holes (OLMH) are very rare compared to inner lamellar macular holes. An OLMH can occur associated with optic pit maculopathy, in the progression of myopic macular retinoschisis, transient in the development of full thickness macular holes or idiopathic. This article reports on infrared imaging of OLMHs. METHODS: Infrared (IR) images in 2 patients aged 22 and 34 years with OLMH were taken using IR reflection at a wavelength of 820 nm with a confocal scanning laser ophthalmoscope (Heidelberg Retina Angiograph 2, Heidelberg Engineering). IR images were correlated with linear optical coherence tomography (OCT) scans (Stratus-OCT, Zeiss). Images were acquired during follow-up of up to 30 months and if applicable preoperatively and postoperatively. RESULTS: Clear infrared signals were recorded especially in OLMH associated with optic pit maculopathy. Correlation with linear OCT scans showed the enhanced infrared signals to be restricted to the extent of the OLMH. The borders of the OLMH could be clearly delineated. Infrared imaging enables a top view of OLMH and therefore allows an excellent documentation of the course of OLMH. CONCLUSIONS: Infrared reflection is useful for two-dimensional imaging of OLMH. Infrared imaging can provide a supplement to slice imaging for OCT diagnostics and allows monitoring of OLMH over time. The postoperative sequence of OLMH closure in patients with optic pit maculopathy can be studied in more detail using infrared imaging.

[Effect of intravitreal bevacizumab on pigment epithelial detachment in occult choroidal neovascularization]. / Effekt von Bevacizumab auf die Abhebung des retinalen Pigmentepithels bei okkulter choroidaler Neovaskularisation.

PURPOSE: This study aimed to investigate the effect of bevacizumab on pigment epithelial detachment (PED) in occult choroidal neovascularization (CNV) in patients with age-related macular degeneration (AMD) and to determine predictive factors. METHODS: 73 eyes of patients with AMD and PED due to CNV with subretinal and/or intraretinal fluid were assessed. Patients were treated with 1.25 mg of intravitreal bevacizumab. RESULTS: After 30.6 weeks, the mean visual acuity (VA) increased from 0.53 to 0.49 logMAR (p=0.170). The mean PED height decreased from 354.4 µm to 277.4 µm (p=0.004). Although 53.4% of the eyes showed a reduction in PED, this did not correlate with a significant change in VA. Predictive factors were a high baseline PED and VA <0.32. CONCLUSION: Half of the patients showed PED flattening. Especially in patients with distinctive PED, a response to intravitreal bevacizumab may be expected. This therapy can stabilize VA, but PED flattening does not essentially correlate with an increase in VA.

[High-resolution fluorescence microscopy of retinal pigment epithelium using structured illumination]. / Hochauflösende Fluoreszenzmikroskopie des retinalen Pigmentepithels mittels strukturierter Beleuchtung.

BACKGROUND: The accumulation of autofluorescent bodies in retinal pigment epithelium (RPE) cells has an impact on the pathogenesis of retinal diseases, including age-related macular degeneration. While current in vivo fluorescence microscopy allows a lateral resolution of fluorophores in a micrometer range, with ex vivo microscopy a lateral resolution down to 200 nm is possible. For the first time, we used structured illumination microscopy for ex vivo high-resolution fluorescence microscopy of RPE cells. METHODS: Histological sections were prepared from a 68-year-old patient. With epifluorescence microscopy, fluorescent RPE cells were detectable. Structured illumination uses inhomogeneous illumination for resolution of previously nonresolvable structures, similar to the Moiré effect. Images were taken from RPE cells at different excitation wavelengths (488, 568, and 647 nm) and were reconstructed with special software. The different excitation patterns of the fluorescent granules in the RPE cells were colour-coded and analysed. RESULTS: With structured illumination microscopy, autofluorescence signals of RPE cells were detectable, and a lateral resolution of 110 nm could be achieved. Using varying wavelengths, different pigments were excitable. Lipofuscin gave the highest signals, at 488 and 568 nm. The improved resolution showed inhomogeneous intragranular fluorophore patterns. CONCLUSION: Structured illumination microscopy enabled us to generate images of fluorescent structures in RPE cells ex vivo with a lateral resolution of 110 nm. With the use of different excitation wavelengths, intracellular fluorescence patterns in single cell compartments are visible and allow further differentiation.

[Primary intrastromal iris cysts]. / Primäre stromale Iriszysten.

BACKGROUND: Cysts of the iris are uncommon and most of them occur secondarily after surgery or penetrating injury. The minority of the iris cysts is primary without a reasonable cause. They are classified into the more common pigment epithelial cysts and the rare cysts of iris stroma ("intrastromal cysts"). These intrastromal iris cysts are generally diagnosed in children and often cause symptoms such as a decrease of visual acuity because of ingrowth into the optical axis. A diagnosis of stromal cysts in adults is very rare. Most of these patients remain without any symptoms and do not need treatment. The cellular origin is so far unknown. Mesoderm, neuroectoderm and surface ectoderm have been discussed in this context. CASE REPORTS: Two patients with primary intrastromal iris cysts are presented, a 5-year-old boy and a 65-year-old woman. In both cases, the cyst affected the optical axis and was removed by sector iridectomy. In histological and electron-microscopic examinations both cysts presented a typical epithelial structure. Immunohistochemical examination revealed positivity for epithelial markers and negativity for mesenchymal and neuroectodermal markers. CONCLUSION: Primary intrastromal iris cysts can occur in advanced age and may cause symptoms due to progressive growth. The cellular origin of primary intrastromal iris cysts is controversially discussed in the literature. On electron microscopy and immunohistochemistry, the iris cysts presented here showed characteristic features of surface ectodermal origin.

Treatment of peripapillary choroidal neovascularization with intravitreal bevacizumab.

PURPOSE: Peripapillary choroidal neovascularization (CNV) is an uncommon condition and often shows a growth tendency towards the fovea during spontaneous progression that threatens visual acuity. Treatment of peripapillary CNV is difficult. The authors report results of intravitreal bevacizumab therapy for peripapillary CNV. METHODS: Four patients with CNV located in the temporal or superior peripapillary area received intravitreal bevacizumab injections. Ophthalmologic examinations including OCT were performed at baseline and at 6-week intervals. Fluorescein angiography was performed at baseline and depending on clinical and OCT findings. The mean follow-up was 34+/-20 (22-69) weeks. RESULTS: The patients received an average of 3.5+/-3.1 (1-8) injections. In all patients fluorescein angiography showed inactivation of peripapillary CNV. No further increase in size was observed in any of the patients. The OCT showed a decrease of intraretinal and subretinal fluid. No intraocular or systemic side effects were observed. CONCLUSIONS: In this series of patients, intravitreal bevacizumab appears to be efficacious. A progression of peripapillary CNV could be prevented in all patients and the lesion was successfully inactivated. Anti-VEGF treatment with bevacizumab represents a promising therapy option for peripapillary CNV.

[Endophthalmitis after repeated bevacizumab injections]. / Endophthalmitis nach mehrfachen Bevacizumab-Injektionen. Diagnose: Immunreaktion mit Pseudohypopyon nach mehrfachen Bevacizumab-Injektionen.

Symptoms resembling endophthalmitis developed 1 day after the seventh injection of bevacizumab in a 76-year-old woman with extrafoveal occult choroidal neovascularization in conjunction with age-related macular degeneration. The diagnosis reached was an immune reaction with pseudohypopyon after repeated bevacizumab injections. The condition resolved completely within 5 days under sole administration of corticosteroids. Treatment was then continued with pegaptanib and no further intraocular irritation occurred.

[OCT-based re-injections for anti-VEGF-treatment for neovascular ARMD]. / OCT-Befund als Reinjektionskriterium bei der Anti-VEGF-Therapie für neovaskuläre AMD.

BACKGROUND: We present an optical coherence tomography (OCT)-based individual reinjection procedure for bevacizumab treatment in neovascular age-related macular degeneration (ARMD). METHODS: Thirty-two patients with active subfoveal occult choroidal neovascularisation in ARMD received a single intravitreal injection of 1.25 mg bevacizumab and were reinjected based on new or persisting subretinal or intraretinal fluid on OCT. Patient visits were every 6-8 weeks. RESULTS: After a single injection, 74% of patients demonstrated complete retinal fluid absorption, with 44% of patients showing no relapse during a follow-up of 30+/-13 weeks. Fifty-six percent of patients required a second injection after a mean of 19+/-8 weeks, with 82% of patients showing absorption of macular fluid thereafter with regain of their previous achieved best-corrected visual acuity. Thirty-two percent did not require any further injection (follow-up 32+/-12 weeks). Of those patients not showing retinal fluid absorption after the first injection (26%), 44% demonstrated retinal fluid absorption after the second injection. All patients achieved stabilisation of visual acuity during follow-up, with 30% of patients showing a significant gain of >or=3 lines. CONCLUSIONS: OCT-based reinjections of bevacizumab in neovascular ARMD reduce the number of injections and lead to anatomic and functional retinal stabilisation.

[Intravitreal bevacizumab for choroidal neovascularization due to pathological myopia]. / Intravitreal Bevacizumab bei choroidaler Neovaskularisation infolge pathologischer Myopie.

PURPOSE: The aim of this study was to evaluate the safety and efficacy of intravitreal bevacizumab as a treatment for choroidal neovascularization (mCNV) due to pathological myopia. METHODS: A consecutive series of 23 patients with mCNV treated with 1.25 mg intravitreal bevacizumab after being thoroughly informed about the off-label character of the treatment. Of the patients 6 received additional photodynamic therapy at the time of first injection. Reinjections were given every 6 weeks if intraretinal or subretinal fluid persisted. RESULTS: The pre-injection mean visual acuity (VA) was 0.25 (0.58 logMAR+/-0.36). During a follow up of 16.6+/-13.7 weeks 1.4+/-0.8 injections were given. Complete resorption of subretinal or intraretinal fluid was achieved in all patients. VA improved by 2.3+/-3.5 lines on average, 9 patients (39.1%) had an increase of >or=3 lines, none lost more than 1 line. Patients with bevacizumab monotherapy (n=17) had an improvement of 2.59+/-3.9 lines, 7 patients (41.2%) had an increase of >or=3 lines. No intraocular or systemic side effects were observed. CONCLUSIONS: In this as yet largest series of patients with mCNV treated with intravitreal bevacizumab, the treatment seemed to be effective and safe.