[Long-term outcome of macular neovascularization secondary to choroidal osteoma with and without intravitreal anti-VEGF(vascular endothelial growth factor)- treatment]. / Langzeitverlauf von makulären Neovaskularisationen bei chorioidalen Osteomen mit und ohne intravitreale Anti-VEGF(vascular endothelial growth factor)-Therapie.

BACKGROUND: Choroidal osteoma (CO) is a benign ossifying ocular tumor, which is unilateral in most cases. The CO may cause severe visual impairment, especially in the case of a secondary macular neovascularization (MNV). OBJECTIVE: Based on a case series of patients with MNV secondary to CO, the variability of the clinical course with and without intravitreal anti-vascular endothelial growth factor (VEGF) treatment is presented. METHODS: All patients diagnosed with secondary MNV due to CO between 2007 and 2023 were retrospectively assessed with respect to the clinical course. RESULTS: In this study 7 eyes of 5 patients (4 women, 1 man) were diagnosed with secondary MNV due to CO. Intravitreal anti-VEGF treatment was carried out in 2 patients with unilateral MNV and 1 patient was treated in both eyes for bilateral MNV. In another case with bilateral MNV, only 1 eye was treated because of fibrosis in the other eye. A further case with unilateral CO and MNV scars at the initial diagnosis was left untreated. Overall, in 3 out of 5 eyes treated with intravitreal VEGF inhibition stabilization or improvement of visual acuity could be achieved. CONCLUSION: In our case series intravitreal anti-VEGF treatment attained a functional stabilization or improvement in 3 out of 5 treated eyes. In one case of CO-associated MNV fibrosis rapidly developed without treatment. Therefore, the clarification for patients with CO about the lifelong risk for development of a secondary MNV is essential in individual cases for early treatment. As no standardized treatment scheme for intravitreal VEGF antibodies for CO-related MNV exists, the treatment is planned on an individual basis.

Unexplained visual loss after primary pars-plana-vitrectomy with silicone oil tamponade in fovea-sparing retinal detachment.

BACKGROUND: To investigate the incidence and clinical characteristics of unexplained visual loss in patients with fovea-sparing rhegmatogenous retinal detachment (RRD) during or after silicone oil (SO) tamponade. METHODS: The medical charts of all patients with macula-on RRDs, who underwent pars-plana-vitrectomy (ppV) with SO tamponade were retrospectively assessed regarding unexplained visual loss (UVL) of ≥ 3 Snellen lines and alterations on optical coherence tomography (OCT) during or after SO tamponade. The clinical data analysed included visual acuity, surgical parameters, OCT images, duration of SO tamponade and the time point of visual decline. Cases with re-detachment or secondary causes of visual loss such as SO emulsification, epiretinal membranes or macular edema were excluded. RESULTS: Over a 15-year-period, 22 cases with macula-on RRD, which had primarily been treated with ppV and SO tamponade, met the inclusion criteria. In most eyes (n = 20; 91%), the RRD was caused by a giant retinal tear (GRT). In 11 of these 22 cases (50%), best-corrected visual acuity (BCVA) had dropped by at least 3 lines for no apparent reason. In these 11 cases, mean preoperative logMAR BCVA was 0.2 (SD 0.13; range 0-0.5), equal to Snellen's VA of 0.63, and mean postoperative logMAR BCVA 1.0 (SD 0.24; range 0.5-1.3), equal to Snellen's VA of 0.10. Visual decline occurred about 12 weeks postoperatively (SD 6.2; range 3-20 ) and comprised 8 lines (SD 2.3; range -11 to -4). SO was removed on average 139 (SD 50.0; range 88-271) days after the first ppV. In 9 cases visual decline occurred while the SO was in-situ. In 2 patients, BCVA decline was noted 2 weeks after SO removal. In all eyes, preoperative central foveal thickness (CFT) was 254 µm (SD 24.2), which decreased to 224 µm (SD 29.6) during SO tamponade and increased to 247 µm (SD 29.2) after SO removal, irrespective of the presence of UVL. The mean follow-up time was 20 months (SD 30.6) after SO removal. CONCLUSION: UVL after SO tamponade for macula-on RRD is more frequent than expected. The incidence in our case series was 50%. The mechanism of this phenomenon is still unknown. In general, vitreoretinal surgeons should thoroughly question the need for SO tamponade, inform their patients of possible UVL and remove SO as early as possible. TRIAL REGISTRATION: The study was approved by the local ethics committee on 6th of May 2022 (Ethikkommission der Universität Regensburg, Votum 22-2925-104) and was conducted in accordance with the ethical standards of the Declaration of Helsinki.

[Anti-VEGF-therapy of fibrovascular and serous-vascularized pigment epithelial detachment in neovascular AMD : A retrospective five-year-analysis]. / Anti-VEGF-Therapie bei fibrovaskulärer und serös-vaskularisierter Pigmentepithelabhebung bei neovaskulärer AMD : Eine retrospektive Fünf-Jahres-Analyse.

BACKGROUND: Neovascular age-related macular degeneration (nAMD) is the most frequent cause of pigment epithelial detachment (PED). In the clinical routine the treatment of fibrovascular PED (fPED) and serous vascularized PED (svPED) with intravitreal vascular endothelial growth factor (VEGF) inhibitors has a restricted prognosis. OBJECTIVE: There are limited data on the long-term outcome of PED under anti-VEGF therapy. Therefore, this study recorded the course of treated PEDs in nAMD eyes over a period of 5 years. METHODS: All eyes with fPED or svPED that underwent anti-VEGF medication between 2006 and 2015 were retrospectively analyzed regarding the clinical course and the morphology seen on optical coherence tomography (OCT). The inclusion criteria were the detection of a PED on OCT, the angiographic verification of nAMD, a documented clinical history over 5 years and a good image quality. RESULTS: A total of 23 eyes from 22 patients met the inclusion criteria. After 5 years a significant deterioration of visual acuity (VA) was seen in all eyes (p = 0.007) and in the subgroup of cases with fPED (p = 0.045). In the eyes with svPED the decline of VA was not significant (p = 0.097). In the collective study group a statistically significant reduction of PED height (p = 0.006) and an increase of PED diameter was measured (p = 0.002). In the subgroup analysis the decrease of PED height and increase of PED diameter were significant for cases with svPED (p = 0.004, p = 0.013, respectively) but were not statistically significant for fPED eyes (height: p = 0.616; diameter: p = 0.097). In 17 (74%) eyes fibrosis or atrophy were seen on the final assessment of OCT images. DISCUSSION: After 5 years of anti-VEGF therapy for nAMD-associated PED the VA declined in half of the eyes and the OCT showed an unfavorable morphology in 3/4 of the cases. The average number of visits and injections was distinctly lower than in clinical trials and other real-life analyses. In summary, we observed an undertreatment with a worse functional and anatomical outcome in our clinical routine compared to other studies.

[Gender medicine in ophthalmology : The "small difference" between women and men]. / Gender-Medizin in der Augenheilkunde : Der "kleine Unterschied" zwischen Frauen und Männern.

Gender-specific or sex-specific medicine is part of "personalized" medicine. After differences in heart diseases between women and men were first identified and increasingly published in the field of cardiology since the 1980s, differences between the sexes have also become the focus of interest in other disciplines. Immunological and hormonal aspects indicate significant differences, e.g. in the severity of the disease or the response to treatment. Even in ophthalmology epidemiological differences in some diseases are known but so far these do not lead to a different approach in the practical treatment of patients. This CME article aims to raise awareness of gender medicine also in the field of ophthalmology and at the same time to promote understanding of these differences by presenting the fundamental differences between the sexes.

[Outcome of pterygium excision after various surgical techniques-is excision with simple conjunctival closure still lege artis?] / Ergebnisse der Pterygiumchirurgie nach verschiedenen Operationstechniken ­ Ist die Exzision mit einfachem Bindehautverschluss noch lege artis?

BACKGROUND: There is no consensus about the best method for pterygium excision. Variable recurrence rates have been reported in the literature depending on the surgical technique. OBJECTIVE: To evaluate the postoperative outcome after pterygium excision depending on the preoperative extent of the pterygium and the surgical method. MATERIAL AND METHODS: A total of 109 patients (72 men, 37 women) who underwent 109 pterygium surgeries were retrospectively analyzed. In 87 cases postoperative data over a 5-year follow-up period were available. Besides recording the preoperative extent of the pterygium the functional outcome was analyzed and recurrence rates of the various techniques by simple excision with primary conjunctival closure (SE), conjunctival autograft (BHT) and amniotic membrane transplantation (AMT) were compared. RESULTS: Overall, recurrence was noted in 21 %. The recurrence rate of SE was 20 %. After BHT fewer recurrences (11 %) were seen than after AMT (39 %). After the intraoperative use of mitomycin C (MMC) more recurrences (31 %) occurred than without the use of MMC (17%). In 45 % of the cases delayed recurrence occurred after the first postoperative year. CONCLUSION: In our opinion the method of SE is not obsolete. Good results can be achieved with SE in pterygia with a small extent. The lowest recurrence rate was seen after BHT; therefore, BHT is the method of choice in general and especially for larger pterygia. The higher recurrence rate after intraoperative use of MMC is probably caused by selection bias. Regular follow-up examinations are required beyond the first postoperative year for timely detection of delayed recurrence.

[Ranibizumab and aflibercept for diabetic macular edema-retrospective study with real-life data after 12 months]. / Ranibizumab und Aflibercept bei diabetischem Makulaödem ­ Retrospektive Studie mit Ergebnissen aus dem klinischen Alltag nach 12 Monaten.

BACKGROUND: Currently only few data are available on a direct comparison of the treatment reality with ranibizumab and aflibercept in patients with diabetic macular edema (DME). This study assessed best corrected visual acuity (BCVA) outcomes and central retinal thickness (CRT) under treatment with ranibizumab and aflibercept. MATERIAL AND METHODS: Patients with DME involving the fovea in treatment-naïve eyes and a follow-up period of least 12 months were retrospectively identified. Patients underwent treatment with ranibizumab 0.5 mg or aflibercept 2.0 mg. The findings were obtained using clinical examination, fluorescein angiography and spectral domain optical coherence tomography (SD-OCT, measuring CRT). RESULTS: A total of 41 treatment-naïve eyes were identified in 29 patients with DME involving the fovea. The mean 12-month improvement was +9.5 letters in 19 eyes treated with ranibizumab and BCVA improving from 0.57 log MAR (95% confidence interval, CI 0.45-0.70 log MAR) to 0.38 log MAR (95% CI 0.25-0.50 log MAR; p < 0.001) and +8.5 letters in the aflibercept group with 22 eyes and BCVA improving from 0.38 log MAR (95% CI 0.25-0.51 log MAR) to 0.21 log MAR (95% CI 0.08-0.34 log MAR; p < 0.001). The difference between the two groups was not statistically significant (p = 0.599). When the initial visual acuity was 0.4 or less, the mean BCVA improved in 14 eyes treated with ranibizumab from 0.62 log MAR (95% CI 0.47-0.79 log MAR) to 0.38 log MAR (95% CI 0.21-0.55 log MAR), an improvement of 12.0 letters (p < 0.001), in 11 eyes treated with aflibercept from 0.63 log MAR (95% CI 0.42-0.84 log MAR) to 0.29 log MAR (95% CI 0.08-0.50 log MAR), an improvement of 17.0 letters (p < 0.001). The difference between the two groups was significant (p < 0.001). The mean number of intravitreal injections was 6.4 (95% CI 5.1-7.7) in the ranibizumab group, 7.5 (95% CI 6.2-8.8) in the aflibercept group (p = 0.199). The mean CRT decreased significantly (p < 0.001) in patients treated with both ranibizumab and aflibercept without any evidence of a significant difference between the two groups (p = 0.514). DISCUSSION: In the patients studied ranibizumab and aflibercept showed a good safety and efficacy in the treatment of DME regarding BCVA and CRT under real-life conditions after 12 months. In cases of lower initial visual acuity (0.4 or 20/50 or less) aflibercept was more effective at improving vision.

Intravitreal anti-VEGF treatment for choroidal neovascularization secondary to traumatic choroidal rupture.

BACKGROUND: So far only single cases with short follow-up have been reported on the use of intravitreal anti-VEGF for traumatic choroidal neovascularizations (CNV). This paper reports a large case series of patients with CNV secondary to choroidal rupture after ocular trauma receiving intravitreal anti-VEGF (vascular endothelial growth factor) injections. METHODS: Fifty-four patients with unilateral choroidal rupture after ocular trauma diagnosed between 2000 and 2016 were retrospectively evaluated. Eleven patients with CNV secondary to choroidal rupture were identified. Five eyes with traumatic secondary CNV were treated with anti-VEGF and were systematically analysed. The other 4 patients with inactive CNV underwent watchful observation. RESULTS: Four men and one woman with a mean age of 29 years (SD 12.4; range 19-45) had intravitreal anti-VEGF therapy for traumatic CNV. Another 4 patients with a mean age of 37 years (SD 6.6; range 31-46) presented with inactive CNV and did not receive specific treatment. In all 9 cases the mean interval between the ocular trauma and the diagnosis of CNV was 5.7 months (SD 4.75; range 2-12). In the treatment group per eye 4.2 injections (SD 3.2; range 1-8) were given on average. Four eyes were treated with bevacizumab and one eye with ranibizumab. Regression of CNV was noted in all eyes. In 4 eyes visual acuity (VA) improved, one eye kept stable visual acuity. CONCLUSIONS: Here, we present the up to now largest case series of traumatic CNV membranes treated with anti-VEGF injections with a mean follow-up period of 5 years. Intravitreal anti-VEGF therapy seems to be safe and effective for secondary CNV after choroidal rupture. Compared to exudative age-related macular degeneration fewer injections are needed to control the disease. TRIAL REGISTRATION: Retrospective registration with local ethics committee on 21 March 2019. Trial registration number is 19-1368-104.

Intravitreal anti-VEGF treatment for choroidal neovascularization secondary to punctate inner choroidopathy.

PURPOSE: To assess the outcome of patients with choroidal neovascularization (CNV) secondary to punctate inner choroidopathy (PIC) receiving intravitreal anti-VEGF (vascular endothelial growth factor) injections. METHODS: Sixteen eyes of 16 patients diagnosed with CNV secondary to PIC were retrospectively assessed. RESULTS: Eleven women and five men with a mean age of 35 years (SD 11, range 16-56 years) received intravitreal anti-VEGF for PIC-related CNV. On average, 3.5 injections (SD 2.7, range 1-9) were given per eye. Thirteen eyes were treated with bevacizumab, two eyes with ranibizumab and one eye received both substances. The mean follow-up was 15 months (SD 11, range 6-40 months). BCVA improved in eight eyes (mean Δ +2.8 lines), remained stable in four eyes and decreased in four eyes (mean Δ -4.3 lines). CONCLUSIONS: CNV development is a frequent complication of PIC. Intravitreal anti-VEGF therapy seems to be safe and effective for PIC-related CNV.

[Volumetric analysis of vascularized pigment epithelium detachment in AMD: post hoc analysis of the RECOVER study]. / Volumetrische Analyse der vaskularisierten Pigmentepithelabhebung bei AMD: Post-hoc-Analyse der RECOVER-Studie.

BACKGROUND: The ratio of choroidal neovascularization (CNV) and pigment epithelium detachment (PED) represents an important parameter regarding the risk of developing a tear of the retinal pigment epithelium (RPE) in patients with vascularized PED due to age-related macular degeneration (AMD). METHODS: Within the framework of the RECOVER study a total of 29 treatment-naive patients with vascularized PED underwent fluorescein angiography (FA), indocyanine green angiography (ICGA) and optical coherence tomography (OCT) volume scans. The CNV-PED ratio was evaluated retrospectively by two independent graders in three ways: 1) manually based on the en face image of the FA late phase and 2) manually based on the en face image of the ICGA late phase. 3) In every OCT scan encompassing the PED, the area between the RPE and Bruch's membrane and the CNV area was measured and multiplied by the distance between OCT scans in order to determine volumetric data of CNV, PED and the serous cavity. RESULTS: The FA and ICGA showed a mean serous area of 6.14 ± 4.21 mm2 (ICGA 5.94 ± 4.13 mm2), a mean CNV area of 3.25 ± 1.79 mm2 (ICGA 2.84 ± 1.68 mm2) and a mean PED area of 9.39 ± 4.27 mm2 (ICGA 8.79 ± 4.23 mm2) resulting in a mean two-dimensional morphological ratio of 0.35 ± 0.21 (ICGA 0.32 ± 0.22). The volumetric measurement revealed a mean CNV volume of 0.63 ± 0.67 mm3, a mean serous volume of 3.61 ± 3.83 mm3 and a mean total PED volume of 4.25 ± 3.68 mm3. The mean three-dimensional morphological ratio was 0.15 ± 0.29. The difference between the two-dimensional ratios of FA (p < 0.0001) and ICGA (p = 0.0004) was significant compared to the three-dimensional OCT ratio. CONCLUSION: Assessment of the CNV-PED ratio using volumetric OCT measurements is an additional tool to the en face modalities FA and ICGA. This seems to be clinically relevant regarding the risk stratification of RPE tear development in PED patients and for the planning of the treatment regimen.

[POEMS syndrome as a rare cause of bilateral optic disc edema]. / POEMS-Syndrom als seltene Ursache eines bilateralen Papillenödems.

The POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes) is a rare paraneoplastic syndrome based on a clonal plasma cell disorder. Optic disc edema (ODE) is a frequent ocular sign in POEMS syndrome. The cause of the ODE has not yet been entirely clarified. This article reports the case of a 62-year-old male suffering from POEMS syndrome with a bilateral ODE.

[Conjunctival amyloidosis]. / Konjunktivale Amyloidose.

BACKGROUND: This article reports a case of primary localized conjunctival λ light-chain (AL) amyloidosis. METHODS: Case report. RESULTS: A 73-year-old woman presented with a 1-year history of a painless growth in the conjunctiva of the left eye. A yellow-salmon pink diffuse mass of tissue was identified in the inferomedial bulbar conjunctiva and inferior fornix. An incisional biopsy was performed. The histopathological and immunohistochemical examinations revealed interstitial and vascular amyloid deposits of λ light chains. The diagnosis was amyloidosis of the conjunctiva. The systemic evaluation revealed normal findings and systemic amyloidosis was excluded. Nevertheless, due to an unexplained cardiac insufficiency and after consultation with the treating hematologist a treatment with three cycles of systemic chemotherapy with melphalan and prednisolone was initiated but 6 months later the conjunctival mass in the inferior fornix showed persistence and complete excision was performed. At 16, 24 and 44 months of follow-up no evidence of recurrence was seen on clinical examination. The magnetic resonance imaging (MRI) at 16 and 24 months of follow-up showed no associated cranial or orbital infiltration. CONCLUSION: Conjunctival AL amyloidosis is a rare clinical entity. Because of the heterogeneity of amyloidosis in clinical presentation, pattern of amyloid-related organ toxicity, association with lymphoproliferative diseases and rate of disease progression, identification of amyloid deposits is essential and systemic involvement has to be excluded.

[Drusen characteristics after internal limiting membrane peeling]. / Verhalten von Drusen nach "internal limiting membrane peeling".

BACKGROUND: There are some reports showing isolated cases of drusen regression after pars plana vitrectomy (ppV) with peeling of the internal limiting membrane (iLM). Drusen characteristics after iLM peeling was investigated in this study. PATIENTS AND METHODS: The data of 527 patients who had received iLM peeling between 2004 and 2012 were retrospectively collected and those patients with retinal drusen were selected for the study. Fundus photographs before and after vitrectomy due to a macular hole or epiretinal gliosis were compared and drusen arrangement in the peeling site was analyzed. The aim of the study was to show whether there was drusen regression 2-5 months after surgery. RESULTS: Out of the 527 patients 11 showed central macular drusen, 4 with confluent large drusen (> 63 µm diameter) and 7 with small hard drusen (≤ 63 µm diameter). One patient showed drusen regression after iLM peeling without any changes in the other eye and all other patients showed no differences in the drusen findings (n = 6) or even some additional drusen (n = 4) without drusen alterations in the other eye. CONCLUSION: The results of this study could not confirm some reports showing drusen regression after iLM peeling in the peeling site in general and there was only one single case of central drusen regression.

Ocular color-coded sonography - a promising tool for neurologists and intensive care physicians.

Ocular color-coded duplex sonography (OCCS), when performed within the safety limits of diagnostic ultrasonography, is an easy noninvasive technique with high potential for diagnosis and therapy in diseases with raised intracranial pressure and vascular diseases affecting the eye. Despite the capabilities of modern ultrasound systems and its scientific validation, OCCS has not gained widespread use in neurological practice. In this review, the authors describe the technique and main parameter settings of OCCS systems to reduce potential risks as thermal or cavitational effects for sensitive orbital structures. Applications of OCCS are the determination of intracranial pressure in emergency medicine, and follow-up evaluations of idiopathic intracranial hypertension and ventricular shunting by measuring the optic nerve sheath diameter. A diameter of 5.7 - 6.0 mm corresponds well with symptomatically increased intracranial pressure (> 20 cmH2O). OCCS also helps to discriminate between different etiologies of central retinal artery occlusion - by visualization of a "spot sign" and Doppler flow analysis of the central retinal artery - and aids the differential diagnosis of papilledema. At the end perspectives are illustrated that combine established ultrasound methods such as transcranial color-coded sonography with OCCS.

[Differential diagnosis and therapy of pigment epithelial detachment]. / Differenzialdiagnose und Therapie von Pigmentepithelabhebungen.

Retinal pigment epithelial detachment (PED) can occur associated with multiple ocular and infrequently also primarily non-ocular pathologies. They can be sub-divided into drusenoid, serous, serous-vascularized and fibrovascular PED. Most commonly PED is found in age-related macular degeneration. The knowledge of possible differential diagnoses is important for the prognosis and helps in the choice of therapy and in the individual counseling of patients.