Treatment of type I ROP with intravitreal bevacizumab or laser photocoagulation according to retinal zone.

AIMS: To investigate the outcome of intravitreal bevacizumab (IVB) compared with laser photocoagulation in type I retinopathy of prematurity (ROP). METHODS: Case records of 54 consecutive very low birth weight (VLBW) infants with type I ROP (posterior ROP, n=33; peripheral zone II, n=21) who were treated either with IVB (n=37) or laser photocoagulation (n=17) between 2011 and 2015 were retrospectively evaluated. RESULTS: Patients with posterior ROP displayed significantly faster regression of active ROP within 12 days (range 9-15 days) if treated with IVB compared with laser photocoagulation, where active ROP regressed within 57 days (range 28-63 days) (p>0.001). No difference was observed in peripheral zone II.Five of seven patients (12%) who developed a recurrence in both eyes after IVB required additional laser photocoagulation within a mean of 12.7 weeks (11.3-15.6 weeks) after the previous treatment. After laser photocoagulation one patient with posterior ROP developed macular dragging and another patient developed a temporary exudative retinal detachment in both eyes. 12 months after treatment the spherical equivalent was not statistically significant different between IVB and laser photocoagulation in posterior ROP patients. However, IVB lead to a significant lower spherical equivalent in infants with posterior ROP (+0.37 dioptres, range -0.5 to +1.88 dioptres) compared with peripheral zone II (+3.0 dioptres range +2.0 to +4.0 dioptres, p<0.001). CONCLUSIONS: IVB leads to faster regression of active ROP in infants with posterior ROP compared with laser photocoagulation. Spherical equivalent after 12 months was comparable in those treated with IVB and laser photocoagulation, but it was significantly lower in posterior ROP than in peripheral zone II.

[Ocular Hypotension: How the Retina Surgeon Sees the Causes and Therapeutic Options]. / Okuläre Hypotonie - Ursachen und therapeutische Möglichkeiten aus Sicht des Netzhautchirurgen.

Ocular hypotension is a result of a lack of production or a loss of intraocular fluid. Intraocular inflammation, drugs, or proliferative vitreoretinopathy (PVR) with overgrowth of the ciliary body can result in reduced secretion of intraocular fluid. Loss of intraocular fluid can result from external loss, such as in fistulating surgery or trauma, or internally, e.g. from cyclodialysis clefts or retinal detachment. In this review, we discuss the causal therapy of ocular hypotension: fixation of the ciliary body, removal of ciliary body membranes, surgery for PVR, choice of tamponade, possibilities and limitations of an iris diaphragm, and pharmacological options.

[Trabeculectomy Ab Interno in Primary Open Angle Glaucoma and Exfoliative Glaucoma]. / Trabekulotomie ab interno (Trabectome) - Kumulierte klinische Ergebnisse eines großen Glaukomkollektivs.

BACKGROUND: To assess the outcome of routine trabectomy surgery in the treatment of primary (POAG) and secondary open angle glaucoma. PATIENTS/METHODS: 296 eyes of 296 patients with diagnosed open angle glaucoma and exfoliative glaucoma were analysed from June 2012 until June 2014. IOP readings (intraocular pressure) and the number of antiglaucoma medications was evaluated at every follow-up visit. For statistical analysis, 4 study cohorts were built (cohort 1 = trabectomy in POAG, cohort 2 = trabectomy in exfoliative glaucoma (PEX), cohort 3 = trabectomy + IOL in POAG, cohort 4 = trabectomy + IOL in PEX glaucoma). RESULTS: Mean IOP before trabectomy surgery was 19.8 ± 5.9 mmHg and 23.7 ± 9.5 mmHg in cohorts 1 and 2, respectively. At 1 year follow-up, IOP was reduced to normal level for cohorts 1 and 2 (14.8 ± 3.2 mmHg (p = 0.001) and 14.0 ± 3.3 mmHg (p = 0.046), respectively). The number of topical antiglaucoma medications changed to 2.1 ± 1.2 (p = 0.004) and 2.4 ± 1.2, respectively (p = 0.593) at one year follow-up, respectively, for POAG and exfoliative glaucoma. In study cohort 3 and 4, mean IOP before trabectomy surgery was 19.2 ± 4.0 mmHg and 23.2 ± 9.2 mmHg, respectively. At 1 year follow-up, IOP was reduced to normal levels in cohorts 3 and 4 (11.8 ± 3.1 mmHg (p < 0.01) and 12.6 ± 1.1 mmHg, respectively (p = 0.043)); the number of topical antiglaucoma medications changed to 2.3 ± 1.4 (p = 0.469) and 1.4 ± 0.8, respectively, (p = 0.102) at 1 year follow-up. A significant difference in IOP reduction could be demonstrated in POAG between the trabectomy + IOL group and the trabectomy cohort 1 year postoperative (p = 0.017); in the PEX trabectomy + IOL versus PEX trabectomy cohort no statistically significant difference (p = 0.678) could be demonstrated. No serious postoperative complications were recorded. CONCLUSION: Trabectomy surgery seemed to be a reliable and effective tool for the management of mild and moderate primary and secondary open angle glaucoma with uncontrolled IOP in daily routine. One year follow-up showed a significant reduction in intraocular pressure in all cohorts.

Trabeculectomy ab interno (trabectome): yet another possibility in the treatment of uncontrolled glaucomatocyclitic crisis under systemic valganciclovir therapy?

PURPOSE: To assess the outcome of trabectome surgery in the treatment of glaucomatocyclitic crisis (Posner-Schlossman syndrome) in patients with uncontrolled intraocular pressure (IOP). PATIENTS/METHODS: Trabectome surgery was performed in seven patients with diagnosed glaucomatocyclitic crisis and uncontrolled IOP where cytomegalovirus DNA was verified by polymerase chain reaction in aqueous humour samples. All patients were treated with oral valganciclovir. After surgery the patients were followed-up for 12 months. RESULTS: Mean IOP before trabectome surgery was 40±10 mm Hg (range 33-58 mm Hg). The mean number of antiglaucoma medication prior to surgery was 3.1±0.4. By the end of the 12 months, IOP in all patients was reduced to normal level (13±1 mm Hg) and their antiglaucoma medication was decreased to 0.8±1.1. No recurring attack of glaucomatocyclitic crisis occurred. DISCUSSION: In addition to oral valganciclovir therapy, trabectome surgery seems to be a reliable and effective tool for the management of glaucomatocyclitic crisis with uncontrolled IOP.

Retrospective contralateral study comparing Descemet membrane endothelial keratoplasty with Descemet stripping automated endothelial keratoplasty.

PURPOSE: In this retrospective study, the visual outcomes and postoperative complications after Descemet stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK) in the fellow eye were compared. The patient's satisfaction was evaluated. METHODS: A retrospective analysis of 10 patients, who underwent DSAEK in one eye and DMEK surgery in their fellow eye, was performed. Intraoperative and postoperative complications were recorded. Visual and refractive outcomes were evaluated, including higher-order aberrations (HOA) and contrast thresholds. A subjective questionnaire was used to evaluate patient satisfaction. RESULTS: Best-corrected visual acuity (BCVA) was significantly better in DMEK when compared with DSAEK (0.16±0.10 vs 0.45±0.58 logMAR, P=0.043). Contrast threshold was significantly higher after DMEK than after DSAEK (0.49±0.23 vs 0.25±0.18, P=0.043). Post-keratoplasty astigmatism, mean spherical equivalent, and HOA did not differ. Nine out of ten patients preferred the DMEK procedure. Visual outcome (4.80±1.14 vs 4.50±1.58, P=0.257), surgery associated pain and burden (DMEK: 1.30±0.48 vs DSAEK: 1.30±0.48, P=1.0), estimated time for recovery and rehabilitation (27.6±54.0 vs 24.9±54.8 days, P=0.173), and mean patient satisfaction (5.40±0.84 vs 5.00±1.05, P=0.257) were evaluated equally. CONCLUSION: Patient satisfaction reached high, equal values after DMEK and after DSAEK. Nevertheless, patients preferred DMEK, if given a choice. Reasons for the preference may include better uncorrected and BCVA, and especially a better contrast sensitivity.

Does ocriplasmin affect the RPE-photoreceptor adhesion in macular holes?

BACKGROUND: To evaluate the anatomical outcome of patients after vitrectomy due to persisting symptomatic vitreomacular traction (VMT), including full-thickness macular holes (FTMHs) of less than 400 µm, after ocriplasmin treatment. METHODS: Retrospective, single centre, consecutive interventional case series. Patients were treated with a single intravitreal injection of ocriplasmin (Jetrea, Thrombogenics Inc, USA, Alcon/Novartis EU). MAIN OUTCOME MEASURES: resolution of VMT, closure of FTMH and anatomical outcome of vitrectomy after unsuccessful treatment with ocriplasmin. RESULTS: Five patients were treated with ocriplasmin injection. VMT persisted in all but one case. Four patients underwent pars-plana vitrectomy (PPV) for treatment of persistent VMT and FTMH (n=2, size of macular hole <400 µm) in spectral-domain optical coherence tomography (SD-OCT). FTMHs were closed in both cases within the first week postoperatively. After PPV, in three eyes newly developed subretinal fluid was detected, which persisted up to several months postoperatively. CONCLUSIONS: Data on ocriplasmin remain controversial. We report on four cases with resolution of VMT following PPV after unsuccessful ocriplasmin treatment. Newly developed subretinal fluid has been described after ocriplasmin treatment, predominantly in cases with resolution of VMT. We also detected this newly developed subretinal fluid after vitrectomy, which persisted for several weeks up to 7 months in two cases with FTMHs. This may be attributable to loosening of the photoreceptor complex due to enzyme activity of ocriplasmin. Long-term effects of ocriplasmin are still to be evaluated using SD-OCT.

[Surgery for age-related macular degeneration. Still an option in the age of pharmacotherapy?]. / Chirurgie der altersbedingten Makuladegeneration--Ist das im Zeitalter der Pharmakotherapie noch eine Option?

This review assesses the relevance of surgical approaches for age-related macular degeneration (AMD) with respect to the pathophysiology of AMD and the current pharmacological possibilities. We discuss the different surgical approaches such as subretinal membrane excision, cell transplantation (IPE and RPE) and transplantation of retina and choroid (PATCH), as well as translocation surgery. Peeling of epiretinal membranes in patients with drusen as well as vitrectomy before epiretinal brachytherapy (VIDEON system) are the final topics. While overall pharmacotherapy has displaced surgical approaches, surgery is worthy of consideration in selected cases. For these patients surgical options need to be maintained in the armamentarium of retinal surgeons.

[Retinal Arterial Macroaneurysms (RAM)--pathology, differenzial diagnoses, and therapy]. / Retinale arterielle Makroaneurysmen (RAM)--Pathologie, Differenzialdiagnose und Therapie.

Retinal arterial macroaneurysms (RAM) are unilateral, solitary, acquired saccular or fusiform dilatations of the large arterioles of the retina, usually within the first three orders of bifurcation. They are associated with systemic vascular conditions such as hypertension and arteriosclerotic disease and occur most commonly in elderly women. Cases of simple RAM are predominated by the vascular ectasia. These macroaneurysms regress without treatment and without causing decreased visual acuity and will usually remain undetected. Complex RAM often go along with vision loss due to haemorrhage or oedema affecting the macula. Poor visual outcome may occur secondary to foveal exudates and subfoveal haemorrhage, the latter appear as pre-retinal, intra-, and subretinal haemorrhage. This overview discusses conservative and surgical therapeutic options for complex cases.

[Endothelial cell loss after retropupillary iris-claw intraocular lens implantation]. / Endothelzellverlust nach retropupillar fixierter Irisklauen-Linse.

BACKGROUND: The aim of this study was to evaluate the indication, visual and refractive outcome, endothelial cell loss and complication rate after implantation of a posterior iris-claw aphakic intraocular lens (IOL). PATIENTS AND METHODS: This retrospective study comprised 62 eyes of 56 patients without adequate capsular support undergoing posterior iris-claw aphakic IOL implantation (Verisyse™/Artisan®) between 2006 and 2012. Mean follow-up was 34 months (range from 13 to 78 months). RESULTS: The IOLs were inserted during primary lens surgery in 11 phakic eyes (17.8 %), during an IOL exchange procedure for dislocated posterior chamber IOLs in 34 eyes (54.8 %), and as a secondary procedure in 17 aphakic eyes (27.4 %). The final best spectacle-corrected visual acuity (BSCVA) in logMAR (mean 0.24 ± 0.45) improved significantly (p < 0.001) compared to the preoperative BSCVA (mean 0.61 ± 0.65). The mean spherical equivalent improved from preoperative 7,25 ± 5,04 diopters (D) (range - 10.25 to + 16.0 D) to - 0.21 ± 1.01 D (range - 4.0 to 3.0 D) postoperatively. Mean central endothelial cell density was 1844 ± 690 cells/mm(2) preoperatively. After surgery mean endothelial cell density decreased statistically not significant with a loss of 5.5 % to 1743 ± 721 cells/mm(2) (p > 0.05) at last follow-up visit. Complications included cystoid macular oedema in 4 eyes (6.4 %), early postoperative hypotony in 2 eyes (3.2 %), pupil ovalisation in 2 eyes (3.2 %), traumatic iris-claw IOL disenclavation in 2 eyes (3.2 %) and spontaneous IOL disenclavation in one eye (1.6 %). CONCLUSIONS: Retropupillar iris-claw IOL provides good visual and refractive outcomes with a low endothelial cell loss and can be used for a wide range of indications in eyes without adequate capsular support.

Long-term (4 years) results of choroidal hemangioma treated with proton beam irradiation.

BACKGROUND: The aim of this retrospective study was to determine the efficacy of proton beam irradiation in choroidal hemangioma in a long-term follow-up. PATIENTS AND METHODS: A total dose of 20 Cobalt Gray equivalent (CGE) was administered to 50 eyes of 50 patients from September 1998 to September 2010. All treated patients presented with a symptomatic tumor. Nine patients were pre-treated by photodynamic therapy (PDT). Visual outcome, tumor regression, and complications resulting from radiation were investigated. RESULTS: The mean follow-up was 55.4 months (range 13-132). Tumor thickness decreased in all patients. Retinal re-attachment was achieved without evidence of tumor leakage. Visual acuity improved by two lines after one year in 43.4 % of patients and after two years in 36.8 % of patients. During the 55.4 months of long-term follow-up the visual acuity improved from 6/15 to 6/12 after proton therapy. Twenty-three patients (46.0 %) developed radiation retinopathy. According to the Finger classification of 2004, 21 patients (42.0 %) showed a stage 1 or 2 (functionally not relevant) retinopathy, and two patients (4.0 %) presented a stage 3 or 4 (functionally relevant) retinopathy. Further complications included sicca syndrome in nine cases, cataract formation in 10 cases, and radiation optic neuropathy in four cases. CONCLUSION: Proton therapy with 20 CGE is an efficient primary therapy in choroidal hemangioma and is very effective as a secondary treatment after PDT.

[Influence of donor lamella thickness on visual acuity after Descemet's stripping automated endothelial keratoplasty (DSAEK)]. / Einfluss der Spenderlamellendicke auf die Sehschärfe nach "Descemet's stripping automated endothelial keratoplasty" (DSAEK).

BACKGROUND: The aim of this study was to evaluate the effect of donor lamella thickness on postoperative visual acuity after Descemet's stripping automated endothelial keratoplasty (DSAEK). MATERIALS AND METHODS: A retrospective analysis of 65 eyes from 61 patients who underwent DSAEK surgery in cases of Fuchs' corneal dystrophy or bullous keratopathy between 2008 and 2011 was performed. The thickness of donor lamella was measured intraoperatively by ultrasonic pachymetry and postoperatively by anterior segment optical coherence tomography (OCT) and correlated to the visual acuity and number of endothelial cells. RESULTS: The donor lamella thickness measured intraoperatively and postoperatively correlated significantly with each other (r = 0.874, p < 0.001). A significant correlation was found between postoperative corneal lamella thickness measured by anterior segment OCT and visual acuity (r = 0.273, p = 0.028) but not between intraoperative donor lamella thickness measured by ultrasonic pachymetry and visual acuity (r = 0.241, p = 0.103). The postoperative endothelial cell number did not show a correlation with either the intraoperatively or the postoperatively measured donor lamella thickness (r = - 0.059, p = 0.731, r = 0.024, p = 0.869, respectively). CONCLUSIONS: Corneal lamella thickness < 120 µm was found to be correlated with a better visual outcome than in cases of thicker corneas > 120 µm. Despite greater difficulty in corneal transplant technique in cases of thinner lamella no increased damage of corneal endothelium was shown. Therefore, DSAEK with corneal lamella thickness < 120 µm is an interesting therapeutic alternative to DMEK.

[Diagnosis of and therapy for choroidal melanoma]. / Diagnostik und Therapie choroidaler Melanome.

BACKGROUND: Prognosis evaluation of patients with choroidal and ciliary melanoma has experienced recent progress through tumour sampling and cytogenetic analysis of metastatic risk. By allocating tumor extension, height and linear basal diameter to defined TNM stages, an estimation of prognosis can also be made without invasive tissue sampling. METHODS: Therapeutic strategies of organ preserving irradiation using different sources have clearly come to the forefront. RESULTS: Due to microscopic haematogenous spreading of tumour cells prior to treatment, the metastatic risk following radiation of any form is not influenced in comparison to primary enucleation. CONCLUSION: However, metastatic disease still remains a fatal condition which currently may only be influenced by early detection and treatment of uveal melanomas.

[Childhood retinal detachment: ROP and myopia]. / Kindliche Ablationes: ROP und Myopie.

This article reviews the cause and treatment options for retinopathy of prematurity (ROP)-related tractional detachment and detachments in ROP residuals during childhood and early adulthood. Retinal vascularisation is incomplete after premature birth. Phase I of ROP consists of a delayed retinal vascular growth and vessel loss after premature birth resulting in hypoxia, phase II results in hypoxia-induced vascular proliferation and as a consequence to vitreoretinal traction. The anatomic and functional outcome of tractional detachment in ROP is determined by the previous treatment (e.g., laser to the avascular periphery or anti-VEGF). While the literature reports re-attachment rates > 70 % in ROP IV a, functional and anatomic outcome in the later stages is limited. ROP residuals may cause rhegmatogenous rather than tractional detachments in childhood or early adulthood. Myopia is associated with ROP and may further complicate the retinal situation and the risk for rhegmatogenous detachment. The retinal changes due to ROP warrant lifelong controls.

[Retinal exudative disease in childhood: Coats' disease and familial exudative vitreoretinopathy (FEVR)]. / Retinal exsudative Gefäßerkrankungen im Kindesalter: Morbus Coats und familiär exsudative Vitreoretinopathie (FEVR).

This article reviews the pathophysiology of retinal vascular disease with emphasis on Coats' disease and familial exudative vitreoretinopathy (FEVR). Both Coats' disease and FEVR demonstrate vascular abnormalities and associated exudation. Coats' disease manifests as teleangiectasia and aneurysms. Exudative subretinal lipid deposits can be extensive. Coats' disease is in 90 % unilateral and affects predominantly otherwise healthy young males. If the retina is attached, laser and cryocoagulation are the method of choice. Vitreoretinal surgery is only rarely indicated in advanced cases after a retinoblastoma has been excluded prior to surgery. FEVR inheritance is 56 % dominant (FZD4 und TSPAN12) and 44 % recessive (LRP5 und NDP). Temporal dragging of the vascular arcades and heterotopia of the macula are characteristic for FEVR. Subretinal exudates are indicators for progression of the disease with visual loss due to subsequent exudative or tractive retinal detachment. Exudative forms require treatment and reduction of peripheral ischaemia with laser photocoagulation and cryopexia. In cases of tractive detachments vitreoretinal surgery is necessary. Coats' disease and FEVR are both progressive diseases requiring lifelong follow-up and therapy.

Comparison of functional and morphological diagnostics in glaucoma patients and healthy subjects.

PURPOSE: To evaluate the diagnostic value of microperimetry (MP), blue-on-yellow perimetry (B/YP), confocal scanning laser ophthalmoscopy (Heidelberg Retina Tomograph, HRT, III) and optical coherence tomography (OCT) in discriminating eyes with early glaucoma from healthy subjects. MATERIAL AND METHODS: Prospective examination of 22 eyes of subjects with early primary open-angle glaucoma and 24 eyes of healthy control subjects. After a complete ophthalmological examination, B/YP, MP, OCT and HRT III were determined. Morphological and functional parameters were analysed. RESULTS: Mean sensitivity threshold values obtained with B/YP and MP did not show significant differences between glaucoma patients and the control group (p = 0.321 and p = 0.281). Retinal nerve fibre layer (RNFL) thickness was significantly decreased in patients with glaucoma with both HRT III and OCT (p = 0.018 and p < 0.001). CONCLUSIONS: While B/YP and MP had no ability to discriminate between subjects with early glaucoma and healthy subjects, RNFL thickness measured with HRT III and OCT showed a significant difference. In early primary open-angle glaucoma, morphological changes like RNFL thickness seem to occur prior to functional defects in the visual field.