Comparison of the horizontal diameter to a modeled area of traction in eyes with vitreomacular traction: is the diameter close enough to the truth?

PURPOSE: In daily practice, vitreomacular traction (VMT) is described by the horizontal diameter of its attachment site implying a regular round shape of VMT. We investigated the deviation from this circular area of vitreous traction in patients with VMT. METHODS: A retrospective analysis of optical coherence tomography (OCT) scans was performed. The area of vitreomacular attachment was determined using six radial OCT scans (Ameasured). The assumed circular area of traction was calculated based on measuring the maximal horizontal diameter for comparison (Acircular). RESULTS: Thirty-seven eyes of 37 patients with pure VMT were included. Patients' mean age was 72.8 ± 8.2 years. Mean horizontal VMT diameter was 400.8 ± 230.5 µm (median 361 µm; range 44-991 µm). While there was no difference between mean areas of traction for Acircular and Ameasured (P = 0.93), the individual difference (|Acircular - Ameasured|) was 0.042 (± 0.044) mm2 in mean or relative 73.0% (± 135.8%). A difference of ≥ 30% of Ameasured to Acircular was found in 16 eyes (43.2%) and ≥ 100% in 7 eyes (18.9%), respectively. CONCLUSION: Vitreous attachment sites possess an irregular non-circular shape in a significant number of eyes with VMT. Consequently, the area of traction appears inaccurately described by its horizontal VMT diameter alone. As the area of traction is important for therapeutic recommendation, our results emphasize the need for a more precise description of the area of traction in eyes with VMT.

[Good outcome in Acanthamoeba keratitis]. / Akanthamöbenkeratitis mit gutem Outcome.

A 31-year-old woman presented with mild keratitis of her left eye. The use of daily disposable contact lenses, regularly rinsed with tap water, and the development of perineural corneal infiltrates resulted in the clinical suspicion of infection with Acanthamoeba. Corneal epithelial scraping probe for polymerase chain reaction on Acanthamoeba confirmed the clinical diagnosis. Although the treatment was limited to low-dose propamidine monotherapy because of reduced tolerability, the keratitis healed with almost no scarring after 13 months of consequent medication.

[Orbital emphysema with exophthalmos following transconjunctival pars plana vitrectomy]. / Orbitales Emphysem mit Exophthalmus nach transkonjunktivaler Pars-plana-Vitrektomie.

The case example presented shows that an orbital emphysema with exophthalmos can occur as a rare complication of a transconjunctival pars plana vitrectomy. Close monitoring of the patient symptoms, ocular motility, intraocular pressure and the fundus showed no evidence of compressive optic neuropathy or perfusion abnormalities through orbital vessels. The exophthalmos resolved spontaneously within a few days without any consequences.

[Memantine for optic nerve atrophy in Friedreich's Ataxia]. / Memantin bei Optikusatrophie in Friedreich-Ataxie.

A 24-year-old patient with Friedreich's ataxia presented with advanced visual loss due to optic nerve atrophy. After interdisciplinary consultation and after obtaining informed consent, an off-label therapy with the N-methyl-D-aspartate (NMDA) antagonist memantine was initiated. In a 1-year follow-up no further loss of the nerve fiber layer could be detected by optical coherence tomography (OCT) and visual acuity remained stable. Despite the limitations of this single and time limited case observational study, memantine should be discussed as an option for treatment of acute optic nerve atrophy in Friedreich's ataxia.

[Intravitreal fibrinolysis and retinal vein occlusion]. / Intravitreale Fibrinolyse und retinaler Venenverschluss.

BACKGROUND: The aim of this study was to analyze and compare intravitreal activity and concentrations of different components of the fibrinolytic cascade in eyes with central retinal vein occlusion (CRVO) as well as branch RVO (BRVO) and healthy controls. These results were correlated with corresponding intravitreal vascular endothelial growth factor (VEGF) concentrations as a biomarker for the severity of blood-retina barrier (BRB) breakdown. MATERIAL AND METHODS: Vitreous samples were obtained from 14 eyes with CRVO, 22 eyes with BRVO and 11 controls and the activities and concentrations of plasminogen, plasmin-alpha2-antiplasmin (PAP) and VEGF were analyzed. RESULTS: Intravitreal activities and concentrations in the CRVO, BRVO and control groups were 2.07 ± 1.87%, 1.24 ± 1.12% and 0.38 ± 0.63% for functional plasminogen, 8.14 ± 7.07 ng/ml, 6.96 ± 4.8 ng/ml and 9.74 ± 10.98 ng/ml for PAP while respective results for VEG levels were 1269 ± 1318 pg/ml, 528 ± 543 pg/ml and 105 ± 116 pg/ml, respectively. There were significant differences in intravitreal functional plasminogen and VEGF between the groups analyzed (in each case p < 0.001). Intravitreal functional plasminogen correlated with intravitreal VEGF concentrations (r = 0.478, p = 0.001). No adverse events or serious side effects occurred. CONCLUSION: There were significant differences in intravitreal functional plasminogen and VEGF between eyes with CRVO, BRVO and controls. Intravitreal activity of plasminogen was significantly correlated with the severity of BRB breakdown in RVO affected eyes. The knowledge of intravitreal activities and concentrations of different components of the fibrinolytic cascade could offer new therapeutic strategies in RVO-affected eyes in the future.

[Vitreous body and retinal vein occlusion]. / Glaskörperstatus und retinaler Venenverschluss.

PURPOSE: The aim of this study was to evaluate whether the adhesion status of the posterior vitreous cortex (PVC) towards the internal limiting membrane (ILM) has an impact on the development of retinal vein occlusion (RVO). MATERIAL AND METHODS: In a retrospective analysis the operation protocols of 238 eyes receiving pars plana vitrectomy (ppV) and radial optic neurotomy (RON) for central retinal vein occlusion (CRVO) or ppV in combination with arteriovenous sheathotomy (AVS) for branch retinal vein occlusion (BRVO) were evaluated with respect to the intraoperative status of posterior vitreous body adhesion. The results were compared with age-matched healthy controls. RESULTS: In this study 145 eyes (60.9 %) suffering from CRVO and 93 eyes (39.1 %) diagnosed with BRVO were included. In eyes with CRVO and BRVO the posterior vitreous cortex (PVC) was significantly more often attached (126 eyes, 86.9 % and 89 eyes, 95.7 %, respectively) than completely detached (19 eyes, 13.1 % and 4 eyes, 4.3 %, respectively, in each case p < 0.001). In the age groups between 70 and 79 years as well as between 80 and 89 years the PVC was significantly more often attached in both RVO entities in comparison to age-matched healthy controls (CRVO 70-79 years, p = 0.001 and 80-89 years, p = 0.002 and BRVO 70-79 years, p < 0.001, 80-89 years, p = 0.011). In eyes from the age group between 65 and 69 years (of age) the PVC was not significantly more often attached in comparison to healthy controls (CRVO p = 0.334 and BRVO p = 0.114). CONCLUSION: According to these findings posterior vitreous adhesion is an independent risk factor for the development of retinal vein occlusion among patients aged 70 years or older.

[Accidental staining of corneal nerves by methylene blue]. / Akzidentelle Methylenblau-Färbung kornealer Nerven.

A 10-year-old child presented after accidental exposure of the left eye to a blue hair dye containing methylene blue. Mild ocular surface changes and a selective blue staining of the usually invisible corneal nerve fibre bundles were present. Corneal sensitivity was reduced. Despite copious lubrication a transient neurotrophic keratitis developed which did not resolve until corneal sensitivity became normal 2 weeks later. Association of mild chemical burns with neurotrophic keratitis is unusual but is of high clinical relevance as keratitis is a vision-threatening complication.

[Pseudophakic cystoid macular oedema]. / Das pseudophakiebedingte zystoide Makulaödem.

Pseudophakic cystoid macular oedema is still a relevant clinical disease entity although major progress in modern cataract surgery has been made within the last decades. The relevance is attributed to the large number of cases that are performed each year. Even after uneventful surgery, a pseudophakic cystoid macular oedema can develop and may lead to severe and lasting visual impairments. In respect to the pathophysiology, four consecutive steps have to be considered: (i) surgical procedure-related induction and release of various inflammation mediators into the anterior chamber; (ii) removal of the physiological lens barrier between the anterior and posterior segments of the eye, leading consecutively to an increase in diffusion rate in either direction; (iii) local action of the inflammation mediators towards the macular area; and (iv) increased vitreoretinal traction due to the anteriorly oriented drive of the vitreous. To prevent the development of a pseudophakic cystoid macular oedema, systemic and ocular pathologies should be treated consequently prior to surgery. Furthermore, an individual risk profile of each patient needs to be evaluated to define the best pre- and postsurgical medical treatment. A less traumatic surgical approach can help to prevent macular oedema development additionally. The diagnosis is made by performing biomicroscopy, fluorescence angiography and optical coherence tomography as well as by evaluating the patients' major complaints. Standard operation procedures or recommended guidelines by the specialised eye associations to prevent and treat pseudophakic cystoid macular oedema are not available up to date. A synopsis of recommendations in the literature suggests a step-wise treatment regimen, including topical medical treatment on the one hand and a surgical approach on the other hand as well as a combination of both, if needed. Topical medical treatment options include the use of non-steroidal, corticosteroid and/or carbonic anhydrase inhibitor eye drops. Surgical interventions include pars plana vitrectomy.

[Corneal opacity in a contact lens wearer on hemodialysis for renal failure]. / Hornhauttrübungen bei einer Kontaktlinsenträgerin mit hämodialysepflichtiger Niereninsuffizienz.

A 53-year-old contact lens wearer on renal dialysis developed visual impairment due to corneal opacity. The opacity was of a crystalline type and diffusely scattered in the anterior cornea. As oxalosis was suspected ascorbic acid was immediately omitted from the dialysis treatment schedule. Within a few weeks the visual acuity recovered and the corneas became nearly clear. The cornea is an uncommon manifestation site for oxalosis. Nevertheless, one should be aware of this possible sign for oxalosis, which can be a life-threatening complication of treatment with high dose ascorbic acid.

[Subluxation of a retropupillary iris claw lens after cyclophotocoagulation]. / Subluxation einer retropupillaren Irisklauenlinse nach Zyklophotokoagulation.

A 78-year-old patient underwent diode cyclophotocoagulation for end-stage pseudoexfoliation glaucoma after many surgical interventions on the only functional eye. On the first post-operative day the eye showed a mild flare and the intraocular eye pressure was normal. Nevertheless the patient complained of a severe decrease of visual acuity. A subluxation of a retropupillary iris claw intraocular lens within an atrophic area of the iris was found. During surgical revision the iris claw lens was successfully repositioned in the posterior chamber and an enclavation was performed at a different location avoiding atrophic areas of the iris. Fixation of an iris claw lens onto an atrophic iris structure should be avoided. Subluxation of an iris claw lens can occur following an uncomplicated diode laser cyclophotocoagulation operation.

[Restricted eyeball with proptosis]. / "Eingemauerter" Bulbus mit Protrusio.

Orbital cellulitis is an acute inflammation of the orbital content with exophthalmos, chemosis, blepharedema, reduction of eyeball motility and generalized illness, occasionally with fever. It is predominantly transmitted from the ENT region and rarely occurs as a complication after a scleral buckling procedure. The patient concerned contracted orbital cellulitis many years after scleral buckling because the cerclage was infected. Alterations to the sclera with atrophy and thinning in the context of myopia were probably favorable factors for development.

[The role of the vitreous in the pathogenesis of age-related macular degeneration]. / Der Einfluss des Glaskörpers auf die Pathogenese der altersabhängigen Makuladegeneration.

Age-related macular degeneration (AMD) is the main cause of severe visual decease in elderly people in the industrialised countries. AMD is a multifactorial disease with only limited therapeutic options before anti-VEGF treatment was introduced. In spite of all the progress no long-term healing is possible. Actually, the vitreous is being investigated as a possible co-factor in the pathogenesis of AMD. Numerous authors demonstrated a higher incidence of vitreoretinal adhesion in exudative AMD by considering age, genetic and environmental factors. The essential question is whether the therapeutic release of vitreoretinal adhesion could affect the development and progress of AMD. Up to now only case reports and case series have demonstrated a positive effect on disease progress. An ongoing multicentre, prospective, comparative, randomised, double-blind clinical trial with enzymatic vitreolysis is now evaluting the effect of vitreoretinal release on the progress of AMD. The results are necessary to evaluate whether vitreoretinal release is a therapeutic option for the future.

[Different indications of photodynamic therapy in ophthalmology]. / Verschiedene Indikationen der photodynamischen Therapie in der Augenheilkunde.

BACKGROUND: Photodynamic therapy (PDT) in eye disease was approved 10 years ago for age-related macular degeneration (AMD). Thereafter it was approved for choroidal neovascularisation (CNV) in pathological myopia. The treatment regimen is based on two prospective, multicentre trials (TAP and VIP studies). MATERIAL AND METHODS: In the meantime PDT has been successfully used also in several other ocular diseases. PDT is minimally invasive and has an excellent side effect profile. Different diseases and their treatment with PDT are discussed. RESULTS: The treatments of idiopathic CNV, secondary CNV in inflammatory diseases of the retina and choroid, choroidal haemangioma, vasoproliferative tumours, malignant melanoma of the choroid, and central serous chorioretinopathy with PDT are described. In most patients the disease progression can be stopped and in some the PDT treatment results in visual improvement. The prognosis is better in patients with early disease detection and small lesions. CONCLUSION: Several retinal and choroidal diseases can be treated successfully with PDT. Except for AMD and pathological myopia, PDT is an off label treatment.

[Massive subretinal bleeding--treat it or leave it?]. / Massive subretinale Blutung bei AMD am letzten Auge - behandeln oder nicht?

In eyes with massive subretinal haemorrhages, ambulatory vision can be achieved by pars plana vitrectomy and subretinal surgery. In patients with only one functional eye, this treatment is important to preserve the quality of life. The resulting large pigment epithelial defect limits visual rehabilitation. For the same reason, rTPA/gas injection or a macular translocation are possible but not sufficient in these cases.

[Anatomical and functional results after macular hole surgery]. / Anatomische und funktionelle Ergebnisse nach Makulaforamenchirurgie.

BACKGROUND: In a retrospective study we examined the anatomical and functional effects of a combined macular hole surgery with and without the application of indocyanin green (ICG) as well as phacoemulsification. METHODS AND PATIENTS: Out of 91 patients (91 eyes) with idiopatic macular holes 82 eyes were phacic. 25 cases received during the first surgery a combined pars plana vitrectomy with phacoemulsification. In 46 eyes the vitrectomy and consecutive peeling of the inner limiting membrane (ILM) was performed without ICG (Group A), in 45 eyes with ICG-assisted staining of the ILM (Group B). The average follow-up time was 19 months (12 - 24 months). RESULTS: The primary closure rate was 82.4 % and 94.5 % after reoperation. In Group A there were primarily 76 % and at the end 89.1 % closed results compared with 88.9 % and 100 % in group 2 (p = 0.172). Five persisting holes had a preoperative diameter above 600 microm (p = 0.014). Visual acuity improved in Group A preoperatively from 0.17 to postoperatively 0.33 and in Group B from 0.22 to postoperatively 0.38. The difference between both groups was not significant (p = 0.106). From 82 phacic eyes 25 were treated by a combined vitrectomy with phacoemulsification, 23 eyes received later a phacoemulsification while 34 remained phacic. DISCUSSION: Peeling of the ILM was complete after staining with ICG resulting in an increased closure rate. The functional results between both groups did not differ significantly. Phacic eyes may keep their clear lens even after multiple surgeries.

[Incidence of endophthalmitis after intravitreal Avastin injection with and without postoperative topical antibiotic application]. / Endophthalmitisrate mit und ohne topische postoperative antibiotikagabe nach intravitrealer Avastin-injektion.

BACKGROUND: Intravitreal injection of vascular endothelial growth factor inhibitors is safe as a standardized procedure. In a retrospective study, we examined the incidence of intraocular inflammation and endophthalmitis when intravitreal Avastin was given on both an outpatient and an inpatient basis. METHODS AND PATIENTS: Two centers treated a total of 1844 patients with intravitreal Avastin injection (IVA), 1.25 mg/0.05 ml. The medication was given under aseptic conditions with a sterile drape and lid speculum and after an incubation of 5% povidone-iodine for 60 s in the conjunctival fornix. Center A performed all applications as an outpatient procedure with no postoperative topical antibiotics. Center B performed all IVAs prior to a 1-day hospital admission and gave topical antibiotics for 3 days. In both centers the patients were told to return to the hospital immediately if visual disturbance, pain, or redness of the eyes was noticed. RESULTS: Center A did 984 IVAs. Postoperatively no patients had endophthalmitis. On the 2nd postoperative day, two patients developed a mild intraocular uveitis, which was treated with local steroid ointments. Center B did 860 IVAs. Five days after discharge from the hospital, two patients presented with endophthalmitis and underwent vitrectomy when their vision dropped to counting fingers. There was no positive microbiological result of either vitreous probe. CONCLUSIONS: Although equal treatment guidelines were established, the perioperative hospital admission and postoperative application of topical antibiotic ointment could not reduce the occurrence of mild to severe intraocular endophthalmitis.

[Treatment of idiopathic juxtafoveolar retinal telangiectasis with bevacizumab (avastin)]. / Behandlung idiopathischer juxtafoveolärer retinaler Teleangiektasien mit Bevacizumab (Avastin).

BACKGROUND: Idiopathic juxtafoveolar retinal telangiectasis presents areas of occult capillary telangiectasis involving the temporal half of the fovea. Its treatment by laser photocoagulation, photodynamic therapy or intravitreal injection of triamcinolone is unsatisfying concerning visual acuity. Recently it has been demonstrated that intravitreal bevacizumab injection could be successful in the treatment of choroidal neovascularisations secondary to ARMD. The principle of this treatment may be successful for the treatment of idiopathic juxtafoveolar retinal telangiectasis as well. PATIENTS AND METHODS: We report about 3 cases treated with three monthly intravitreal injections of bevacizumab. Fluorescein angiographies and OCT measurements of retinal thickness were performed. RESULTS: The mean increase of VA was 2 visual steps. In two cases an increase of 5 and 1 visual steps, respectively, could be determined, in the other case no increase was found. The mean retinal thickness decreased from 300 microns to 287 microns. CONCLUSIONS: According to our results bevacizumab seems to be less suitable for treatment of idiopathic juxtafoveolar retinal telangiectasis because only a small decrease of retinal thickness can be observed.