[Diagnostics and treatment of ocular toxoplasmosis : Results of a survey]. / Diagnostik und Behandlung der okulären Toxoplasmose : Ergebnisse einer Umfrage.

BACKGROUND: Ocular toxoplasmosis (OT) is the most common infectious cause of posterior uveitis. This survey aimed to evaluate the current diagnostic and therapeutic approach to OT in Germany. MATERIAL AND METHODS: A detailed questionnaire with specific patient examples was sent in July 2021 to the members of the Uveitis Section of the German Ophthalmological Society (DOG) and the Retinological Society (RG). RESULTS: The questionnaire was answered by 53 (29 RG and 24 DOG) ophthalmologists. Of the respondents 16 (30%) work in private practice, 18 (34%) in a clinical facility and 19 (36%) in university hospital, 9 (17%) colleagues see < 50, 28 (53%) 50-200 and 16 (30%) more than 200 uveitis patients per year. The clinical results are still the gold standard (87%) for the diagnosis of OT and in cases of first manifestation 60% are supported by serological antibody investigations, while 10 out of 53 (19%) ophthalmologists rely on the clinical presentation only. An IgM test is requested by 25 (47%) respondents, 6 expected an increase in IgG titer (11%) and 1 the detection of specific IgA antibodies (2%). The majority (n = 28, 53%) of ophthalmologists would aim at confirming the diagnosis by an anterior chamber puncture, from which 20 (38%) prefer PCR, 3 (6%) determination of Goldmann-Witmer coefficients (GW) and 5 (9%) a combination of both methods. Clindamycin was most frequently used for treatment (n = 21, 40%), followed by pyrimethamine/sulfadiazine (n = 17, 32%) and trimethoprime + sulfamethoxazole (TMP/SMX) (n = 10, 19%); the latter was also used (n = 40, 75%) for secondary prophylaxis. CONCLUSION: The results show that apart from the clinical results as the gold standard for the diagnosis, there is no uniform approach to diagnosis and treatment of OT. The high request rate for serum IgM antibodies indicates a widespread uncertainty about the importance of serological findings. This should be viewed critically, given the continued high seroprevalence in Germany.

[Sarcoidosis and uveitis : An update]. / Sarkoidose und Uveitis : Ein Update.

Ocular involvement in sarcoidosis is present in up to one third of patients and is frequently manifested before the underlying systemic disease has been diagnosed. With a view to the therapeutic consequences an early diagnosis of the underlying disease is advantageous. In cases of visual loss early diagnostic measures include invasive procedures, such as ultrasound-guided bronchoalveolar lavage and transbronchial biopsy, if nodular conjunctival or cutaneous manifestations which would confirm the diagnosis are not present. Sufficiently sensitive biomarkers of disease activity have not yet been identified. As elevated activity of angiotensin-converting enzyme (ACE) and lysozyme are associated with disease activity they may be supportive of but not specific for the diagnosis. Other indicators include calcemia, calciuria, augmented activity of hepatic enzymes, cutaneous anergy and hilar changes in the lungs. In patients with newly diagnosed anterior uveitis presenting with granulomatous mutton-fat corneal precipitates, snow balls and vitreous body base condensates with mild retinal periphlebitis in intermediate uveitis as well as multifocal choroiditis (creamy choroidal lesions at different stages of activity and approximately 500 µm in diameter), a diagnosis of sarcoidosis has to be considered and tuberculosis should be excluded, even in the absence of a known systemic disease. Anterior uveitis is frequently a self-limiting condition, which can be well-controlled with topical steroids. On the other hand, intermediate, posterior and panuveitis are typically associated with a chronic course and require systemic therapy to prevent severe loss of vision. If the response to systemic corticosteroids is insufficient, treatment with immunomodulatory agents and biologics is initiated at progressively earlier stages, with a view to averting permanent organ damage and frequently with a positive impact on the short and long-term outcomes, even in therapy-refractive cases.

[Atrophy of the macula in the context of its wet, age-related degeneration : An inescapable consequence of anti-VEGF therapy?] / Makula-Atrophie bei feuchter altersabhängiger Makuladegeneration : Unausweichliche Folge der anti-VEGF-Therapie ?

BACKGROUND: Current understanding of the mechanisms that underlie the long-term consequences of anti-VEGF therapy in wet, age-related macular degeneration (AMD) is poor. Here, the impact of this treatment on the development of macular atrophy (MA) is discussed based on our current pathophysiological understanding. METHODS: This review is based on a PubMed literature survey using the MeSH terms "wet AMD" and "macular atrophy" (151 hits) and limited to publications since 2013 (n = 90). Publications focussing on diagnostics and clinical course not in the context of therapy were excluded. Macular atrophy is defined herein as atrophy affecting the functionally relevant complex of photoreceptors, retinal pigmented epithelium (RPE), Bruch's membrane and choriocapillaris. RESULTS: Experimentally, a primary complete suppression of local VEGF leads to evident changes in the choriocapillaris, whereas its incomplete suppression exacerbates cell death of RPE and photoreceptors. Since pre-existing atrophic changes are already present at diagnosis, the role of anti-VEGF treatment cannot be separated from the spontaneous progression of AMD. The progression of MA appears to be faster under ranibizumab than bevacizumab, and likewise on a monthly rather than as-needed basis. Although MA progresses more rapidly under consequent therapy, visual function remains better. Hence, a functionally relevant progression of atrophy during the first five years of treatment would only be expected in pre-existing advanced MA. CONCLUSIONS: Despite doubts regarding the long-term safety of anti-VEGF therapy, it is the author's view that this is the only option to stabilise visual function. The impact of therapy-induced damage on the spontaneous progression of AMD and the biological status of the aging individual cannot be unequivocally assessed.

Ocular Toxoplasmosis: an Update.

INTRODUCTION: Although the seroprevalence of toxoplasmosis has undergone a progressive 50 % decline during the past 20 years, the disease remains an economically important health hazard in many countries. Ocular toxoplasmosis (OT) is the most frequent cause of infectious posterior uveitis, and new insights into its pathophysiology have paved the way for new therapeutic strategies. METHODS: This review summarises recent insights into the disease, its clinical manifestations and therapeutic options. The data have been gleaned from a PubMed search, which was conducted in August 2015 using the key term "ocular toxoplasmosis". RESULTS: A laboratory confirmation of the diagnosis serves as the basis for estimating the clinical burden of OT. This is more severe in South America than in Europe, due to the higher incidence of the more virulent New World parasitic strains. It is not yet possible to differentiate between acquired and congenital cases in most patients. However, in elderly individuals, clinical manifestations of acquired OT are more frequently encountered and in atypical forms. Although inflammation may initially be more pronounced in acquired than in congenital cases of OT, the final visual acuity is usually better and the risk of recurrence lower. Amongst the numerous therapeutic options, none is clearly superior. In immunocompromised individuals and in those with frequent recurrences, prophylactic measures should be considered. CONCLUSION: OT is still a potentially vision-threatening affection, namely in elderly individuals with acquired disease and in those patients harbouring the more aggressive New World strains of the parasite. Owing to the limitations in diagnostic sensitivity and therapeutic efficacy, treatment strategies have to be tailored to the individual needs.

Update on regional anaesthesia in intraocular surgery.

BACKGROUND: Retrobulbar anaesthesia is a valuable alternative not only for polymorbid and haemodynamically compromised patients. Complications are rare but may be devastating. METHODS: Principally, any intraocular surgery can be made under local anaesthesia. There are only a few contraindications to regional anaesthesia such as denial against regional anaesthesia, allergy to local anaesthetics, local infection, severe orthopnea, insufficiently controlled psychiatric disorders or small children and non-cooperative patients. RESULTS: The success rate of retrobulbar anaesthesia in terms of control of intraoperative discomfort approaches 100% with an intraconal injection in 94% and a distribution of fluid into the intraconal space in 97%. CONCLUSION: Based on the recent literature, the present review compares techniques, describes possible complications and in the absence of evidence-based studies provides suggestions for the handling of patients under thrombocyte aggregation inhibitor and vitamin K antagonist therapy and anticoagulation.

[Differential diagnosis in infectious posterior uveitis]. / Differenzialdiagnose der infektiösen posterioren Uveitis.

Infectious aetiologies represent the largest entity in patients affected by posterior uveitis. As a single diagnosis, ocular toxoplasmosis ist the most frequently diagnosed infectious entity, wheres Behçet's uveitis represents the most frequently encountered immunologic aetiology. In acute posterior uveitis, an exact clinical diagnosis is sometimes prohibited by a dense vitreal infiltration. In this situation, the clinical course and progression of the disease may help in the differential diagnosis. Rapidly progressive instances such as viral retinal necrosis may be differentiated from cases of ocular toxoplasmosis and Behçet's disease, which tend to present in the office within one to two weeks of symptoms, and from other more slowly progressive diseases such as mycotic or nematode infections. The clinical picture at presentation is influenced by the duration of disease, underlying systemic conditions, and by the natural course of disease including the healing process and scare formation. Generally, visual function has to be assumed at risk, if a lesion is located close to the macula, if frequent recurrences increase the likelihood of macular involvement and, furthermore, if secondary complications affect the macula, e. g., macular oedema. In paediatric cases, the risk of amblyopia is frequently under-estimated, namely in the context of persistent dense vitreal infiltration. Therefore, a rapid interdisciplinary clinically tailored diagnostic access has to be reinforced in order to establish an early, targeted and etiologically based therapeutic strategy including steroid-sparing immunomodulating agents and possibly surgical alternatives.

[Diabetic maculopathy and retinopathy. Functional and sociomedical significance]. / Diabetische Makulopathie und Retinopathie. Funktionelle und sozialmedizinische Bedeutung.

OBJECTIVE: The incidence of diabetic microvascular complications is expected to increase by 20-50% in the coming years. Diabetic macular edema (DME) is already a leading cause of blindness in the working-age population in developed countries, and its impact is expected to increase dramatically. METHODS: Recent literature on the epidemiology and impact of diabetic microangiopathy (maculopathy) on visual function was reviewed to provide a comprehensive overview of the functional and socioeconomic consequences of diabetic retinal microangiopathy and new therapeutic strategies. RESULTS: The first changes indicating diabetic microangiopathy are detectable shortly after the development of hyperglycemia, and in the long term they induce severe organ damage. More resources are used for this condition's treatment than for the treatment of hyperglycemia, corresponding to an enormous sociomedical burden of disease. Early detection of increased retinal vascular permeability may help control treatment effects. The control of recognized risk factors for the development and progression of DME, namely hyperglycemia and hyperlipidemia, as well as of hypertension has remained the cornerstone of therapy and serves as the basis for preserving visual function. CONCLUSIONS: Modern treatment options, begun early, may result in a remarkably delayed occurrence of irreversible diabetic microvascular pathologies, particularly diabetic retinopathy and maculopathy. Ophthalmological screening nowadays aims at earlier recognition of at-risk individuals to optimize the therapeutic strategy--that is, before visual impairment is imminent. Close interdisciplinary medical cooperation and implementation of new therapeutic options may provide the foundation for success in terms of maintaining visual function.

Secondary intraocular lenses in eyes with aphakia or dislocated IOL: impact of suture fixation on early and late complications.

BACKGROUND: Secondary intraocular lens (IOL) implantation is exposed to an increased risk of complications, including endophthalmitis and retinal detachment. The present analysis compares the outcomes and complications experienced in our own series of patients. PATIENTS AND METHODS: We retrospectively reviewed a consecutive series of secondary posterior chamber IOL implantations performed in a single centre, two surgeon setting over a period of 8 years and with a follow up-time of at least 4 months. RESULTS: Between 1997 and 2005, 75 patients received a sulcus-supported secondary IOL without suture fixation, whereas suture fixation was required in 137 instances. Visual acuity improved in both groups (group 1: from 0.36 +/- 0.39 (0.01-1.2) to 0.73 +/- 0.33 (0.02-1.0; p = 0.18); group 2: from 0.33 +/- 0.34 (0.02-1.0) to 0.46 +/- 0.33 (0.01-1.0; p = 0.006), but more pronounced in eyes not requiring suture fixation (p = 0.012). IOL placement was more likely to be combined with endophacoemulsification in the not suture-fixed IOLs (12.7 vs. 5.3 %). In contrast, retinal tears (10.6 vs. 8.6 %, respectively) and retinal detachment (5.3 vs. 2.2 %, respectively) were equally distributed. In the early postoperative phase, IOP was lower in suture-fixed eyes, which showed a higher incidence of minor intraocular haemorrhages and cystoid macular edema (5.3 vs. 8.0 %); late complications up to 5 years postoperatively were equally distributed. CONCLUSION: A preoperatively less complicated anterior segment situation and a lower incidence of postoperative macular edema may account for a better visual outcome after placement of a sulcus supported IOLs without suturing. If required, suture fixation may be performed without exposing the eye to an increased risk of late postoperative complications.

Recurrence characteristics in European patients with ocular toxoplasmosis.

BACKGROUND: The risk of function loss after each episode of ocular toxoplasmosis (OT) supports efforts to improve our understanding of the disease. PATIENTS AND METHODS: 139 patients with OT were contacted retrospectively and requested to complete a questionnaire addressing course and activity of their disease. This information was compared with that retrieved from their medical records. Sixty-three patients completed the questionnaire and were included in the study. They were allocated according to their median age to one of two groups (group 1: <20.9 years; group 2: >or=20.9 years). RESULTS: The mean reported age at the time of first ocular manifestation was 23.9 (median 20.9, range 0 to 70.5; SD 12.9) years. The clinical diagnosis was made 3.5 years later (p = 0.0008). The follow-up time was 6.5 (median 5.0; range 0.5 to 49.9; SD 7.6) years. The recurrence rate was higher in patients below 20.9 years (66%; n = 35) than in older patients (39%; n = 28; chi(2) test, p<0.05). Patients reporting only one episode were older at first manifestation (29.6 (median 25.6; range 10.6 to 70.5; SD 14.3) years; n = 29) than those reporting two episodes (17.9 (median 19.5; range 5.9 to 33.9; SD 7.8) years; n = 15 (p<0.05)). The proportion of patients who developed a recurrence was 54-63% after each episode without a tendency to enlarge, and the interval between successive episodes remained stable between 1.0 and 1.7 years for the first three recurrences. CONCLUSION: Younger OT patients carry a higher risk of developing a recurrence than older ones. After each episode, two-thirds of all OT patients will develop another one.

Recovery of visual field and acuity after removal of epiretinal and inner limiting membranes.

BACKGROUND: Visual acuity serves as only a rough gauge of macular function. The aim therefore was to ascertain whether central an assessment of the central visual field afforded a closer insight into visual function after removal of epiretinal membranes and Infracyanine-Green- or Trypan-Blue-assisted peeling of the inner limiting membrane. PATIENTS AND METHODS: Fourty-three patients undergoing pars-plana vitrectomy for the removal of epimacular membranes and dye-assisted peeling of the inner limiting membrane using either Infracyanine Green (n = 29; group 1) or Trypan Blue (n = 14; group 2) were monitored prospectively for 12 months. Preoperatively, and 1, 6 and 12 months postoperatively, distance and reading visual acuities were evaluated; the central visual field was assessed by automated static perimetry. RESULTS: Twelve months after surgery, distance and reading visual acuities had improved in both groups, but to a significant degree only in Trypan-Blue-treated eyes. The difference between the two groups was not significant. Likewise at this juncture, the mean size of the visual-field defect remained unchanged in Trypan-Blue-treated eyes (preoperative: 4.3 (SD 2.1) dB; 12 months: 4.0 (2.1) dB (p = 0.15)), but had increased in Infracyanine-Green-treated ones (from 5.3 (3.7) dB to 8.0 (5.2) dB (p = 0.027)). CONCLUSION: Unlike visual acuity, the central visual field had deteriorated in Infracyanine-Green-treated eyes but not in Trypan-Blue-treated eyes 12 months after surgery. Hence, as a predictor of functional outcome, testing of the central visual field may be a more sensitive gauge than visual acuity. Furthermore, Infracyanine Green may have a chronic and potentially clinically relevant effect on the macula which is not reflected in the visual acuity.

Influence of intraocular lens material on the development of acute endophthalmitis after cataract surgery?

PURPOSE: To investigate the causal relationship between acute postoperative endophthalmitis (POE) after cataract surgery and the biomaterial properties of the intraocular lens (IOLs) implanted. METHODS: This retrospective cohort study included all patients who had undergone cataract surgery with IOL implantation at the Lyon Croix-Rousse University Hospital between 1st January 1994 and 31st December 2004. Details respecting the type of IOL implanted (material and manufacturer) were meticulously recorded. The number of patients presenting with POE within 6 weeks of cataract surgery was documented together with their medical characteristics. These data were then compared, and Fisher's exact test was used to establish the significance of any apparent associations. RESULTS: Eight of the 5837 eyes manifested acute POE (0.14%). Seven of these were composed of polymethylmethacrylate (PMMA) and one of heparinized PMMA. Patients with PMMA IOLs carried a higher risk of developing POE than did those implanted with either heparinized PMMA (P=0.001), hydrophilic acrylic, or hydrophobic acrylic IOLs (P=0.002). CONCLUSIONS: The incidence of acute POE after cataract surgery in our hospital is similar to that currently reported for other institutions in developed countries. Our results add further evidence that IOL material and type are factors contributing to the risk to develop an acute POE after cataract surgery, and that PMMA IOLs may be associated with an increased risk of POE.

[Ocular toxoplasmosis and toxocariasis in childhood]. / Okuläre Toxoplasmose und Toxocariasis im Kindesalter.

Toxoplasmosis and toxocariasis are parasitic infections that are transmitted by cats and dogs, respectively, to humans, and which may induce posterior uveitis already in childhood. Toxoplasmosis presents as a congenitally or postnatally contracted infection whereas toxocariasis is always an acquired disease. The typical ocular sign of toxoplasmosis is retinochoroiditis, occurring as an active lesion, in most instances, associated with an inactive pigmented scar. In contrast, toxocariasis leads to a choroidal granuloma secondarily involving the retina or an endophthalmitis-like picture. Although toxoplasmosis represents the most common cause of posterior uveitis, there are uncertainties regarding the timing and specificity of the diagnosis, namely in atypical cases and those at risk of permanent severe loss of function. Antiparasitic treatment should be tailored to the severity of the inflammation and the risk of visual function loss. Concomitant steroids may be used to control the sequelae of unspecific inflammation, but should be used with caution and must be combined with an antimicrobial regimen. Because it is a rare disorder, one may not be familiar with the clinical presentation and suggested therapy for ocular toxocariasis. With this survey we, therefore, wish to provide a current, practice-oriented overview on the infection, ocular manifestations, diagnosis and treatment of ocular toxoplasmosis and toxocariasis in childhood.

[Update on vitrectomy for pediatric uveitis]. / Vitrektomie bei Uveitis im Kindes- und Jugendalter.

PURPOSE: The role of vitrectomy in pediatric uveitis has as yet not been established. Addressing this question has been reinforced since the recent introduction of the new and relatively well tolerated medical treatment options using biologicals, i. e. TNFalpha blocking agents. METHODS: A systematic review of literature has been supplemented by results of vitrectomy performed in 41 consecutive eyes of 33 children and adolescents at our institution and followed for 0.5 to 10 years. RESULTS: No single controlled study on the role of vitrectomy for uveitis has been identified. Beyond a total of 44 case series including 1762 eyes within the last 25 years, 3 papers specifically focussed on vitrectomy for pediatric uveitis including 73 eyes. This series included 29 eyes of our series. Published and recent own data indicate 2 specific findings consistent for all series: reduction of CME presence from 36 to 6.9% with a resulting visual improvement in 79.1% of cases and a quietening down of inflammatory activity postoperatively allowing to taper down or stop steroid and immunosuppressive therapy from preoperatively 80 and 30% to approximately 30 and 10%, respectively. CONCLUSION: In the absence of evidence-based results, the data from case series indicate that vitrectomy for pediatric uveitis at least meets the expectations from vitrectomy in adult forms of uveitis regarding the reduction of cystoid macular edema and required systemic steroid and immunosuppressive therapies.

[Options and strategy for the treatment of chronic endogenous uveitis]. / Zur Behandlungsstrategie bei chronischer endogener Uveitis.

PURPOSE: The treatment of chronic endogenous uveitis has included the use of local and systemic corticosteroids since the early 1950 s, and these still constitute the first-line option in the treatment, once an infectious aetiology has been excluded. METHODS: Since the 1960 s, broad experience has been collected with antiproliferative and alkylating agents, and since the 1980 s several immunosuppressants have been employed in the therapy for endogenous uveitis. It has been recognised that the therapeutic response is not only related to a specific uveitic entity, but also to the genetic background of the individual. RESULTS: Therefore, no clear guide lines for therapy exist and, for most of the drugs, controlled studies are not available. Vitrectomy and intravitreal drug delivery have been added as local options on top or in case of failure of systemic therapies. The advent of biological agents, however, i. e. the introduction of interferon alpha and TNF alpha blocking agents, has opened a new era in the treatment of immunogenetic and autoimmune disorders. CONCLUSION: Evidence-based knowledge and personal experience have been reviewed to provide an update on the therapeutic strategy for chronic endogenous uveitis. The newly introduced biologicals seem to represent an interesting addition to the existing therapeutic options. Informations pertaining to efficacy and side effects of a long-term treatment of uveitis are, nevertheless, as yet not available.

The diagnostic yield of vitrectomy specimen analysis in chronic idiopathic endogenous uveitis.

PURPOSE: The low diagnostic yield of vitrectomy specimen analysis in chronic idiopathic uveitis (CIU) has been related to the complex nature of the underlying disease and to methodologic and tissue immanent factors in older studies. In an attempt to evaluate the impact of recently acquired analytic methods, the authors assessed the current diagnostic yield in CIU. METHODS: Retrospective analysis of consecutive vitrectomy specimens from patients with chronic endogenous uveitis (n = 56) in whom extensive systemic workup had not revealed a specific diagnosis (idiopathic) and medical treatment had not resulted in a satisfying clinical situation. Patients with acute postoperative endophthalmitis served a basis for methodologic comparison (Group 2; n = 21). RESULTS: In CIU, a specific diagnosis provided in 17.9% and a specific diagnosis excluded in 21.4%. In 60.7% the laboratory investigations were inconclusive. In postoperative endophthalmitis, microbiological culture established the infectious agent in 47.6%. In six of eight randomly selected cases, eubacterial PCR identified bacterial DNA confirming the culture results in three, remaining negative in two with a positive culture and being positive in three no growth specimens. A double negative result never occurred, suggesting a very high detection rate, when both tests were applied. CONCLUSIONS: The diagnostic yield of vitrectomy specimen analysis has not been improved by currently routinely applied methods in recent years in contrast to the significantly improved sensitivity of combined standardized culture and PCR analysis in endophthalmitis. Consequently, the low diagnostic yield in CIU has to be attributed to insufficient understanding of the underlying pathophysiologic mechanisms.

PVR recurrence and the timing of silicon oil removal.

BACKGROUND: Following vitrectomy for PVR-associated retinal detachment, placement of an encircling band, filling with silicone oil (SO) and successful retinal reattachment, a recurrence of PVR can develop. Retinal redetachment after SO removal is usually due to secondary or residual PVR. We wanted to ascertain whether the anatomical and functional outcomes of surgery in patients with a reattached retina and recurrent PVR can be improved by delaying the removal of SO. PATIENTS AND METHODS: 112 consecutive patients with PVR-associated retinal detachment who had undergone vitrectomy with SO filling, were monitored for at least 6 months after SO removal. Prior to SO removal, the retina posterior to the encircling band had to be completely reattached. Patients who developed PVR after SO filling were divided into two groups according to the duration of SO retention: 12 - 18 months (group 2: n = 48); > 18 months (group 3: n = 21). Individuals without PVR recurrence after SO filling and in whom the SO was consequently removed within 4 - 12 months served as control (group 1: n = 43). Anatomical success, intraocular pressure (IOP) and best-corrected visual acuity (BCVA) served as the primary clinical outcome parameters. RESULTS: Six months after SO removal, the anatomical success rates (86.3 %, 88.8 % and 84.6 %, in groups 1, 2 and 3, respectively; log rank = 0.794) and the BCVAs (p = 0.861) were comparable in the three groups. Mean IOP (p = 0.766), and the frequency of complications such as PVR recurrence (p = 0.936), bullous keratopathy (p = 0.981) and macular pucker (p = 0.943) were likewise similar. Patients in whom SO was retained for more than 18 months had the highest IOPs and required the heaviest dosage with anti-glaucoma drugs. CONCLUSIONS: In patients who develop a recurrence of PVR after vitrectomy and SO filling the surgeon can observe and treat retinal changes for up to 18 months without impairing the anatomical and functional outcomes. The retention of SO for more than 18 months does not improve the anatomical outcome. However, it can impair the functional outcome by precipitating the development of a persisting secondary glaucoma.

Morphometric assessment of normal, suspect and glaucomatous optic discs with Stratus OCT and HRT II.

AIMS: To compare morphometric parameters and diagnostic performance of the new Stratus Optical Coherence Tomograph (OCT) Disc mode and the Heidelberg Retina Tomograph (HRT); to evaluate OCT's accuracy in determining optic nerve head (ONH) borders. METHODS: Controls and patients with ocular hypertension, glaucoma-like discs, and glaucoma were imaged with OCT Disc mode, HRT II, and colour disc photography (DISC-PHOT). In a separate session, automatically depicted ONH shape and size in OCT were compared with DISC-PHOT, and disc borders adjusted manually where required. In a masked fashion, all print-outs and photographs were studied and discs classified as normal, borderline, and abnormal. The Cohen kappa method was then applied to test for agreement of classification. Bland-Altman analysis was used for comparison of disc measures. RESULTS: In all, 49 eyes were evaluated. Automated disc margin recognition failed in 53%. Misplaced margin points were more frequently found in myopic eyes, but only 31/187 were located in an area of peripapillary atrophy. Agreement of OCT with photography-based diagnosis was excellent in normally looking ONHs, but moderate in discs with large cups, where HRT performed better. OCT values were consistently larger than HRT values for disc and cup area. Compared with HRT, small rim areas and volumes tended to be minimized by OCT, and larger ones to be magnified. CONCLUSIONS: Stratus OCT Disc protocol performed overall well in differentiating between normal and glaucomatous ONHs. However, failure of disc border recognition was frequently observed, making manual correction necessary. ONH measures cannot be directly compared between HRT and OCT.

Vitrectomy for juvenile uveitis: prognostic factors for the long-term functional outcome.

PURPOSE: This study evaluated the long-term effect of pars plana vitrectomy (PPV) in children and adolescents with chronic uveitis on visual function, anatomical outcome, and the requirement of systemic treatment. Further, predictive preoperative factors associated with a beneficial visual outcome were assessed. METHODS: Retrospective review of 29 eyes of 23 consecutive paediatric and juvenile patients below 20 years of age with chronic uveitis who underwent a PPV for visually significant opacities in 25 eyes, vitreous haemorrhage in three eyes, and retinal detachment in one eye. The clinical diagnosis was chronic intermediate uveitis in 22 eyes and retinal vasculitis of different origin in seven eyes. RESULTS: LogMAR visual acuity improved from an average of 0.91 to 0.33 (P<0.001). Cystoid macular oedema (CME) was significantly reduced in eight of 10 eyes postoperatively (P=0.021). In the multiple regression analysis, a low preoperative logMAR visual acuity and the presence of a CME had a negative influence on the final logMAR visual acuity. Furthermore, the appearance of chronic uveitis relapses was significantly reduced from 15 eyes before to seven eyes after surgery (P=0.042). CONCLUSIONS: PPV has a beneficial effect on the course and the complications of chronic uveitis in paediatric and juvenile patients with respect to the anatomical and visual outcome. Preoperative logMAR visual acuity and clinically significant CME were the most accurate predictors for the functional outcome.

[Congenital ocular toxoplasmosis--ocular manifestations and prognosis after early diagnosis of infection]. / Kongenitale okuläre Toxoplasmose -- Okuläre Manifestationen und Verlauf nach Frühdiagnostik der Infektion.

BACKGROUND: Congenital toxoplasmosis (CT) is the most frequently encountered congenital infection. The aim of the present review is to report about the long-term outcome of functional and morphological manifestations after an early confirmation of the diagnosis. PATIENTS AND METHODS: We report on a cohort of patients with serologically confirmed CT, born between 1988 and 2001, who were followed up prospectively at a single centre (Institute of Parasitology, Hôpital de la Croix Rousse, University of Lyon). All patients underwent regular ophthalmological, parasitological and paediatric controls on a half-yearly or annual basis. Ocular manifestations were documented and visual acuity was assessed as far as was possible. RESULTS: 1,506 seroconversions were diagnosed during pregnancy, and 327 of the live-born offspring were seropositive for CT. At the end of the study period, ocular manifestations occurred in 79 of the children (24 %), and in 7 cases (9 %) they were discovered during the first month of life. In 72 of the patients (91 %), the ocular manifestations developed between 1 and 151 months (median follow-up time: 6.3 +/- 3.7 years; range: 0.5 - 14 years) under medical treatment for the first year of life. At the end of the study period, information regarding visual acuity was available for 66 patients. In 55 of these (83 %), visual acuity was normal in both eyes, and in 11 (17 %), it was reduced below 0.5. In 1 child, both eyes were functionally affected, one severely. CONCLUSION: CT may not become manifest ocularly until after a decade, which underlines the necessity for long-term ophthalmological monitoring of the infected individuals. In our patients, the prognostic outcome after therapy for the first year of life was better than that reported in the literature. This favourable outcome may serve as a basis for patient counselling.