[Unusual coloboma of the optic disc?] / Ungewöhnliches Optikuskolobom?

A twelve-year old girl presented herself for a routine ophthalmologic examination in our clinic. Best-corrected visual acuity (BCVA) was 1.0 on both eyes. On funduscopic examination we saw a yellow round structure inferior to the optic nerve head. In optical coherence tomography (OCT) examination the structure showed cupping and opening of the Bruch membrane and retinal pigment epithelium (RPE). Visual field testing revealed an absolute scotoma right in the area were the abnormal coloboma was localized. We diagnosed a pseudo-doubling of the optic disk, which is a rare condition with just a few reports about it in the literature. This finding is harmless and requires no treatment.

[First diagnosis of systemic sclerosis based on ocular complications]. / Erstdiagnosestellung einer systemischen Sklerose anhand okulärer Komplikationen.

BACKGROUND: Systemic sclerosis is a chronic connective tissue disease in which immune system dysfunction alters the structure and function of blood vessels. It is characterized by enhanced tissue fibrosis, which may rapidly affect a large area of the skin as well as internal organs. Dry eye symptoms are the most common ocular findings. CASE REPORT: This case presents a 51-year-old male patient suffering from blurred vision in the left eye. The ophthalmoscopic examination revealed retinal thrombotic microangiopathy in both eyes. Spectral-domain optical coherence tomography (SD OCT) showed a macular edema in the left eye. Although these ocular symptoms do not represent the initial manifestation of the primary disease, correct diagnosis was only made in the context of the retinal findings. CONCLUSION: Retinal microangiopathic lesions can play a seminal role in diagnosing systemic sclerosis.

[Intravitreal methotrexate for treatment of uveitic cystoid macular edema]. / Intravitreales Methotrexat zur Behandlung eines uveitisch bedingten zystoiden Makulaödems.

We present the case of a patient who had several intravitreal methotrexate injections due to a uveitic macular edema and a known steroid response. An earlier off-label therapy with avastin had not been successful. After the intravitreal methotrexate injections a good resorption of the retinal fluid as well as a good intraocular pressure and a good visual acuity could be achieved. Visual acuity was limited by pre-existing glaucomatous optic nerve atrophy and a central scar in the cornea.

[Initial Clinical Experiences Using Ocriplasmin for the Treatment of Vitreomacular Traction with or without a Macular Hole]. / Stellenwert von Ocriplasmin bei der Therapie der vitreomakulären Traktion mit und ohne Makulaforamen ­ erste klinische Erfahrungen.

PURPOSE: In vitreomacular traction (VMT), there is abnormal adhesion between the vitreous cortex and the retina, especially in the fovea. Symptoms of VMT include metamorphopsia and a decrease in visual acuity. Since 2013, ocriplasmin (Jetrea®) has been approved for treatment of symptomatic vitreomacular traction with or without macular holes (≤ 400 µm). METHODS: We retrospectively examined twenty-three eyes of twenty-one patients who underwent intravitreal ocriplasmin treatment for symptomatic vitreomacular traction with or without macular holes. Best corrected visual acuity and central retinal thickness (CRT) were measured in advance and after ocriplasmin treatment. The numbers of resolved vitreomacular traction and closed macular holes were documented. RESULTS: Vitreomacular traction was resolved in eight of twenty-three eyes (34.8 %); in fifteen eyes (65.2 %) it was persistent and two of four macular holes were found closed. The average best corrected visual acuity was 0.39 ± 0.25 logMAR at baseline and 0.41 ± 0.24 logMAR at the first follow-up visit after injection (p = 0.613). The average CRT was 453.3 ± 172.7 µm at baseline, with a slight decrease to 412.0 ± 212 µm (p = 0.124). CONCLUSION: Intravitreal injection of ocriplasmin appears is an experimental therapy in patients with symptomatic vitreomacular traction. Patient selection seems to be critically important for the therapeutic outcome, whereas greater age, specific VMT morphology and missing chromatopsia seem to be negative predictors.

[Methotrexate in Atypical Non-Arteritic Ischemic Optic Neuropathy]. / Methotrexat bei atypischer nicht arteriitischer anteriorer ischämischer Optikusneuropathie.

Background: Optic nerve disease can occur from a variety of different causes, with vascular, inflammatory or toxic pathologies. In such cases, it is hardly possible to clarify the aetiology. These diseases of the optic nerve are usually accompanied by progressive loss of visual field and visual impairment. Patient: We report a case of a 74-year-old woman complaining of loss of visual acuity, visual and blurred vision in the left eye in 2010. We made the diagnosis of non-arteritic ischemic optic neuropathy (NAION). With steroid therapy, there was an improvement in both visual acuity and visual field defects. But if an attempt was made to reduce steroids, her condition progressed. Except for a very small optic disk and arterial hypotension, there were no typical risk factors for NAION. We started treatment with methotrexate (MTX), with a starting dose of 10 mg per week, and observed the patient over two years. Results: Using MTX therapy, the swelling of the optic nerve head and visual field loss were reversible, so we increased the dose of MTX up to 15 mg/week. Steroid therapy could be stopped and the patient's visual acuity and visual field have now been stable for two years. There was no visible pallor in the optic nerve head, as normally occurs after AION, so we considered different underlying pathologies, including autoimmune disease. There were no adverse events with MTX therapy. Conclusion: If the course of the disease is atypical, the pathology may include an autoimmune component. Immunosuppressive MTX therapy may be started in order to avoid long-term steroid use. It may then be possible to maintain a stable visual field and prevent remitting episodes.

[Intravitreal ranibizumab for the treatment of retinal angiomatous proliferation]. / Intravitreales Ranibizumab für die Behandlung von retinalen angiomatösen Proliferationen.

BACKGROUND: Retinal angiomatous proliferations (RAP) are a subgroup of exsudative or "wet" age-related macular degeneration (wAMD) with devastating reduction of visual acuity in later stages. Intravitreal ranibizumab provides good therapy, but is considered to be less effective than in other choroidal neovascularizations (CNV). OBJECTIVE: We investigated the efficacy of ranibizumab in late-stage III RAP with retinochoroidal anastomosis compared to the outcome of other CNV lesions. MATERIALS AND METHODS: The data of all patients with wAMD treated with ranibizumab were retrospectively analyzed. Patients were divided into groups depending on the lesion type into RAP (identified and selected clinically, proven by fluorescein angiography) and CNV lesions (identified by fluorescein angiography only) named occult, minimally and predominantly classic groups. The best-corrected visual acuity (BCVA) was obtained before (at the timepoint "diagnosis"), during (1st, 2nd, and 3rd injection), and after upload ("1st control"). RESULTS: Before first injection, visual acuity decreased in all groups (0.73 to 0.78 logMAR for all CNV, 0.95 to 1.02 logMAR for RAP). During upload there was no further decline in visual acuity but no improvement as well up to the 1st control visit in the RAP group (1.02 to 1.03 logMAR), but a statistically significant increase in all other groups (0.78 to 0.67 logMAR). CONCLUSION: Treatment of late-stage III RAP with ranibizumab is effective. Stabiliziation of visual acuity can be achieved, but-in contrast to other forms of CNV lesions-no further improvement. Therefore, patients with this special form need to be identified and treated as early as possible.

[Effectiveness of Intravitreal Aflibercept Injections in Patients who had Received 10 and More Ranibizumab Injections in Advance]. / Wirksamkeit von Aflibercept bei Patienten mit mehr als 10 vorangegangenen intravitrealen Ranibizumab-Injektionen.

BACKGROUND: Since 2007, the standard treatment for age related macular degeneration has been intravitreal injection of ranibizumab. However, despite continuous treatment, some patients fail to achieve remission or stabilisation of the disease. Since 2012, the recombinant fusion protein aflibercept has been available as an alternative treatment. In this study, we investigated whether patients who appear to be resistant to ranibizumab would benefit from treatment with aflibercept. METHODOLOGY: This retrospective study covered 83 eyes of 81 patients, for whom treatment switch from ranibizumab to aflibercept was indicated. Inclusion criteria were an age ≥ 50 years and at least 10 ranibizumab injections before a switch to aflibercept. Patients with severely impaired visual acuity were excluded. Primary outcomes were improvement or loss of visual acuity (VA) and evaluation of central macular thickness (CMT) via SD-OCT. Secondary endpoints were percentage of eyes without activity of the choroidal neovascular membrane after aflibercept injections and loss or gain of letters on the visual chart. Statistical analysis was performed using SPSS. RESULTS: VA was 0.83 ± 0.34 logMAR before the first aflibercept injection, with a slight but not statistically significant improvement up to 0.79 ± 0.33 logMAR after the third aflibercept injection (p = 0.205). On the other hand, there was a clear reduction of CMT in OCT, from 451.4 ± 263.0 to 288.2 ± 128.2 µm (p = 0.0001). Overall, 73 % of eyes exhibited better or stable VA and 27 % of eyes lost VA. Interestingly, eyes with worse initial VA gained greater benefit from the switch to aflibercept (p = 0.001). CONCLUSION: A switch to aflibercept may lead to stabilisation of choroidal neovascularisation and thus stabilise the visual acuity for patients who appear to be no longer responsive to treatment with ranibizumab.

[Visual impairment due to rare optic nerve tumor]. / Visusabfall bei seltenem Sehnerventumor.

A 49-year-old male patient presented with acute symptoms of reduced vision and relative afferent pupillary defects. Static perimetry testing revealed severe visual field defects and the diagnosis of neuritis of the optic nerve was suspected. A magnetic resonance imaging (MRI) scan was performed and showed an intraocular right-sided semicircular mass around the optic nerve which was partially calcified in computer tomography (CT). The diagnosis of an optic nerve sheath meningioma was made. The visual acuity and visual field defects improved under therapy with prednisolone. Therapeutic options were discussed in an interdisciplinary board but no intervention is planned so far and only regular follow-up controls have been arranged.

[Attitudes and opinions of general practitioners and lung specialists about a new medicines counselling service for asthma patients in community pharmacies: a qualitative study]. / Points de vue des medécins généralists et des pneumologues sur l'entretien d'accompagnement de novuvelle médication pour les patients asthmatiques: une enquête qualitative.

INTRODUCTION: Since October 2013, pharmacists can offer a new medicines counselling service (NMC). to asthma patients, who start a treatment with an inhaled corticosteroid. Although this individualized service can be organized at the request of the general practitioner (GP). the patient or the pharmacist, the uptake remains quite low. The limited involvement of GPs has already been identified as one of the obstacles to the successful implementation of this project. OBJECTIVE: To explore the attitudes and opinions of GPs and pulmonologists about NMC. METHOD: Focus group discussions with GPs were organized during eight meetings of local quality groups in the province of Antwerp, at which a total of 72 physicians were present. Also, five pulmonologists and two GPs with expertise in organization of primary healthcare participated in an interview. RESULTS: A large group of GPs was not aware of the existence of NMC and only a small number of them had experience with it. Nearly all pulmonologists and GPs agreed that repetition of the inhalation technique and follow-up of the adherence are useful. However, there was disagreement about the importance of taking the Asthma Control Test and explaining the pathology by the pharmacist. We could find five barriers that made physicians withhold support for the NMC. The most important obstacle seemed to be that the pharmacist is not obligated to communicate with the physician about the service. In addition, mainly GPs believed that the remuneration is too high and too focused on the number of NMC services performed and that pharmacists enter their domain with delivering this service. Both pulmonologists and GPs were concerned about how the pharmacist will include patients in a NMC, because it isn't always clear what the indication is of the prescribed inhaled corticosteroid. Furthermore, everyone was convinced that the inclusion criteria should be extended, since each patient using inhalation therapy, would benefit from additional support. Finally, some physicians had an objection to the fact that pharmacists are not obliged to follow an additional course before providing the service. CONCLUSION: The opinions of GPs about NMC were mixed and rather critical, while pulmonologists were somewhat more enthusiastic about the initiative. Although all physicians agreed that there is room for improvement of the concept, some GPs are willing to prescribe BNM for certain patients.

[Early treatment of exudative age-related macular degeneration with ranibizumab (Lucentis®): the key to success]. / Frühzeitige Behandlung mit Ranibizumab (Lucentis®) bei exsudativer AMD: Voraussetzung für einen Erfolg.

BACKGROUND: Intravitreal ranibizumab (Lucentis®) is an effective treatment for exudative age-related macular degeneration (AMD). Up to now, settlement for this therapy remains quite complex and is handled differently by insurance companies as well as in the different German states. Often applications must be submitted and approved before an injection can be made. This procedure is time consuming and a delay in starting treatment might result. The aim of this study was to determine the effect of late-onset injection on visual acuity before and during the upload procedure. METHODS: All patients treated with ranibizumab intravitreally between February 2007 and May 2010 were retrospectively evaluated for their best-corrected visual acuity at the day of diagnosis, injections during the upload phase and first follow-up visit after upload. RESULTS: A total of 1,149 eyes were evaluated and divided into 2 groups according to time between diagnosis and first injection (group 1: ≤10 days, group 2: >10 days). There was no statistically significant difference between the groups for average age, gender, visual acuity at day of diagnosis and type of choroidal neovascularisation. However, both groups differed in the loss of visual acuity before the first injection and the possible increase in visual acuity. Group 1 waiting ≤10 days showed - in contrast to group 2 waiting >10 days--a smaller loss of visual acuity before upload and greater gain of visual acuity during upload. Those differences were statistically significant. CONCLUSION: Successful treatment of exudative AMD requires small intervals between diagnosis and first ranibizumab injection. After diagnosis, the first injection with ranibizumab should be given as early as possible.

[Monotherapy of exudative age-related macular degeneration with ranibizumab in patients at cardiovascular risk. Advantages of ranibizumab compared to a combination with pegaptanib]. / Monotherapie der exsudativen altersbedingten Makuladegeneration bei kardiovaskulären Risikopatienten. Vorteile für Ranibizumab gegenüber einer Kombination mit Pegaptanib.

BACKGROUND: Intravitreal ranibizumab (Lucentis®) and pegaptanib (Macugen®) are effective treatment options for exudative age-related macular degeneration (AMD). There might be some differences regarding effectiveness (higher with ranibizumab) and safety issues (presumed to be higher with pegaptanib), which led to the question whether these advantages might be combined. To clarify this question the current study was performed. METHODS: All patients treated for exudative AMD between February 2007 and May 2010 were evaluated for a potential cardiovascular risk profile. Patients with a positive history of coronary heart disease, proven by medical treatment, history of myocardial infarction, stent implantation or bypass operation or a history of stroke were classified as risk patients, while others without such a history were classified as non-risk patients. Risk patients were treated with a combination therapy (first injection: ranibizumab, second and third injections pegaptanib--combination group) when presenting between February 2008 and September 2009 or standard care (first, second and third injections ranibizumab--standard group) during upload. All patients were evaluated for best-corrected visual acuity on the day of diagnosis, injections during the upload phase and first follow-up visit after upload. RESULTS: Both groups did no differ regarding age, gender, subtype of choroidal neovascularization or waiting time between first visit and first injection. Visual acuity changes showed no differences up to the third injection and control visit. Visual acuity continued to improve within the standard group but rapidly declined in the combination group. CONCLUSIONS: Even patients at risk for cardiovascular accidents should not be treated with a combination therapy of ranibizumab and pegaptanib as this combination results in a decline of visual acuity during upload.