[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.

[Choroidal Neovascularisation Other than Typical Neovascular Age-Related Macular Degeneration]. / Sonderformen choroidaler Neovaskularisationsmembranen.

Choroidal neovascularisation (CNV) in the context of exsudative age-related macular degeneration (nAMD) can be divided into type 1 (occult) and type 2 (classical) membranes. Retinal angiomatous proliferation (RAP) or polypoidal choroidal vasculopathy (PCV) are "rare subtypes" of chorioretinal neovascularisation and are distinguished by their distinct morphology and the sometimes worse response to therapy. Chorioretinal anastomosis, severe exsudates with serosanguinous pigment epithelial detachment and, in PCV, orange-red lesions in the papillomacular bundle can be diagnostic. Indocyanine green angiography (ICGA) is considered the gold standard for diagnosis of PCV and delivers important information for RAP too. Typical characteristics of PCV include foci of hyperfluoresence, with pulsatile filling in the early phase. This characterises choroidal polypoidal lesions, often in connection with an abnormal choroidal vascular network. In RAP, typical retino-retinal anastomosis can be identified, in particular in areas with pigment epithelial detachment. Optical coherence tomography (OCT) can complement diagnostic testing. In cases of RAP, early therapy initiation with intravitreal anti-VEGF is crucial for the prognosis of visual acuity. PCV can exhibit spontaneous regression. In active disease, photodynamic therapy (PDT) is efficient in the closure of PCV polyps. In association with CNV, it makes sense to combine PDT and intravitreal anti-VEGF medication. In spite of the initial increase in visual acuity, this state is normally "only" stabilised in the long term. In patients with idiopathic secondary CNV membranes (high myopia, post-inflammatory, post-traumatic changes or in hereditary connective tissue diseases), small "classical" type 2 membranes are mostly involved. Hence, these are strictly speaking not directly rare subtypes. Nevertheless, these patients are mostly younger, with less protracted illness and limited available regeneration ability of the retinal pigment epithelium (RPE): they may therefore differ favourably from the courses with nAMD, with earlier inactivation and with fewer required anti-VEGF injections. CNV with angioid streaks are a special case in this group. Unfortunately, these lesions have a recurrent, protracted and, in the end, mostly frustrating course.

[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.

Serum and Plasma Levels of Vascular Endothelial Growth Factors in Relation to Quality of Glucose Control, Biomarkers of Inflammation, and Diabetic Nephropathy.

Levels of vascular endothelial growth factors (VEGF) are regulated in a complex network of adipokines, glucose control, and low grade inflammation together with activated platelets, leucocytes, and endothelial dysfunction. Increased levels of VEGF are associated with enhanced angiogenesis and impaired repair mechanisms of vascular lesions in endorgans. Little is known about the interaction of systemic VEGF levels with quality of diabetes control, biomarkers of inflammation, and diabetic nephropathy. Moreover, it is unclear, whether serum and plasma VEGF levels are similarly suited to reflect risk associated with VEGF.In this case control study, we analyzed these parameters in serum and plasma of age and sex matched controls without diabetes (n=99) and type 2 diabetes (n=302). Serum VEGF-A was significantly increased in patients with T2DM while plasma levels were in the same range as for controls. Individual levels varied in a wide range. Serum levels were 4.9 times higher in controls and 7.3 times higher in T2DM as compared to plasma levels. T2DM was associated with significantly higher levels of hsCRP, ALAT, and albumin/creatinine ratio. When calculated for tertiles of HbA1c, we observed a highly significant increase from tertile one to the upper tertile for serum VEGF-A but not for plasma VEGF-A. Correlation analysis revealed a significant relationship between VEGF-A, HbA1c, inflammation, and diabetic nephropathy. Our results indicate that increased VEGF-A levels in T2DM significantly depend on quality of HbA1c control. Serum levels of VEGF-A, with a strong contribution of platelet derived VEGF, better reflect the glycemic burden than plasma levels of VEGF-A. Mechanistic studies are needed to explore links to inflammation and diabetic nephropathy.

[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.

[Gingival hyperplasia and visual reduction]. / Zahnfleischschwellung und Visusreduktion.

This case report describes the unilateral acute reduction of vision in the right eye of a 48-year-old woman. The patient was otherwise healthy but 2 days previously had suffered from dizziness and blurred vision. Secondary to this, the patient had already been under dental treatment for 1 week due to gingival swelling. At the first examination a macular branch retinal vein occlusion and Roth spots were found in the right eye by indirect ophthalmoscopy. The immediate diagnostic procedure identified aute amyeloid leukemia (AML) as the cause of the vascular pathology. The AML can be manifested in different ways and the retina is involved in approximately 50% of cases. Due to a secondary hyperviscosity syndrome, which is found in approx. 20% of acute leukaemias, symptomatic central vein occlusion or macular branch vein occlusion can occur. Ophthalmic symptoms can be the first and only signs to be detected. Therefore, ophthalmologists should also consider a systemic disease and initiate a clarification. A differential blood count is indispensable. The results usually improve by a rapidly arranged and suitable therapy. Ophthalmological follow-up examinations are imperative as an initiated chemotherapy can also produce ophthalmological side-effects.

[Maculopathy with subretinal yellow deposits]. / Makulopathie mit subretinalen, gelblichen Ablagerungen.

We present the case of a 52-year-old female patient who presented with bilateral loss of vision over the course of several years. Funduscopy revealed multiple drusen in a "honeycomb"-like configuration at the entire posterior pole and in the peripapillary region. Autofluorescence and fluorescence angiography (FLA) showed multiple hyperfluorescent defects which show no leakage due to staining of the drusen-like lesions. Optical coherence tomography (OCT) revealed a marked irregularity of the photoreceptor-retinal pigment epithelium complex. Electroretinography (ERG) was without pathological findings, while the electrooculography (EOG) was abnormal, reflecting a functional disturbance of the retinal pigment epithelium. In consideration of all clinical findings, our patient suffered from Doyne honeycomb retinal dystrophy (DHRD) which is a rare autosomal dominant inherited retinal disease with full penetrance. Patients with DHRD are usually asymptomatic until the age of 30-40 years. In the later stages of this disease, central vision deteriorates as a result of geographic atrophy or choroidal neovascularization.

[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.

[Siderosis bulbi after injury by an intraocular metal foreign body]. / Siderosis bulbi nach intraokularem Metallfremdkörper.

We report the case of a 42-year-old patient who presented with unilateral loss of vision in the left eye. The clinical examination revealed retinal detachment and a low intraocular pressure was found in the left eye. Except for an extinct electroretinogram (ERG) and a siderosis bulbi in the left eye no signs of an intraocular body were detectable, either in the ultrasound B-scan or in the clinical examination. Pars plana vitrectomy with silicon oil tamponade was performed and revealed an iron-containing body next to the fovea which was removed without any complications. Despite an initially easily visible retinal detachment, a newly acquired siderosis bulbi in combination with ocular trauma in the clinical history should raise the suspicion of a residual intraocular iron foreign body, until this can be disproven.

[Applanation tonometry in "normal" patients and patients after LASIK]. / Applanationstonometrie bei Normalpatienten und Patienten nach LASIK.

BACKGROUND: Until now it was thought that morphological parameters of the eye such as corneal thickness, corneal curvature and axial length do not affect tonometry results. However, the aim of this study was to find out whether there actually is an influence of these parameters on applanation tonometry. PATIENTS AND METHOD: In this prospective study we examined 125 eyes of 125 normal patients with a corneal thickness of 568.8 +/- 43.79 microm, a corneal curvature of 7.72 +/- 0.27 mm and an axial length of 23.62 +/- 2.05 mm. Before performing a phacoemulsification, the anterior chamber was temporarily punctured. With a closed system the intraocular pressure (IOP) was manometrically set at 20, 35 and 50 mmHg using an H (2)O column. The IOP was then measured with a Perkins tonometer. With these patients we compared 102 eyes that had undergone LASIK due to a myopia of 6.3 +/- 2.17 D. Before and 6 months after surgery, IOD, k-values and central corneal thickness of these patients were measured. RESULTS: At all set pressure levels there was a highly significant correlation of measured IOP and corneal thickness. At all set pressure levels the measured IOP significantly depended on corneal thickness (r(2) = 0.78 - 0.83). After LASIK, IOP was reduced from 16.5 +/- 2.1 to 12.9 +/- 1.9 mmHg. There was a significant correlation between IOP and corneal curvature as well as corneal thickness (r(2) = 0.631; P < 0.001). The biomechanical characteristics of the cornea are changed so that the measured IOP has to be corrected by an additional 0.75 mmHg. CONCLUSION: Since corneal thickness does affect Goldmann applanation tonometry we recommend to use the "Dresden Correction Table" (Tab. ) to achieve the real IOP. Pressure measurements after LASIK are inaccurate because of a change in corneal biomechanics, corneal thickness and curvature and they should be corrected as follows: IOP (real) = IOP (measured) + (540 - CCT)/71 + (43 - K-value)/2.7 + 0.75 mmHg.

[A new treatment of keratectasia after LASIK by using collagen with riboflavin/UVA light cross-linking]. / Eine neue Behandlung der Keratektasie nach LASIK durch Kollagenvernetzung mit Riboflavin/UVA-Licht.

BACKGROUND: Keratectasia is one of the most severe complications after refractive laser surgery. Usually penetrating keratoplasty is the treatment of choice to achieve an optical rehabilitation in such cases. PATIENTS AND METHODS: We report on a female patient who developed keratectasia in both eyes 4 weeks after LASIK. Due to a severe keratectasia 10 months after LASIK, a treatment with riboflavin/UVA cross-linking was performed. RESULTS: Due to the induced collagen cross-linking the biomechanical status of the cornea was stabilized and a progression of the keratectasia was prevented. The postoperative refraction and corneal topography have been stable for 18 months. CONCLUSION: Collagen cross-linking leads to a stiffening of the anterior parts of the corneal stroma. The increase of biomechanical stability can stop the progression of a keratectasia after LASIK by means of a simple procedure.

Endovascular management of "endoleaks" after transluminal infrarenal abdominal aneurysm repair.

PURPOSE: To investigate the reasons for endoleaks after transluminal infrarenal abdominal aneurysm management and the potential for transluminal interventions in subsequent management. METHODS: Prospective analysis of 50 consecutive patients undergoing endovascular aneurysm repair at a single institution with Stentor and Vanguard grafts from March 1995 to March 1997. SETTING: Academic teaching hospital. RESULTS: Two procedures were converted for other reasons than leak. In the remaining 48 successful procedures endoleaks were detected in 11 (22.9%): proximal aortic leak (2.1%), distal aortic leak (8.3%), iliac leak (12.5%). Leaks were treated at the initial procedure in five patients, resulting in 87.5% excluded aneurysms. Twelve and a half per cent were discharged with a primary leak. Redo was performed on all iliac leaks within 7 weeks. All aortic leaks showed spontaneous thrombosis within 3 months, but reappeared with local aneurysm expansion. Aortic redo-procedures were performed by proximal tubular extension or converting a tube graft into a bifurcation graft. All rescue procedures were successful. Secondary leaks have been observed twice in this series, both treated by endovascular means. CONCLUSIONS: Endovascular treatment of primary and secondary endoleaks is possible, and may be a safe alternative to a difficult open procedure.

[The founding of group analysis by Trigant Burrow - a peculiar amnesia within the tradition of group analysis]. / Die Begründung der Gruppenanalyse durch Trigant Burrow: Eine eigentümliche Amnesie innerhalb der gruppenanalytischen Tradition.

The concept of group analysis as formulated by Trigant Burrow (1875-1950), the founder of group analysis, will be explicated on the basis of three of his most important essays. Emphasis will be placed 1. on Burrow's dialogue with psychoanalysis--he regarded group analysis as a methodological development of psychoanalysis--as well as 2. on the particular meaning of certain contents which are defended against on the social level and which can be made conscious and worked through in group analysis. Burrow's work has been largely forgotten by group analysts. This amnesia is understood as a social defense elicited by Burrow's thoughts and analyses of pathological social relationships, which exist throughout society and to which psychoanalysts and group analysts are also subject.