Accuracy of Focal Laser Treatment Based on External Imaging (OCT) Using a Navigated Retinal Laser System - a Case Series.

Background The navigated laser photocoagulation system (NAVILAS®, OD-OS GmBH, Teltow, Germany) is a laser treatment device that provides navigated laser treatment of the retina based on a fundus image. The purpose of this study was to investigate the accuracy of laser treatment based on external optical coherence tomography (OCT) images - a new application of the device. Patients and Methods This retrospective case series evaluated the accuracy of laser spot placement in 7 eyes after using overlaid external OCT images for planning NAVILAS laser treatment. After a mean time of 33 days, a post-treatment OCT was obtained and compared with the pretreatment plan on the previous OCT. Laser spots touching or overlapping the planned 100 µm laser spots were classified as "match" and invisible laser spots as "laser spot not evolved". Results A total of 477 laser spots in 7 eyes were evaluated (mean: 68 spots per eye). Of all planned laser spots, 361 (75.7 %) were visible on post-treatment OCT. 58.7 % of these spots matched the pretreatment plan. Non-matching laser spots showed no uniform pattern of dislocation. Conclusions Planning navigated NAVILAS Laser treatment based on manually imported OCT images seems to be less accurate than planning with NAVILAS integrated imaging. These findings warrant further evaluation, not only regarding the recently installed automated picture importing tool but also concerning its clinical impact, which is possibly outweighed by the advantages of the additional image information.

The impact of infectious ocular emergencies on hospital resources.

BACKGROUND: Infectious ocular emergencies cannot be pre-planned, need a more labour-intensive treatment and are often associated with prolonged hospitalisation. The aim of this study is to assess the impact of infectious ocular emergencies on hospital resources and identify changing trends over the last 10 years. PATIENTS AND METHODS: In a retrospective chart review 13,587 inpatient records from 1998 to 2007 were analyzed for the reason for emergency hospitalization, treatment data, length of hospitalizations and economical impact. RESULTS: 341 cases of severe infectious ocular emergencies with the need for emergency hospitalization were identified. The annual incidence of such emergencies increased continuously and has more than doubled during the last 10 years (51 vs. 24 annual cases). Within the same period the average hospitalization time of all non-infectious patients decreased from 5.41 to 4.95 days while inpatient stay due to infectious ocular emergencies decreased from 10.13 to 8.18 days. The average nursing effort was 4.26 hours per day in the infectious group, while electively admitted patients had an average requirement for nursing time of only 2.92 hours per day. CONCLUSION: The increase in infectious-related hospitalizations, their unpredictability and the need for a more intensive treatment regime have an increasing impact on hospital resources.

[Complications of Descemet Stripping Automated Endothelial Keratoplasty (DSAEK)]. / Komplikationen der Descemet Stripping Automatisierten Endothelkeratoplastik (DSAEK).

BACKGROUND: Lamellar keratoplasties, e.g. Descemet's stripping automated endothelial keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK) are considered the procedures of choice for corneal endothelial diseases. In comparison to penetrating keratoplasty (PK) they are associated with faster visual rehabilitation, a lower risk of complications and a decreased necessity for follow-up visits, which reduces the burden on quality of life in elderly patients. In order to advise patients regarding the indications for surgery and to facilitate the follow-up management, it is important to know the most important complications associated with these keratoplasty techniques. RESULTS AND DISCUSSION: The most important preoperative complication is a delayed indication for the operation. In contrast to PK, DSAEK and DMEK surgery should be provided at an earlier stage of disease as chronic edema alters the stroma and reduces the speed of visual recovery. The most important complications during or early after surgery are detached lamellae, pupillary blocks with increased pressure or air bubbles in the vitreous cavity in patients with previous vitrectomy. The main long-term complications include chronic increased intraocular pressure and immune-mediated graft rejections in DSAEK patients after reducing or stopping topical corticosteroid therapy. This article describes the potential complications of endothelial keratoplasty and provides a detailed explanation of strategies to avoid these complications.

Blood flow velocity measured using the Retinal Function Imager predicts successful ranibizumab treatment in neovascular age-related macular degeneration: early prospective cohort study.

PURPOSE: Anti-VEGF treatment has a potent vasoconstrictive effect. Early changes of retinal blood flow velocity (RBFV) measured using the Retinal Function Imager (RFI) combined with indicators of vascular status may help in predicting the visual outcome 1 month post injection in patients with neovascular age-related macular degeneration (nvAMD) under ranibizumab treatment. To develop a simple prediction model based on the change in RBFV 3 days post injection and indicators of a patient's vascular status to assess the probability of a successful visual outcome 1 month post injection. METHODS: RBFV measured using RFI were prospectively collected pre-injection and 3 days post injection in 18 eyes of 15 patients. Indicators of vascular status (history of hypertension, diabetes mellitus without retinal affection, and smoking) were assessed by medical history. By univariate analyses, parameters associated with visual outcome were weighted (-1 to 6 points). A multivariate logistic regression model with the categorized visual outcome parameter (≥0 letters gained after 1 month) as the dependent variate and the sum score as the independent variate (continuous scale) was used to estimate the score value-specific probabilities of letters gained ≥0 1 month post injection. RESULTS: The indicators of vascular status negatively influenced the likelihood of a letter gain ≥0 whereas an increase in the arterial RBFV strongly increased it. The area under the receiver operating characteristics curve for these parameters investigated was 0.71 (95% CI: 0.43-1.00). CONCLUSION: Changes in the arterial RBFV following 3 days after ranibizumab injection combined with three indicators of the vascular status identified nvAMD patients with favorable visual outcome accurately.

Interaction between silicone oil and silicone intraocular lenses: an in vitro study.

The objective of this study was to examine the interaction between silicone oil and silicone intraocular lenses (IOLs) in vitro. Six types of silicone IOLs were placed in silicone oil (1000 or 5000 centistokes) for 1 minute, 7 days, and 420 days. Slit-lamp examination, target photographs, and opacity measurements were performed. Optical measurements were repeated in a balanced salt solution after removal from the oil. The IOL surface was examined through scanning electron microscopy, and surface irregularities underwent x-ray spectroscopy. No changes were observed while the IOLs were stored in silicone oil, but in the balanced salt solution, the IOLs were observed to have a layer of silicone oil droplets that reduced the optical quality. Scanning electron microscopy showed that oil-coated foreign body particles were simulating IOL surface defects. After ultrasonic cleaning with ethanol, the oil layer was broken, and no damage to the IOL surface could be detected. The length of exposure to silicone oil, the type of oil, and the type of IOL were found to have no bearing on the interaction between silicone oil and silicone IOLs. Although no surface damage is incurred by silicone IOLs from silicone oil, the reduction in optical quality and fundus view due to remnant oil droplets seems to indicate that complex cases requiring silicone oil injection may contraindicate IOLs made of silicone.

Diagnostic accuracy of the Amsler grid and the preferential hyperacuity perimetry in the screening of patients with age-related macular degeneration: systematic review and meta-analysis.

OBJECTIVE: To clarify the screening potential of the Amsler grid and preferential hyperacuity perimetry (PHP) in detecting or ruling out wet age-related macular degeneration (AMD). EVIDENCE ACQUISITION: Medline, Scopus and Web of Science (by citation of reference) were searched. Checking of reference lists of review articles and of included articles complemented electronic searches. Papers were selected, assessed, and extracted in duplicate. EVIDENCE SYNTHESIS: Systematic review and meta-analysis. Twelve included studies enrolled 903 patients and allowed constructing 27 two-by-two tables. Twelve tables reported on the Amsler grid and its modifications, twelve tables reported on the PHP, one table assessed the MCPT and two tables assessed the M-charts. All but two studies had a case-control design. The pooled sensitivity of studies assessing the Amsler grid was 0.78 (95% confidence intervals; 0.64-0.87), and the pooled specificity was 0.97 (95% confidence intervals; 0.91-0.99). The corresponding positive and negative likelihood ratios were 23.1 (95% confidence intervals; 8.4-64.0) and 0.23 (95% confidence intervals; 0.14-0.39), respectively. The pooled sensitivity of studies assessing the PHP was 0.85 (95% confidence intervals; 0.80-0.89), and specificity was 0.87 (95% confidence intervals; 0.82-0.91). The corresponding positive and negative likelihood ratios were 6.7 (95% confidence intervals; 4.6-9.8) and 0.17 (95% confidence intervals; 0.13-0.23). No pooling was possible for MCPT and M-charts. CONCLUSION: Results from small preliminary studies show promising test performance characteristics both for the Amsler grid and PHP to rule out wet AMD in the screening setting. To what extent these findings can be transferred to a real clinic practice still needs to be established.

[Acute anterior non-granulomatous uveitis after intravitreal injection of bevacizumab]. / Akute anteriore nichtgranulomatöse Uveitis nach intravitrealer Bevacizumab-Injektion.

BACKGROUND: Recently, bevacizumab (Avastin(R)) has been used widely as a potential off-label treatment of CNV. The ocular side effects appear to be quite rare, but one concern is the risk of an inflammatory response. We report on an acute nong-ranulomatous anterior uveitis after intravitreal injection of bevacizumab. HISTORY AND SIGNS: A 74-year-old female with subfoveal CNV due to ARMD presented after the second injection of bevacizumab with a symptomatic acute non-granulomatous anterior uveitis. Work-up ruled out any other aetiology. THERAPY AND OUTCOME: Treatment with topical prednisolone and scopolamine resolved inflammation and symptoms. CONCLUSIONS: Intravitreal injection of bevacizumab is related with the possible development of acute non-granulomatous anterior uveitis, after having excluded infectious or other causes of uveitis unrelated to the bevacizumab injection. In recent clinical trials bevacizumab-induced uveitis has been demonstrated to be a rare event. The pathogenesis remains unclear. One possible explanation is the Fc portion of the antibody, which may offer the possibility of an increased cellular immune response. This case underlines the importance to inform patients about the possibility of such an episode.

[Sclerochoroidal calcifications with vision-threatening choroidal neovascularisation]. / Sklerochoroidale Kalzifikationen mit visusbedrohender choroidaler Neovaskularisation.

BACKGROUND: Sclerochoroidal calcification is an uncommon ocular condition in elderly patients. The lesions are frequently bilateral and located at the superotemporal quadrant. The diagnosis is made by fundoscopic appearance, angiography and echography. HISTORY AND SIGNS: A 75-year-old man was referred with bilateral choroidal lesions and visual deterioration in the right eye. Examination revealed apart from old signs of a multifocal choroiditis also bilateral, elevated, yellow lesions located at the upper temporal arcades. In the right eye one lesion was accompanied by hemorrhages, edema and lipid exudates. A subsequent fluorescein angiography disclosed choroidal neovascularisation. Ultrasonography showed the characteristic findings of highly reflective lesions with acoustic shadowing. Serum calcium and phosphate levels were normal. THERAPY AND OUTCOME: Because of rapid visual deterioration on the right eye Ranibizumab (Lucentis) was injected intravitreal. CONCLUSIONS: Despite their good prognosis, sclerochoroidal calcifications associated with neovascular membranes can become a vision-threatening disorder.

["Floaterectomy"--pars-plana-vitrectomy for vitreous opacities]. / "Floaterektomie"--Pars-Plana-Vitrektomie wegen Glaskörpertrübungen.

BACKGROUND: Patients suffer from vitreous opacities, despite good visual acuity. The lack of objective measurements may make it difficult to justify the indication for vitreous surgery. PATIENTS AND METHODS: We analysed retrospectively the outcome of 90 eyes/ 67 patients, age 20 - 86 years (mean 60 +/- 19) after pars plana vitrectomy (ppv) for vitreous opacities. Follow-up was 6 - 40 months (mean 19 +/- 9). Additional pathologies (except cataract) possibly affecting the functional outcome were present in 33 % (uveitis 8 %, premacular membrane 10 %, other 15 %). The technique consisted of a standard 3-port vitrectomy (44 % 25-gauge, 46 % 20-gauge). In 78 % ppv was combined with phacoemulsification + IOL implantation. RESULTS: Mean preoperative visual acuity was 0.6, postoperative 1.0 (+ 2.3 lines, p > 0.0001). One eye lost 2 lines. Peripheral retinal tears occurred in 11 %. Long-term complications (12 - 31 months) consisted of premacular membrane formation (1), luxation of the IOL/capsular bag. Secondary interventions included YAG capsulotomy (4) and glaucoma surgery (1). 94 % of all patients (98 % if additional pathologies were excluded) were satisfied with the outcome. CONCLUSIONS: Pars plana vitrectomy for vitreous opacities is safe and effective. Careful patient selection is crucial.

Reproducibility of the data determined by scanning laser polarimetry.

BACKGROUND: Scanning laser polarimetry is a tool for measuring the retinal nerve fiber layer: both its cross-sectional surface (polarimetric data analysis) and its thickness (mean sector values). METHODS: Two observers examined 56 normal volunteers twice by means of scanning laser polarimetry (Nerve Fiber Analyzer type 1, software version 1.6). Measurements of the retinal nerve fiber layer were carried out in four equal sectors of a circle around the optic nerve head. The measured values of the sectors and the calculated ratios among them were used for statistical analysis. Interobserver and intraobserver reproducibility were analyzed following a balanced random three-way cross classification with interactions. Interobserver reproducibility was defined as the part of variance not influenced by the observers. Intraobserver reproducibility was defined as the part of variance not influenced by the time. RESULTS: For repeated measurements of the retinal nerve fiber layer, better intraobserver than interobserver reproducibility was found (0.57-0.79 vs 0.11-0.44). The interobserver reproducibility was improved (0.24-0.65) in comparison to the intraobserver reproducibility (0.32-0.68) by calculating the ratios of the measured values. CONCLUSION: The instrument is clinically useful only if used by the same observer. If measurements are performed by different observers the ratios of the measurements must be used. Further development in the apparatus is needed to improve interobserver reproducibility.

[Perioperative circulatory side effects of topical 5% phenylephrine for mydriasis]. / Einfluss der Pupillenerweiterung mit Phenylephrin 5% auf das perioperative Kreislaufverhalten.

PURPOSE: To study the systemic effects of topically applied 5% phenylephrine. To investigate intraoperative injection of epinephrine in the anterior chamber as an alternative. METHOD: 75 patients undergoing cataract surgery were randomized into three groups. In group 1, the pupil was dilated using topically 5% phenylephrine and 1% cyclopentolate, the patients blocked the lacrimal drainage system themselves by digital compression. Group 2 received the same drops, digital compression was performed by one of the investigators. In Group 3, no preoperative phenylephrine was used--instead, epinephrine 1:25,000 was injected in the anterior chamber at the beginning of surgery. Retrobulbar anesthesia was performed in a short narcosis with ketamine and propofol. RESULTS: Mean preoperative blood pressure values were higher than the day before. They fell during narcosis, to increase significantly after the injection of the local anesthetics. At the beginning of surgery they were back to prenarcotic values. Intraoperative blood pressure remained stable. Preoperative day values were found two hours postop. There was no significant difference in the circulatory behavior between the three groups. For mydriasis, intraoperative intracameral epinephrine was not as effective as preoperative phenylephrine. CONCLUSION: In normotonic or medically treated arterial hypertensive patients, preoperative mydriasis using 5% phenylephrine is safe--proceeding the way described above. Compression of the lacrimal drainage system can be performed by the patients effectively. Intraoperative intracameral epinephrine does not replace preoperative phenylephrine.

[Ocular barostress and barotrauma. A study of 15 scuba divers]. / Okuläre Druckbelastung und Barotrauma. Studie an 15 Sporttauchern.

BACKGROUND: During SCUBA-diving, relative changes of the pressure in the diving mask, compared to the environmental pressure, are transmitted to the eye and to the periocular tissue. Barotrauma results from lack of pressure equilibration. MATERIAL AND METHODS: In 15 divers (6 experienced, 9 beginners) the pressure difference (delta-p) between inside and outside of the diving mask was measured every second during recreational SCUBA-diving. Data were transmitted wireless to a modified standard diving computer. An overall dive time of 323 minutes was analysed. RESULTS: Mean delta-p was 14.8 mbar (-44 to , std.dev. +/- 9), it was not dependent on the diving depth (r2 = 0.0004). Delta-p oscillated between 0 and 25 mbar (0-19 mm Hg), parallel to respiration. Negative delta-p values were 9.5 times more frequent in beginners than in experienced divers. Negative pressure peaks (changes > or = 10 mbar for more than 6 sec) occurred in the beginner group exclusively (p = 0.01). CONCLUSIONS: During SCUBA diving, ocular tissues undergo oscillating changes of environmental pressure, parallel to respiration. This may be important in eyes with previous surgery. Pressure peaks, leading to severe ocular barotrauma, are easily avoidable.