[Tonometry and pachymetry to evaluate fluctuations of intraocular pressure in the context of SCUBA diving]. / Tonometrie und Pachymetrie zur Erfassung der Augeninnendruckschwankungen beim Scuba-Tauchen.

BACKGROUND: It is currently still not clarified whether diving using a self-contained breathing apparatus (SCUBA) is associated with intraocular pressure (IOP) fluctuations of clinical relevance and whether intensive diving could exacerbate the damage in glaucoma patients. OBJECTIVE: This study aimed to evaluate the effect of SCUBA diving on IOP in healthy volunteers without prior eye injuries or surgery. HYPOTHESIS: recreational diving does not lead to significant increases or fluctuations of the IOP. MATERIAL AND METHODS: The study included 16 divers (5 female) who performed a total of 96 dives with air or nitrox32 to a depth of 20-30 m for an average of 50 min. The central cornea thickness was measured using ultrasonic pachymetry Pocket IITM (Quantel Medical Pocket II™, Quantel Medical, Clermont-Ferrand, France), and the IOP was measured using an Icare® PRO (Icare® PRO, Icare Finland Oy, Espoo, Finland) directly before the dive and 10 min after surfacing. RESULTS: All data refer to the right eye. Average IOP values ranged from 15.6 to 19.2 mm Hg pre-dive and 16.8 to 18.2 mm Hg post-dive. The range of IOP values was 2.2-11.5 mm Hg pre-dive (∆ = 9.3 mm Hg) and 2.7-14.8 mm Hg post-dive (∆ = 12.1 mm Hg). Of the divers 11.5% vs. 18.8% had increased IOP values > 21 mm Hg (pre-dive vs. post-dive). CONCLUSION: This study found no significant differences in IOP values between pre-dive and post-dive measurements in healthy SCUBA divers. Therefore, recreational SCUBA diving is unlikely to affect the IOP in healthy individuals.

[Biomarkers in full-thickness and lamellar defects of the macula]. / Biomarker bei durchgreifenden und lamellären Defekten der Makula.

BACKGROUND: Biomarkers are characteristic biological measurable signs and objective parameters to detect the state of health. Besides functional and temporal factors, imaging biomarkers play an increasingly important role. In full-thickness and lamellar defects of the macula numerous imaging parameters have been described. This knowledge resulted in new classifications for both clinical pictures, which are based on important biomarkers of these clinical pictures and characteristic features of described subtypes. METHODS: Imaging biomarkers for full-thickness and lamellar macular defects are described with respect to the classification and their functional prognostic importance. The importance of these biomarkers is presented. RESULTS: The current classification of full-thickness and lamellar macular defects is based on structural biomarkers. Biomarkers are important for prognostic and therapeutic evaluation and they have an impact on the surgical strategy. There are various surgical strategies for treatment of full-thickness macular holes depending on the size of the foramen and other biomarkers. The inverted ILM flap technique improves the closure rate of large macular holes. In lamellar macular holes showing signs of progression an early surgical intervention results in a good anatomical and functional prognosis. CONCLUSION: Multimodal diagnostics provide important preoperative, intraoperative, and postoperative features for macular holes and lamellar macular holes, which are essential biomarkers for the exact classification, the therapeutic strategy and for assessment of the prognosis.

[Optical coherence tomography biomarkers in epimacular membranes and vitreomacular traction syndrome]. / Optische Kohärenztomographie-Biomarker bei epimakulären Membranen und vitreomakulärem Traktionssyndrom.

Using high-resolution imaging, such as optical coherence tomography (OCT), the different layers of the retina as well as the vitreoretinal interface and its alterations can be very clearly differentiated. This includes the morphological characteristics of tractive maculopathies, such as epiretinal gliosis and vitreomacular traction syndrome. Additionally, structural alterations of the various layers of the neurosensory retina as a result of traction due to these pathologies can be demarcated. The latter have been investigated in clinical trials and evaluated as OCT biomarkers with respect to their prognostic and predictive value. In this review we would like to present and discuss various OCT biomarkers in the context of epimacular membranes and vitreomacular traction syndrome.

[Macular changes in optic disc pits-Optic disc pit maculopathy (ODP-M) : Pathophysiology and possibilities of surgical treatment]. / Makulaveränderungen bei Grubenpapille ­ "Optic disc pit maculopathy" (ODP-M) : Pathophysiologie und Möglichkeiten der chirurgischen Therapie.

An optic disc pit is a rare congenital abnormality of the optic nerve, which in most cases presents as a unilateral finding. Clinically, a greyish oval excavation is seen, most commonly on the temporal side of the optic nerve disc. The optic disc pit alone normally does not lead to substantial symptoms or functional limitations; however, when a maculopathy with intraretinal and/or subretinal fluid and additional other morphological changes in the macula occur, this leads to a decrease in visual acuity. With spectral domain optical coherence tomography (SDOCT) it is possible to identify the various forms of expression, which show different natural courses. Especially the presence of subretinal fluid and defects in the outer retinal layers have a poor prognosis and have the highest risk for further deterioration. Spontaneous resolution can occur but is rare. Observation is recommended in the first step. In cases of progression or pronounced deterioration, surgical intervention is indicated. Many different techniques have been proposed but there is no gold standard at the moment. Most of the surgical approaches comprise pars plana vitrectomy with peeling of the internal limiting membrane (ILM) and gas endotamponade. Newer methods, such as the ILM flap technique also show good results. Generally, it is important to know that postoperative healing and resorption of the fluid often take a long time period of up to 1 year or even longer.

[Histopathological correlation of epiretinal tissue in lamellar macular holes and macular pseudoholes]. / Histopathologische Korrelation epiretinalen Gewebes bei Schichtforamen und Pseudoforamen der Makula.

BACKGROUND: Using high-resolution spectral domain optical coherence tomography (SD-OCT), morphologically different types of epiretinal tissue can be distinguished in lamellar macular holes (LMH) and macular pseudoholes (MPH). OBJECTIVE: This article presents the results of histopathological characterization and differentiation of epiretinal tissue in eyes with LMH and MPH, which are classified based on a morphological differentiation in SD-OCT. MATERIAL AND METHODS: This review is based on the currently available literature and own data analyses. Using SD-OCT, a differentiation into hyporeflective epiretinal tissue and contractile epiretinal membranes (ERM) was performed. For fluorescence and transmission electron microscopic analyses, epiretinal tissue harvested by pars plana vitrectomy and peeling of epiretinal tissue was processed. RESULTS: By SD-OCT hyporeflective tissue appears as a thick homogeneous layer of hypodense material located directly on the surface of the inner retina and has no visible signs of traction. Using immunocytochemistry, hyalocytes and glial cells showing no contractile activity are dominant; however, in contractile ERM in MPH, anti-alpha SMA-positive myofibroblasts are predominantly found representing the contractile element. CONCLUSION: The results of ultrastructual investigations demonstrate that morphological cell components of hyporeflective epiretinal tissue from LMH have less contractile properties than cells of contractile ERM. It can therefore be assumed that there are differences in the pathogenesis of epiretinal cell proliferation in LMH. Histopathological investigations support the hypothesis that hyporeflective epiretinal tissue represents modified material from the outer layer of the vitreous body.

[Indications and surgical approach for lamellar macular holes and pseudoholes]. / Indikation und chirurgisches Vorgehen bei Makulaschichtforamen und Pseudoforamen.

BACKGROUND: This article presents a discussion on the indications for surgical interventions of lamellar macular holes and pseudoholes. OBJECTIVE: What are the criteria for deciding on the surgical intervention for lamellar macular holes and pseudoholes? MATERIAL AND METHODS: The article is based on a literature search in PubMed RESULTS: Lamellar macular holes and pseudoholes are subdivided into degenerative and tractive alterations. Both entities are associated with relatively specific morphological and functional criteria, which correlate with the expected functional and morphological results of the surgical intervention. Patients with pseudoholes therefore profit more from a surgical intervention because alterations to the outer retina are less pronounced in these cases. CONCLUSION: The indications for surgery of lamellar macular holes and pseudoholes are established by the type of lamellar defect and the morphological and functional alterations associated with this condition.

[Retinal OCT: Vitreoretinal Interface]. / Netzhaut-OCT: vitreoretinale Grenzfläche.

The gold standard for the assessment of the vitreoretinal interface (VRI) is high resolution OCT. It is therefore essential to select the appropriate scan modalities to detect all morphological changes in different diseases, not only at the VRI, but also in all layers of the retina and in the foveal and parafoveal areas. These can be raster scans, radial scans or "en face" scans. Morphological changes at the VRI and especially in the outer retinal layers are good prognostic factors in high resolution OCT for the success of surgery for vitreomacular interface disorders. The following article gives an overview of current OCT procedures as well as correlations between morphological and functional findings.

[Diabetic maculopathy]. / Diabetische Makulopathie.

Diabetic maculopathy is the result of multifactorial and complex alterations of the retinal capillaries in association with diabetes mellitus and is divided into two forms, ischemic maculopathy and diabetic macular edema. Diabetic macular edema is the leading cause of blindness among people of working age. The functional and morphological results of intravitreal pharmacotherapy in cases of fovea-involving macular edema using vascular endothelial growth factor (VEGF) inhibitors such as ranibizumab and aflibercept obtained in large randomized clinical trials are excellent and are superior to results obtained with focal or grid laser coagulation alone. Steroids including dexamethasone and fluocinolone implants represent approved alternatives, although flucinolone is considered a second-line therapy in refractory and chronic cases. VEGF inhibitors can be used in different treatment strategies such as PRN and treat and extend strategies. Focal laser photocoagulation remains the gold standard for macular edema not involving the fovea (and therefore usually good visual acuity). Laser is also still indicated as a panretinal photocoagulation of peripheral retinal ischemic areas in order to prevent neovascular complications. It remains to be proven whether panretinal photocoagulation can have an effect on the treatment intervals of intravitreal pharmacotherapy, too. Surgical treatments such as vitrectomy are today limited to cases of macular edema with concomitant obvious tractional pathologies at the vitreoretinal interface.

[Anatomic Success of Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment during the Changeover from 20 to 23 Gauge - A Study on 313 Consecutive Cases]. / Anatomischer Erfolg der Pars-plana-Vitrektomie bei rhegmatogener Netzhautablösung im Rahmen der Umstellung von 20 auf 23 Gauge - eine Studie an 313 konsekutiven Fällen.

BACKGROUND: The aim of this investigation was to evaluate the effect on the anatomic surgical success with the changeover from 20 Gauge (G) (n = 206) to 23 G (n = 107) pars plana vitrectomy (PPV) in rhegmatogenous retinal detachment. METHODS: 313 consecutive patients were retrolective-prospectively analysed. Several parameters including lens status, number of retinal breaks, extent of retinal detachment, proliferative vitreoretinopathy (PVR) and refractive error were examined. Primary success rate was defined as anatomic success after a minimum follow-up of 6 months. The secondary success rate was determined as anatomic success after one further operation if necessary. Moreover recurring retinal detachment after initial success was registered. In additional to the analysis over all patients, cases were grouped according to the severity of the preoperative baseline situation. RESULTS: Primary success rate was 87.4 % for 20 G PPV and 87.9 % for 23 G PPV, secondary success rate was 95.6 % for 20 G PPV and 94.4 % for 23 G PPV. 13.9 % (20 G) and 7.4 % (23 G) of patients with initially reattached retina after one surgery developed recurrent retinal detachment in the follow-up and were successfully treated in 17/25 and 7/7 cases. With 20 G PPV a primary success rate of 85 % was obtained in phakic eyes and 89.6 % in pseudophakic eyes, respectively. However, primary success rate with 23 G PPV was 90.4 % for phakic eyes and 85.5 % for pseudophakic eyes. For simple, medium and severe cases, the primary success rate decreased from 97.1 to 92.4 and 74.2 % in 20 G PPV, whereas no obvious tendency appeared for 23 G PPV (93.9, 83.7, 88 %). In 20 G PPV surgery the lens status had no influence on the primary success rate (p > 0.05), for medium and severe cases in 23 G PPV better results were obtained in phakic eyes (88.5 and 93.3 %) compared to pseudophakic eyes (78.3 and 80 %, n. s.). CONCLUSION: 20 G PPV as well as 23 G PPV are good surgical techniques in rhegmatogenous retinal detachment. Overall the miniaturisation of surgical instruments seems to be without any disadvantage for the surgical success.

[Comparison of Intravitreal Dexamethasone Implant versus Intravitreal Ranibizumab as a First-Line Treatment of Macular Oedema due to Retinal Vein Occlusion]. / Vergleich von intravitrealem Dexamethason-Implantat mit intravitrealem Ranibizumab als Erstbehandlung des Makulaödems bei retinalen venösen Gefäßverschlüssen.

PURPOSE: The present study investigated the treatment effect of dexamethasone implant (Ozurdex®, group 1) and anti-VEGF injection (Lucentis®, group 2) in course of macular oedema due to retinal vein occlusion in a retrospective, non-randomised case series. MATERIAL AND METHODS: Group 1 comprised 60 patients (31 with CRVO and 29 with BRVO) and group 2 included 52 patients, 27 with CRVO and 25 with BRVO) and both groups were further treated in case of recurrence. Preoperative and in monthly intervals best corrected visual acuity (BCVA), central retinal thickness using SD-OCT (Spectralis, Heidelberg Engineering), intraocular pressure, biomicroscopy status and a fundus photo documentation (Optomap) were evaluated. The primary clinical endpoint was visual acuity 12 months after the first intravitreal therapy, while secondary endpoints included the central retinal thickness change and safety of therapy. RESULTS: In group 1, an increase of BCVA (± standard deviation) of 8.4 (± 1.9) letters was observed in CRVO patients and a gain of 10.7 (± 3.8) letters in BRVO patients after 12 months, while in group 2, an increase of BCVA of 6.9 (± 1.9) letters (CRVO) compared to 12.5 (± 3.7) letters (BRVO) was observed after the same time span. In both groups a significant reduction in retinal thickness was achieved. An increase of intraocular pressure above 5 mmHg was observed in nearly half of the cases In group 1, but was well controlled by conservative antiglaucomatous therapy. We observed a progression of lens opacity in approximately 50 % of the cases in group 1. CONCLUSION: The treatment with Ozurdex compared to Lucentis appears to provide a trend towards a better although not significant visual acuity increase after 12 months in CRVO patients. A similar trend favouring anti-VEGF treatment with Lucentis was seen in patients with BRVO. However, the lens status and age of the patient should be taken into account when considering a treatment with Ozurdex.

[Artificial iris after severe trauma of the orbit]. / Irisersatz nach schwerem Bulbustrauma.

INDICATIONS: Surgical revision of the eye of a 52-year-old female patient with iris replacement was carried out 1 year after severe injury of the globe. OBJECTIVE: The further surgical measures were necessary to improve not only the functional but also the cosmetic results. OPERATION TECHNIQUE: Due to the complex initial situation a combination of vitrectomy and peeling of the epiretinal membrane, perforating keratoplasty and finally iris and lens replacement was carried out. The complete surgical procedure is presented in a video accompanying this article. RESULTS: The best corrected vision increased to 0.25, 6 months after the intervention and the patient was satisfied with the functional and cosmetic results. The intraocular pressure remained in the normal range after 1 year of follow-up with no further therapy.

[Clinicopathological correlations at the vitreoretinal interface]. / Klinisch-pathologische Korrelationen an der vitreoretinalen Grenzfläche.

BACKGROUND: Clinicopathological studies of the vitreoretinal interface (VRI) improve our understanding of the pathogenesis of vitreal maculopathy, facilitate differential diagnoses and help to develop new treatment strategies. OBJECTIVE: The aim of the study was to provide a comprehensive overview on clinicopathological correlations of the VRI. METHODS: A semi-structured literature search was performed in the Medline and Embase databases for relevant original studies on clinicopathological correlations of vitreal maculopathy, in addition to the latest books and review articles. RESULTS: Age-related vitreous changes with persistent vitreomacular adhesions on the retinal surface promote cellular migration and proliferation onto the vitreal side of the internal limiting membrane (ILM), thereby cementing the vitreomacular adhesions and strengthening the traction forces on retinal layers. Cellular or fibrocellular proliferation at the vitreomacular interface can be seen in all vitreal maculopathies. Furthermore, vitreoschisis in the context of anomalous posterior vitreous detachment causes the presence of vitreous cortex collagen fibrils on the vitreal side of the ILM which is associated with epiretinal membrane formation. Glial cells, hyalocytes and myofibroblasts represent the major cell types in the epiretinal cell proliferation. Glial cells and hyalocytes are capable of transdifferentiation into myofibroblasts which possess strong contractive properties and are well known for the production of extracellular matrix components. CONCLUSION: Removing vitreomacular adhesions and vitreous cortex collagen fibrils from the retinal surface is most important for successful treatment. In cases with epiretinal cell proliferation, however, removal of the ILM during macular surgery is mandatory to avoid reproliferation and recurrence. Improving the detection of epiretinal cell proliferation and cell distribution in patient eyes by optical coherence tomography or by introduction of new technologies should be addressed in the future.

[Surgical managment of retinal detachment]. / Operative Möglichkeiten bei Ablatio retinae.

The detachment of the neurosensory retina from the underlying retinal pigment epithelium can be related to breaks of the retina allowing vitreous fluid to gain access to the subretinal space, to exudative changes of the choroid such as tumours or inflammatory diseases or to excessive tractional forces exerted by interactions of the collagenous vitreous and the retina. Tractional retinal detachment is usually treated by vitrectomy and exudative detachment can be addressed by treatment of the underlying condition in many cases. In rhegmatogenous retinal detachment two different surgical procedures, vitrectomy and scleral buckling, can be applied for functional and anatomic rehabilitation of our patients. The choice of the surgical procedure is not really standardised and often depends on the experience of the surgeon and other more ocular factors including lens status, the number of retinal breaks, the extent of the detachment and the amount of preexisting PVR. Using both techniques, anatomic success rates of over 90 % can be achieved. Especially in young phakic patients scleral buckling offers the true advantage to prevent the progression of cataract formation requiring cataract extraction and intraocular lens implantation. Therefore, scleral buckling should be considered in selected cases as an alternative surgical option in spite of the very important technical refinements in modern vitrectomy techniques.

In vivo biocompatibility of a new cyanine dye for ILM peeling.

PURPOSE: To investigate the biocompatibility of the new cyanine dye: 3,3'-Di-(4-sulfobutyl)-1,1,1',1'-tetramethyl-di-1H-benz[e]indocarbocyanine (DSS) as a vital dye for intraocular application in an in vivo rat model and to evaluate the effects of this dye on retinal structure and function. METHODS: DSS at a concentration of 0.5% was applied via intravitreal injections to adult Brown Norway rats with BSS serving as a control. Retinal toxicity was assessed 7 days later by means of retinal ganglion cell (RGC) counts, light microscopy, optical coherence tomography (OCT), and electroretinography (ERG). RESULTS: No significant decrease in RGC numbers was observed. No structural changes of the central retina were observed either in vivo (OCT) or under light microscopy. ERGs detected a temporary reduction of retinal function 7 days after injection; this was no longer evident 14 days after injection. CONCLUSIONS: DSS showed good biocompatibility in a well-established experimental in vivo setting and may be usable for intraocular surgery as an alternative to other cyanine dyes. In contrast to indocyanine green, it additionally offers fluorescence in the visual spectrum. Further studies with other animal models are needed before translation into clinical application.

[Importance of morphological and functional diagnostics of the vitreoretinal interface]. / Stellenwert morphologischer und funktioneller Diagnostik an der vitreoretinalen Grenzfläche.

Optical coherence tomography (OCT) is the standard examination for assessment of the vitreoretinal interface (VRI); therefore, it is essential to select the appropriate scan modalities to detect the total amount of morphological changes, not only at the VRI but also in all layers of the retina and in both the foveal and parafoveal areas. For the success of a surgical intervention in the treatment of vitreomacular interface disorders, morphological changes, especially in the outer retinal layers, have been determined to be of prognostic interest in high-resolution OCT. This article gives an overview of current OCT examination procedures as well as correlative aspects of morphological and functional findings.

[A 23-gauge pars plana vitrectomy after induction of general anesthesia: effect of additional retrobulbar anesthesia on postoperative pain]. / 23-Gauge-Pars-plana-Vitrektomien in Allgemeinanästhesie : Effekt einer additiven Retrobulbäranästhesie auf das postoperative Schmerzempfinden.

PURPOSE: Some studies have shown a significant reduction of postoperative pain by additional regional anesthesia in 20-gauge pars plana vitrectomy (20-G-ppV) with the patient under general anesthesia (AN). This observational study examined whether the advantages of additional retrobulbar anesthesia can also be observed with 23-gauge vitrectomy in AN. MATERIAL AND METHODS: Surgery was performed in 130 patients under AN of which 88 received an additional retrobulbar block (group AN+) and 42 patients were treated without additional injection of retrobulbar anesthesia (group AN) using bupivacaine 0.5 % and mepivacaine 1%. The AN was performed with fentanyl and propofol. Postoperatively, the subjective patient pain was recorded using a numeric scale and the use and amount of analgesic drugs in the postoperative course were monitored. RESULTS: The mean age of the patients was 53.6 ± 16.8 years, 52.6% of the patients were male, 31.5% were staged as American Society of Anesthesiologists (ASA) level I, 52.3% as ASA II and 15.4% as ASA III. At no time did the study show a statistically significant difference in pain frequency, intensity and analgesic consumption. However, the results suggest that patients in the AN+ group tended to experienced delayed and more intense postoperative pain, which is also reflected in the postoperative use of pain relief medications. CONCLUSIONS: This study did not show any advantage by additional retrobulbar anesthesia regarding postoperative analgesia compared to an adequate treatment with peripheral acting analgesics during surgery and the early postoperative period.