[Analysis of Anti-VEGF Intravitreal Injection Treatment in Clinical Practice]. / Analyse der Durchführung der intravitrealen operativen Medikamenteneingabe im klinischen Alltag.

BACKGROUND: As AMD patients are very often administered intravitreal operative drugs (IVOM), the relevant procedure in ophthalmological institutes was examined in the present project: A questionnaire was used to collect data on structures, criteria and time expended in the treatment in single or small practices, clinics and (university) departments of ophthalmology. 42 facilities participated in the main study. RESULTS: The patient is usually given an appointment within two weeks of the first contact. If the patient has AMD requiring treatment, the first IVOM is administered within up to two weeks. This often lasts no longer than three hours. The follow-ups after the injection cycle may last up to one hour. If the findings are stable, there is normally a new follow-up after four weeks. The criterion for retreatment is always given as SD-OCT, followed by vision and funduscopy. The next appointment for injection is normally within one week. In diagnostic testing, angiography is almost as important as SD-OCT, funduscopy and vision, but is rarely used as a criterion for retreatment. The main differences in the organisation of the treatment plan are in the time course of the first IVOM and the follow-ups after the injection cycle. In this respect, practice clinics and individual or group practices may be quicker than departments of ophthalmology. One third of the surveyed facilities stated that they cooperated in diagnostic testing. These cooperating facilities repeat many investigations, both in diagnostic testing and in follow-ups. CONCLUSION: Bearing in mind that IVOM patients have a special interest in timely treatment, it would be desirable to shorten the waiting times, both for injection appointments and during treatment. Cooperation between the different service providers is sensible if this shortens the treatment pathways and relieve the patient and ophthalmologist. Moreover, both groups could benefit from standard and efficient treatment pathways, as these simplify patient care, increase the patient's satisfaction with the treatment and therefore tend to increase compliance.

[OCT Angiography - Is this the Future for Macular Diagnosis?]. / OCT-Angiografie - ist dies die Zukunft der makulären Diagnostik?

Recent developements in OCT technology using high speed acquisition and calculation of consecutive scans (SSADA = split spectrum amplitude decorrelation algorithm) have resulted in the possibility to demonstrate retinal and choroidal vessels in the macula. This new technology of "OCT angiography" thus allows the non-invasive and rapid (within seconds) reconstruction of the three-dimensional structure of the retinal and choroidal vascularisation. There are still limitations caused by movement artefacts, superposition of superficial retinal vessels at the RPE level or insufficient three-dimensional imaging, but the first experience with this new method and especially the correlations with the current standard diagnostic procedure fluorescein angiography shows that especially for vascular changes which are predominantly in one retinal layer (e.g., the inner retina) like in diabetic retinopathy or retinal vein occlusions, a very good correlation can be seen. Also in MacTel type 2 patients the proposed vascular changes in the deeper capillary network of the retina can be visualised very well with OCT angiography. In contrast, more three-dimensional vascular changes like the neovascular complex in exsudative AMD need a more sophisticated diagnostic analysis strategy, which has still to be developed. However, the first experience also demonstrates that fluorescein angiographic differentiation can also be seen in OCT angiography. In addition, the new technology gives additional information about the choroidal and outer retinal changes in these pathologies, which may result in a better understanding of the underlying pathologies.

[Initial clinical experience in the treatment of vitreomacular traction and macular holes with ocriplasmin]. / Erste klinische Erfahrungen bei der Behandlung von vitreomakulären Traktionen mit Ocriplasmin.

BACKGROUND: The introduction and approval of Ocriplasmin as an intravitreally applicable drug in the pharmocological treatment of vitreomacular traction represents a new therapeutic approach possibly avoiding vitreoretinal surgery. With our article we report our first experience wih Ocriplasmin in clinical practice. METHODS: The indication for intravitreal therapy with Ocriplasmin was provided for symptomatic VMT or macular hole with VMT in 20 patients since March 2013. Surgery was planned in cases with remaining symptoms. Before IVI we performed SD-OCT. Best visual acuity (BCVA) was evaluated preoperatively, 7 and 28 days after treatment and finally every month in 14 treated eyes. SD-OCT images were analysed before treatment and later on with every follow-up examination. In addition to functional and morphological changes we analysed all side effects. RESULTS: The mean BCVA at the beginning of treatment was 0.3 and 0.4 before injection. The indications for treatment were as follows: symptomatic VMT in 10 patients and 4 patients suffering from full thickness macular hole stage 2. In 3 patients spontaneous regression of VMT could be observed with increasing of vision from 0.3 to 0.5. In one patient his macular hole was closed and BCVA increased from 0.2 to 0.6 within 7 days. Two patients showed significant enlargement of their macular holes after 7 days and finally underwent surgery. A massive cystoid macular oedema occurred in one patient. No change in the SD-OCT image could be observed 28 days after treatment. The mean visual acuity improved to 0.6 during a follow-up period of 90 days. Photopsia and disturbing vitreous opacities up to 28 days post injection could be regarded as minor side effects. CONCLUSION: Our first clinical experience with intravitreous injection of Ocriplasmin were performed to confirm the presumed therapeutic effect in patients suffering from VMT. Small macular holes could frequently be closed. The possibility of special side effects must be taken in consideration just as the possibility of spanteous improvement before performing IVI with Ocriplasmin. Further prospective studies must be recommended to be right about Ocriplasmin injections.

[Endophthalmitis as a serious complication of intravitreal drug delivery]. / Endophthalmitis als schwere Komplikation der intravitrealen Medikamentengabe.

BACKGROUND: Endophthalmitis, regarded as a severe complication, can occur after intraocular injection of drugs (IVI). At present only few reports exist on the development of this disease, although recently the number of intraocular injections to treat especially age-related macular degenerations is increasing considerably. METHODS: In this paper we present our results of a retrospective study of 27 patients suffering from endophthalmitis after IVI. Treatment had been performed between January 2008 and March 2012. The indications for IVI were as follows: age-related macular degeneration 19, venous branch occlusion 1, diabethic retinopathies 6, uveitis 1. The following drugs were injected: bevacizumab in 8, Rranibizumab in 19 patients. The following data were assessed: incubation time, best corrected visual acuity that had been determined before treatment and later 3, 6 and 9 months after therapeutic vitrectomy. Additionally we describe the ophthalmoscopic changes and the results of bacteriological studies. RESULTS: Endophthalmitis was diagnosed 5.8 days after IVI on average. The vision of all patients had only been hand movements during the first examination. During the observation time the postoperative visual acuity could be improved only to 1/35 on average. During vitrectomy in 24 out of 27 patients a whitish retinal infiltration could be observed. 18 of 27 patients showed a hypopyon during slit lamp examination. 11 patients developed a retinal detachment and one eye had to be enucleated. CONCLUSIONS: Endophthalmitis must be regarded as a severe complication causing a high risk of retinal detachment with permanent loss of visual acuity. Retinal infiltrations and haemorrhages occur already in the early stages and cause finally a very poor prognosis. The incubation time as a rule amounts to 6 days. The increasing number of IVI and the high risk of damaged retinal structures due to intraocular infections should make postoperative retinal follow-up examinations mandatory, especially during the first 6 days.

[Effect of intravitreal and orbital floor triamcinolone acetonide injection on intraocular inflammation in patients with active non-infectious uveitis]. / Einfluss von intravitrealem und parabulbärem Triamcinolon Acetonid auf die intraokulare Entzündung bei aktiver nicht infektiöser Uveitis.

BACKGROUND: Currently, triamcinolone acetonide (TA) is frequently used to treat inflammation in non-infectious uveitis. The aim of this study was to compare the effect of TA on intraocular inflammation after a single intravitreal or orbital floor injection of the drug in patients with non-infectious uveitis. PATIENTS AND METHODS: This was a monocentre, retrospective study in 114 eyes (103 patients). Twenty eyes were treated with intravitreal and 94 eyes with orbital floor TA. The main outcome measure was cells in the anterior chamber and anterior vitreous. Secondary outcome measures included protein accumulation in the aqueous humor (according to laser-flare photometry), best-corrected visual acuity, and complications. Follow-up evaluations were performed at 1, 3, and 6 months after TA injection. RESULTS: After either intravitreal or orbital floor TA injection, the intraocular inflammation in the anterior chamber and vitreous decreased (p < 0.001, for both administration forms, and at all follow-up time points). Laser-flare values decreased in both groups. One month after injection, the visual acuity in the intravitreally treated patients was increased (p < 0.01), whereas the poor visual acuity persisted in the orbital floor group. The effect on macular oedema after intravitreal TA was better than in the orbital floor group (p < 0.01). Progression and increased cataract incidence were detected in 50 % after intravitreal and in 29 % after orbital floor TA. CONCLUSIONS: After both intravitreal and orbital floor TA injection, the intraocular inflammation decreased. The effect of intravitreal TA on macular oedema and visual acuity was better than that of orbital floor TA, but intraocular pressure elevation and progressive cataract were more often observed in this group.

[Pro re nata anti-VEGF treatment results for neovascular age-related macular degeneration in routine clinical treatment: comparison of single with triple injections]. / Pro-re-nata-anti-VEGF-Behandlungsergebnisse bei neovaskulärer altersabhängiger Makuladegeneration in der klinischen Routineversorgung: Vergleich von Einzel- mit 3er-Injektionen.

BACKGROUND: Different injection regimens from continuous to pro re nata (PRN) have been proposed for treatment of neovascular age-related macular degeneration (nAMD). So far the PRN single injection on reactivation regimen has not been compared to the PRN triple injection on reactivation regimen (IVAN scheme). OBJECTIVE: Comparison of the two nAMD PRN injection regimens with single and triple injections on reactivation in a real-world setting in a retrospective case series in two German treatment centers. MATERIAL AND METHODS: Naïve nAMD patients, who started treatment according to either the single or triple injection regimen were included. Endpoints were best corrected visual acuity (LogMAR), central retinal thickness on optical coherence tomography (µm) and number of injections, all at 3, 6, 12, 18 and 24 months after treatment initiation. RESULTS: A total of 146 patients with single injection and 148 patients with triple injection regimens were included. There were no significant differences between the two treatment regimens in best corrected visual acuity (single vs. triple injection scheme: 0.50 ± 0.42 vs. 0.56 ± 0.42, p = 0.14), central retinal thickness (303 ± 76.2 vs. 306 ± 110, p = 0.79) and number of injections (13 ± 4.4 vs. 12 ± 5.4, p = 0.31). This was the case for all analyzed time points. CONCLUSION: There were no significant functional or morphological differences between the two PRN injection regimens with single and triple injections on reactivation after 24 months. For evaluation of long-term therapy results further studies are warranted.

[Long-term results after pars plana vitrectomy with 25 gauge technique]. / Langzeitergebnisse nach Pars-plana-Vitrektomie mit 25-Gauge-Technik.

BACKGROUND: The 25-gauge technique of pars plana vitrectomy appears to be a very suitable method, especially for patients with pathological epiretinal alterations of the macula. However, the procedure has been criticized for insufficient impermeability with an increased risk of endophthalmitis and that the flexibility of instruments is too high. METHOD: Between 2002 and 2006, 625 eyes from 620 patients were operated on using the 25-gauge technique. Epiretinal membranes in different stages had been diagnosed in all patients. The operations were performed by only one surgeon. RESULTS: The epiretinal membranes were successfully removed in all patients and 329 eyes were analyzed with long-term follow up over 3.1 years. The mean improvement in visual acuity before and after surgery was -0.41 in LogMAR. One week postoperatively normal IOP was observed in all cases. The mean preoperative IOP was 17 mmHg and 8 mmHg 1 day after surgery. In nine patients with postoperative hypotony and choroidal detachment an additional suture was required and seven patients developed a retinal detachment. Endophthalmitis was not observed in any of the patients during the follow-up period. CONCLUSIONS: The 25-gauge PPV technique appears to be effective and safe for the treatment of epiretinal membranes. The operation has low complication rates with respect to endophthalmitis or retinal detachment. The procedure has recently been further improved by using more stable instruments and better lighting.

[Treatment of vascularised serous pigment epithelium detachment in AMD - observations after changing the intravitreal agent due to lack of response]. / Die Therapie der vaskularisierten serösen Pigmentepithelabhebung bei AMD - Beobachtungen nach Wechsel des intravitrealen Medikamentes bei Therapieversagen.

INTRODUCTION: Based on data from multicentric studies the treatment of exudative age-related macular degeneration (AMD) with VEGF inhibitors has recently become a more and more standard procedure. Nevertheless, the proper end point of the treatment and also the adequate interval between single injections have not been defined yet. In subtypes of AMD associated with pigment epithelium detachment. (PED) the natural course as well as laser coagulation treatment and photodynamic therapy (PDT) showed unsatisfactory results. The main cause of decreased visual acuity has proven to be recurrence of choroidal neovascularisation and ruptures of the pigment epithelium (RIP). This retrospective study presents the clinical results following a change of the injected VEGF inhibitor after ineffective initial therapy. METHOD: 15 patients with serous PED, 7 patients with PED associated with retinal angiomatous proliferation (RAP) exhibited insufficient stabilisation after initial treatment with pegaptanib (Macugen). Therefore we continued treatment with ranibizumab (Lucentis). The mean age was 74.67 years. Best corrected visual acuity was evaluated with logMAR. Additional morphological parameters were fovea full thickness (OCT), measurement of the height of pigment epithelium detachment and finally fluorescein and indocyaningreen angiography. In cases of functional and morphological deterioration, we changed the treatment from 1.25 mg pegaptanib (Macugen) to 0.5 mg ranbizumab (Lucentis). RESULTS: During the mean follow-up of 46.5 weeks (95 % CI 35.9 - 57.1) no RIP occurred. After changing the drug, visual acuity showed a stabilisation or improvement in 11 cases. Also the height of PED decreased after beginning with ranbizumab. Regarding the therapeutic outcome, no difference between eyes with serous PED caused by occult CNV or RAP could be observed. CONCLUSION: Treatment using VEGF inhibitors in patients suffering from AMD with exudative serious PED has proven to be effective regarding both the morphological damage and functional injuries. In cases of therapeutic failure after pegaptanib functional and/or morphological stabilisation of the course of this disease can be achieved by changing to ranbizumab. Nevertheless, prospective clinical studies with a larger number of patients are necessary for confirmation of these findings.

[OCT-Angiography in diabetic maculopathy : Comparison between microaneurysms and the foveal avascular zone with flourescein angiography]. / OCT-Angiographie bei der diabetischen Maculopathie : Vergleich von Mikroaneurysmata und der foveolären avaskulären Zone mit der Fluoreszeinangiographie.

BACKGROUND: Optical coherence tomography angiography allows an exact visualization of retinal vascular changes. To interpret the possibilities and limitations using OCTA in clinical practice, we analysed the quality of OCTA findings concerning the evaluability. Furthermore, we correlated our OCTA findings with fluorescein angiography (FAG) in relation of the presence of microaneurysms (MA) and enlargement of the foveal avascular zone (FAZ) in diabetic maculopathy. PATIENTS AND METHODS: 30 eyes from 15 patients with diabetic maculopathy were imaged in 3 × 3mm volume scans and were depicted in OCTA mode (SSADA algorithm). By using the automatic segmentation we analysed the vascular changes in the superficial and deep capillary plexus and classified them concerning their qualitative evaluability. We analysed the number of MA in OCTA and fluorescein angiography and correlated them using an overlay technique. We analysed the presence of MA in the superficial and deep capillary plexus in OCTA as well. Furthermore we measured the enlargement of the foveal zone with both methods. RESULTS: In a large number of eyes we could not identifiy MA or measure the enlargement of the FAZ because of poor OCTA or FA quality. In the morphological analysis of our findings we identified a comparable number of MA in both methods, although the localization of the MA was different in both methods in a large number of eyes. The majority of MA was located in the deep capillary plexus. The extension of the foveal avascular zone measured in FA revealed a good correlation to the automatically measured "nonflow area" in the OCTA. CONCLUSION: OCTA allows a good visualization of characteristic vascular changes in diabetic maculopathy. In spite of technical limitations OCTA generates a three-dimensional visualisation of avascular changes. The majority of microaneurysms detected by OCTA showed a corresponding finding in FA. The central avascular zone (FAZ) in OCTA correlates well with the findings from FA. OCTA represents an important additional diagnostic tool to interpret vascular changes in DM.

[Reasons for delayed and discontinued therapy in age-related macular degeneration]. / Gründe für Therapieverzögerung und -abbruch bei altersabhängiger Makuladegeneration.

BACKGROUND: Critical prerequisites for successful therapy of neovascular age-related macular degeneration (nvAMD) are an early initiation and continuous monitoring; however, delays in starting therapy and non-medically indicated discontinuation of therapy are frequent, which limits therapy efficacy and, thus, visual outcomes. OBJECTIVE: To identify the reasons for delay in therapy and non-medically indicated termination of therapy. MATERIAL AND METHODS: Patients who had started a new therapy (starters) and those who independently terminated therapy (dropouts) were interviewed by telephone with a specific, standardized questionnaire. Results were summarized descriptively. RESULTS: A total of 100 starters and 55 dropouts were interviewed. The mean therapy delay was 22 (±28 SD) days. This was mainly due to the time until the decision to see an ophthalmologist was made. Main reasons for dropping out were: transportation issues (27%), poor general health (25%) and the assumption that there is no benefit from therapy (11%). Of the patients who dropped out 63% would have liked to continue therapy. CONCLUSION: There is potential for improvement in nvAMD management regarding therapy start as well as therapy maintenance. Sensitizing for initial nvAMD symptoms is important as is reduction of barriers to therapy maintenance, since most therapy dropouts would like to continue the therapy.

[Visual acuity in anti-VEGF therapy for AMD : Can specific characteristics in the SD-OCT help?] / Visusprognose bei der Anti-VEGF-Therapie der AMD : Können spezifische Charakteristika im SD-OCT weiterhelfen?

BACKGROUND: The efficacy of anti-VEGF therapy in exudative AMD has been established in several large clinical trials using a fixed injection regimen as well as a SD-OCT-based PRN regimen. In these studies, after the first three injections, an increase of the mean visual acuity was observed, which could be stabilized with constant treatment for up to 24 months. However, the specific course of the visual acuity is very different between individuals. The aim of the present study was to correlate specific initial SD-OCT parameters with the course of visual acuity in order to characterize factors that may be important for the individual visual prognosis. PATIENTS AND METHODS: In a prospective case study, the visual course and SD-OCT changes of 156 patients with minimum follow-up of 12 months (mean 80.1 months) were analysed. Visual acuity (LogMar) was investigated at regular intervals and correlated with specific SD-OCT parameters (foveal thickness, height of sub-retinal fluid or presence of associated PED, presence of intra-retinal cysts, length of IS/OS break, choroidal thickness). RESULTS: The initial increase in visual acuity could be stabilized over time. This effect was associated with a decrease in foveal retinal thickness, which also persisted over time. While sub-retinal fluid, presence of PED, and choroidal thickness showed no prognostic relevance for the change in visual acuity, the presence of more advanced central retinal thickness, of intra-retinal cysts or a longer break in the IS/OS junction were associated with a less favourable development of visual acuity. CONCLUSION: In the present study, the presence of more advanced central retinal thickness, of intra-retinal cysts or a larger IS/OS break correlated significantly with a worse visual prognosis. These might be clinical signs for more extensive pre-existing intra-retinal changes. Further analysis and new diagnostic tools may prove this and may result in specific additive neuroprotective or regenerative therapeutic approaches in exudative AMD.

[Pitfalls in retinal optical coherence tomography imaging]. / Fallstricke in der Netzhautbildgebung mittels optischer Kohärenztomographie.

Optical coherence tomography (OCT) imaging now plays an important role in the management of macular and retinal diseases. In addition to the many advantages of this noninvasive imaging modality, limitations and pitfalls should be taken into consideration. The aim of this review is to discuss several possible sources of error in the conduct and interpretation of OCT imaging. Ultimately, this article should add to a meaningful and focused use in clinical practice.

[OCT angiography for exudative age-related macular degeneration : Initial experiences]. / OCT-Angiographie bei der exsudativen altersbedingten Makuladegeneration : Erste Erfahrungen.

The new technique of optical coherence tomography (OCT) angiography allows a non-invasive reconstruction of the three-dimensional structure of the total retinal and choroidal vascularization within seconds. There are still limitations caused by movement artefacts, superimposition of superficial retinal vessels at the retinal pigment epithelium (RPE) level and insufficient three-dimensional imaging modalities. Initial experiences with this new method and especially the correlation with the current standard diagnostic procedure of fluorescein angiography show that new information can be obtained regarding specific vascular and neovascular changes. For three-dimensional neovascular changes, such as those found in exudative age-related macular degeneration (AMD,) a more sophisticated diagnostic analysis strategy must be specifically developed. Initial experiences demonstrate that the differentiation into the various types of choroidal neovascularization (CNV) by fluorescein angiography, specifically for type 1 (occult) and type 2 (classical) can also be visualized by OCT angiography. Furthermore, the new technology provides additional information on the choroidal and outer retinal changes associated with this disease, which may result in a better understanding of the underlying pathology.

[Compliance of age related macular degeneration patients undergoing anti-VEGF therapy : Analysis and suggestions for improvement]. / Compliance von Patienten mit altersabhängiger Makuladegeneration unter Anti-VEGF-Therapie : Analyse und Verbesserungsvorschläge.

BACKGROUND: Activity-based treatment regimens with anti-vascular endothelial growth factor (anti-VEGF) are currently the gold standard for treatment of exudative age-related macular degeneration (nAMD). Whereas injection frequencies of approximately seven injections in the first year and six in the second year are expected with a pro re nata (PRN) regimen, retrospective real life observations have recorded significantly reduced numbers of injections. This study was carried out to investigate the reasons for the reduction in follow-up control appointments and to find out whether a telemedicine network could influence the motivation and compliance for regular control examinations and treatment. MATERIAL AND METHODS: The patient collective included 210 eyes from 191 patients with nAMD treated by anti-VEGF therapy in 2010 and 2011. The activity-based anti-VEGF treatment, control examinations and treatment intervals were performed according to the guidelines over a mean follow-up of 2 years. In another collective of 100 eyes from 100 patients with treatment of nAMD 2 groups were observed: 1 group with patients for whom control examinations were carried out close to home including an online transmission of the results to the treating retinal center and another group in which the patients had to be examined in the treatment center. RESULTS: After 140 weeks 50 % of the patients in the first collective regularly attended control examinations and after 1 year the number was 79 %. After 2 years the probability of continuous supervision is given for only 62 % of the patients, whereas in 38 % the treatment was terminated. Of these patients treatment was terminated in 8 % due to valid criteria, whereas in 30 % of the patients the termination was unintentional. The main reason (38 %) for an unintentional termination of examination and treatment was the frequent and long journey. Patients in the second collective had a significantly higher compliance with respect to the control examinations (p < 0.001) and number of injections (p = 0.02) over the period of nearly 2 years due to the introduction of electronic transmission of images. CONCLUSION: A long-term therapy of nAMD in the clinical routine can be achieved by a close relationship with the ophthalmologist, continuous follow-up controls and therapy cycles. A close telemedical networking between the ophthalmologist and the treatment center can lead to better patient compliance. Furthermore, the construction of such platforms represents a challenge not only for the treatment of nAMD but also for other diseases.

[Design of the ORCA module in the OCEAN study : Evaluation of SD-OCT results in daily routine practice]. / Design des ORCA-Moduls der OCEAN-Studie : Evaluierung der SD-OCT-Befunderhebung in der täglichen Praxisroutine.

BACKGROUND: The prevalence of blindness as defined by law could be reduced by the introduction of anti-vascular endothelial growth factor (VEGF) therapy. Because the treatment is governed by patient needs, mostly using morphological criteria, imaging diagnostics are of particular importance. The non-interventional OCEAN study investigates the treatment with ranibizumab in the clinical routine practice. In a subgroup of patients the interpretation of spectral domain optical coherence tomography (SD-OCT) scans by the treating physicians will be analyzed (ORCA module). METHODS: Over a period of 24 months data from patients with exudative age-related macular degeneration (AMD), macular edema due to retinal vein occlusion or diabetes mellitus, who are receiving intravitreal injections of ranibizumab, will be assessed. Information on examinations, visual acuity, treatment and recordings from imaging techniques will be documented using a questionnaire. The SD-OCT scans, fluorescence angiography and fundus photography will be independently analyzed by the ophthalmologist of the study center and by three reading centers (CIRCL Cologne, GRADE Bonn and M3 Münster). Automated measurements of retinal thickness by the manufacturers' software will be checked and if necessary manually corrected. A qualitative interpretation in terms of morphological criteria for (further) treatment will be performed. CONCLUSION: A thorough assessment of SD-OCT images during anti-VEGF therapy provides the basis for the best possible needs-oriented treatment regimen. The control of the quality of data from daily routine practice may indicate possible weaknesses allowing explicit training and therefore optimization of patient treatment.

[Serous vascularized pigment epithelial detachment in exudative AMD. Morphological typing and risk of tears in the RPE]. / Seröse vaskularisierte Pigmentepithelabhebungen bei exsudativer altersbedingter Makuladegeneration : Morphologische Typisierung und Risiko eines Einrisses im retinalen Pigmentepithel.

PURPOSE: Are there any morphological parameters in pigment epithelial detachment (PED) in eyes with age-related macular degeneration (AMD), which could identify the development of tears (RIP) in the retinal pigment epithelium (RPE) before initiation of anti-vascular endothelial growth factor (VEGF) therapy? METHODS: Retrospectively, the spectral domain optical coherence tomography (SD-OCT), FLA and near infrared (NIR) images of 98 eyes with PED in exudative AMD before treatment (ranibizumab or bevacizumab) were analyzed. Eyes in which a tear in the RPE (RIP group) could be observed during treatment were compared to eyes without the development of RIP (PED group) in the following morphological parameters of PED: height, number of peaks, presence of hyporeflective fissures at the base of the PED, structure of the RPE, presence of floating structures in the PED with maximum hyperreflectivity, amount and localization of hyperreflectivity in the PED and hyperreflectivity in the NIR images. RESULTS: In the 80 eyes of the PED group the mean PED height was 373.7± 197 µm and in the 18 eyes of the RIP group the mean PED height was higher (694.2± 284.3 µm, p < 0.0001). A difference was also seen in the number of peaks per PED (PED group 43%, RIP group 72%, p = 0.039) and in the hyperreflectivity in NIR images (PED group 68%, RIP group 94%, p = 0.033). There were no significant differences in the other morphological parameters. A classification into four types of PED was found by the parameters height and number of peaks. The PED type with a height > 350 µm and one peak (RIP 43%) developed tears more often (p = 0.001) than the PED type < 350 µm with one peak (RIP 0%, p = 0.001). A trend in the visual acuity over 156 weeks was seen: in PED types with heights > 350 µm there was a lower increase in the visual acuity than in PED types < 350 µm (rm ANOVA p = 0.18; ɛ HH = 0.88). Furthermore, in PED types > 350 µm with multiple peaks the total number of injections necessary was higher than in the other PED types (p = 0.032). CONCLUSION: Morphological parameters, such as PED height, number of peaks per PED in OCT images and hyperreflectivity in NIR images are prognostic factors for RPE tears in exudative AMD. The PED height and number of peaks per PED are useful for classification of PED in the daily routine.

[Change of therapy from ranibizumab to aflibercept for recurrent or persistent exudative age-related macular degeneration]. / Therapiewechsel von Ranibizumab zu Aflibercept bei rezidivierender oder persistierender exsudativer altersbedingter Makuladegeneration.

BACKGROUND: Even during consistent anti-vascular endothelial growth factor (VEGF) therapy a reactivation of exudative age-related macular degeneration (AMD) lesions can be observed in many patients. The present case series examined whether a switch from ranibizumab to aflibercept is safe and whether differences in potency can be observed. PATIENTS AND METHODS: In 56 consecutive patients with recurrent activity of AMD according to the morphological criteria of the spectral domain optical coherence tomography (SD-OCT) examination, a change to aflibercept was made after 6-41 (mean 18.9, SD 6.3) injections with ranibizumab. In all controls and before each injection logMAR visual acuity was measured and a SD-OCT (volume scan) was performed in addition to the clinical examination. RESULTS: The mean visual acuity was stable under both therapies. The analysis of the morphological parameters showed a greater reduction of the retinal thickness after the change in therapy (mean retinal thickness within 1000 µm and central foveal thickness) compared to the initial treatment. The changes in the subretinal fluid as well as the height of an associated pigment epithelial detachment (PED) did not show any significant differences. The analysis of the morphological parameters at the level of the photoreceptors showed a decrease in discontinuity in the ellipsoid layer and also in the external limiting membrane (ELM). CONCLUSION: In patients with recurrent or high SD-OCT-based activity of exudative AMD lesions, a switch of the treatment strategy from ranibizumab to aflibercept can achieve a new functional stability in spite of multiple pretreatment. We found morphological indications of a regression of intraretinal edema and improvement in the photoreceptor area. In the context of a well-defined treatment strategy, a switch from anti-VEGF therapy to a similar active substance is safe. Before a definitive evaluation can be made, prospective controlled conditions are required to verify the clinical benefits of the switch.

Chronic modifications of lung and heart development in glucocorticoid-treated newborn rats exposed to hyperoxia or room air.

We assessed the mechanics and morphology of the lung in 165 rats treated neonatally with either room air (RA), O2, RA + steroids, or O2 + steroids. Newborn Sprague-Dawley male rats were randomly assigned to these groups. O2-exposure (0.96-1.0 FiO2) lasted 5 days, and dexamethasone treatment consisted of eight daily S.C. injections of drug or buffer in successive doses of 0.5, 0.4, 0.3, 0.2, 0.1, 0.1, 0.1, and 0.1 mg/kg. At 58 days, right ventricular systolic pressure (RVP) was measured. At 60 days, all rats were sacrificed for obtaining lung weight and DNA, saline pressure-volume (P-V) curves, and morphometry. We weighted right ventricles (RV) and left ventricles + septa (LV). Hyperoxia alone did not, but steroid decreased survival rate to 79.4% (95.3% in RA rats, P < 0.02). Only 21 of 40 (52%) O2 + steroids rats survived, less than in both RA groups (P < 0.001). RV weight, RVP and muscularization of alveolar duct arteries were significantly increased in O2 vs. RA rats. In RA + steroids rats, weight of the LV was decreased but RV, RVP, and lung vasculature were not affected. These effects were additive in the O2 + steroid group. Wet lung weights and DNA were increased for RA + steroid rats over all others. O2 and steroids shifted the P-V curve to the left and O2 + steroids still further. Maximal lung volume increased significantly with RA + steroids and still further in O2 + steroids but not in O2 alone. O2 and steroids significantly increased the mean linear intercept and O2 + steroids even more so.(ABSTRACT TRUNCATED AT 250 WORDS)

[Tear in retinal pigment epithelium under anti-VEGF therapy for exudative age-related macular degeneration : function recovery under intensive therapy]. / Einriss im retinalen Pigmentepithel unter Anti-VEGF-Therapie bei der exsudativen altersbedingten Makuladegeneration : Funktionserholung unter intensiver Therapie.

This article reports the case of a 72-year-old woman with pigment epithelial detachment with occult choroidal neovascularization (CNV) in exudative age-related macular degeneration (AMD) which developed under anti-vascular endothelial growth factor (VEGF) therapy of a tear in the retinal pigment epithelium (RPE). In the area of free RPE autofluorescence was completely absent and the microperimetry in this area showed an absolute scotoma. The visual acuity was 0.1. After continuation of anti-VEGF therapy because of persistent subretinal and intraretinal fluid over 3 years an increased autofluorescence was observed and the microperimetry showed an increase in central retinal sensitivity. The central visual acuity improved to 0.5 and in this area a whitish subretinal tissue formed morphologically. In the spectral domain optical coherence tomography (SD-OCT) image this structure was hyperreflective which might suggest a certain regeneration process of the RPE under anti-VEGF-therapy.

[Anti-VEGF therapy of exudative AMD: Prognostic factors for therapy success]. / Anti-VEGF-Therapie der exsudativen AMD: Prognostische Faktoren für den Therapieerfolg.

BACKGROUND: The aim of the study was to evaluate possible prognostic and predictive factors (morphologic and functional) of the individual visual gain/decline after anti-VEGF therapy of exudative AMD. PATIENTS/METHODS: Best corrected visual acuity (VA), microperimetric sensitivity (RS), retinal thickness (RT) and autofluorescence pattern (AF) were documented in 128 patients with exudative AMD. RESULTS: Eyes with classic choroidal neovascularization (CNV) had the best visual gain but still remained at a lower level. Eyes which initially had the lowest VA had the largest gain and those with good initial VA could maintain this level. There was no correlation between RT and visual outcome. Eyes with initially normal AF had a significantly greater visual gain. CONCLUSIONS: The type of CNV, initial VA, RS and the initial RT were only of limited usefulness, while the initial foveal AF was most important predictive factor. This may indicate that preexisting changes and irreversible damage in the outer retina and/or retinal pigment epithelium are responsible for the resulting VA after therapy.