[Suprachoroidal Hydrogel Buckle - a New Minimal-Invasive Technique in Treatment of Rhegmatogenous Retinal Detachment]. / Suprachoroidale Hydrogelplombe ­ eine neue minimalinvasive Technik zur Behandlung der rhegmatogenen Netzhautablösung.

The suprachoroidal hydrogel buckle is a new, simple and safe procedure for the treatment of rhegmatogenous retinal detachment. This technique combines the advantages of modern vitrectomy and classic buckling surgery. Placing the suprachoroidal buckle is possible as a stand-alone procedure or in addition to vitrectomy. The cross-linked hyaluronic acid seems to be the ideal agent for the suprachoroidal buckle with a buckling effect over 8 weeks. We need further investigations with long-term results.

Efficacy of Vitrectomy Combined with Subretinal rtPA Injection with Gas or Air Tamponade.

Background Functional and anatomical outcome after vitrectomy with rtPA combined with gas or air tamponade. Patients and methods Retrospective analysis of pseudophakic patients treated with subretinal rtPA and gas or air tamponade. The primary endpoint was displacement of haemorrhage six months after surgery. The secondary endpoints were visual acuity (BCVA), haemorrhage diameter (MHD) and central macular thickness (CMT), as measured by SD-OCT. Results 53 of 85 eyes were pseudophakic. 27 of these eyes were treated with air tamponade and 26 with gas tamponade. For patients with air tamponade, the mean BCVA improved from 20/530 to 20/355 (p = 0.01). MHD and CMT decreased from 6386 ± 2281 µm to 3805 ± 2397 µm (p < 0.001) and 895 ± 592 µm to 532 ± 386 µm (p < 0.001), respectively. For patients with gas tamponade, the mean BCVA improved only slightly, from 20/471 to 20/394 (p = 0.17). MHD and CMT exhibited statistically significant decreases from 6759 ± 1773 µm to 3525 ± 1548 µm (p < 0.001) and 1089 ± 587 µm to 537 ± 251 µm (p < 0.001), respectively. Conclusions Vitrectomy with subretinal rtPA injection has strong functional and anatomical effects on submacular haemorrhages with both gas and air tamponade.

[Clinical results after Descemet membrane endothelial keratoplasty]. / Klinische Ergebnisse nach Descemet-Membran-Endothelzelltransplantation.

BACKGROUND: Diseases of the endothelial cell layer represent a common indication for perforating keratoplasty. In recent years posterior lamellar keratoplasty techniques have undergone a revival. The latest and most promising advancement is the isolated transplantation of Descemet's membrane (DM) with the endothelial layer - also known as Descemet's membrane endothelial keratoplasty (DMEK). This study was conducted to evaluate the clinical results of our DMEK patients and to assess the perioperative management. PATIENTS AND METHODS: 70 patients (75 eyes) with endothelial cell decompensation (50 eyes with Fuchs endothelial dystrophy and 25 eyes with bullous keratopathy) had undergone DMEK surgery at the Tübingen Eye Clinic. Visual acuity, refractive error, intraocular pressure, slit lamp examination, pachymetry and endothelial cell density were considered and re-examined at intervals of 1, 2 and 4 weeks postoperatively with further 3 monthly follow-ups. RESULTS: The mean age of the 45 female and 25 male patients at time of surgery was 73 years (36 to 91 years). The mean follow-up period was 12.1 months. One patient received an autologous and 4 patients a triple procedure. The mean preoperative LogMAR visual acuity was 0.87 ± 0.41. After 1 week a LogMAR visual acuity of 0.82 ± 0.4 was observed (p = 0.544). At the final examination the LogMAR visual acuity was 0.32 ± 0.35 (p < 0.001, a highly significant result as compared to the preoperative value). The most common and important complication was the dislocation of the transplant which was seen in 23 eyes (31 %). The use of intracameral air pressurisation re-appositioned most transplants. Complications such as highly elevated intraocular pressure, epithelial inclusions or endophthalmitis were not noted in any patient. CONCLUSIONS: DMEK surgery lead to a significant visual rehabilitation in a majority of patients in a relatively short postoperative period. It may be considered as a gold standard to treat isolated endothelial diseases as has been implicated by other studies. Thus, the safety and efficiency of this new type of posterior lamellar keratoplasty technique has been confirmed.

[Preservative-free triamcinolone versus purified triamcinolone preparations]. / Primär konservierungsmittelfreies Triamcinolon im Vergleich zu aufgereinigten Triamcinolonpräparaten.

BACKGROUND: Intravitreal injections of triamcinolone are not only an important therapeutic tool for a variety of vitreo-retinal disorders, but can also be employed for visualisation of the vitreous during pars plana vitrectomy. Triesence® is a preservative-free triamcinolone suspension that has been approved for visualisation during vitrectomy via intravitreal administration and as intravitreal therapy for certain rare ocular diseases. However, the differences between Triesence® and purified (and thus also preservative-free) triamcinolones such as Volon A® or Kenalog® are not well specified, although the manufacturer of Triesence® advertises the product as "specifically formulated for the eye". METHODS: The publicly available FDA application material and information provided by the manufacturer for Triesence®, Kenalog® and Volon A® were analysed with respect to the differences between Triesence® and older triamcinolone preparations. RESULTS: According to the publicly available FDA documents the approval of Triesence mainly was based on studies that have been conducted with the older triamcinolone preparations Kenalog® or purified Volon A®. Apart from the absence of preservative the differences between Triesence® and the "older" triamcinolone preparation seem marginal. Published experimental or clinical studies in respect to the possible advantages of Triesence® compared to Kenalog® or Volon A® are lacking. Triesence® has been approved for sympathetic ophthalmia, temporal arteriitis, uveitis unresponsive to topical corticosteroids and for enhancing tissue visualisation during vitrectomy. Recently, the manufacturer of Kenalog® added a warning label ("not for intraocular use") on each vial of Kenalog®. The motifs for this re-labelling of Kenalog® remain unclear. CONCLUSION: Apart from the intraoperative use during vitrectomy Triesence® has only been approved for sympathetic ophthalmia, temporal arteriitis, and ocular conditions unresponsive to topical steroids. Consequently, the use of Triesence® like the older triamcinolone preparations (Kenalog® or Volon A®) for diabetic macular oedema, for Irivine-Gass syndrome, for neovascular AMD or after retinal vein occlusion is off-label.

[Clinical results after cataract surgery in patients with Behçet's disease]. / Ergebnisse nach Kataraktchirurgie bei Patienten mit Behçet-Erkrankung.

BACKGROUND: Behçet's disease is a systemic vasculitis disorder of unknown aetiology. Ocular involvement, especially with vasculitis, is detected in up to 80 % of the cases. Anterior segment involvement such as cataract is also seen in the follow-up of patients who are then treated surgically. In this study, we aimed to analyze the outcomes of cataract surgery in patients with Behçet's disease retrospectively. PATIENTS AND METHODS: The records of 9 patients (12 eyes) with Behçet's disease who underwent phacoemulsification with IOL implantation in 11 eyes and extracapsular cataract extraction (ECCE) with IOL implantation in one eye between June 2001 and September 2009 were evaluated retrospectively. The visual outcome and complications were analysed. RESULTS: The mean follow-up was 33.8 months (range 3 to 88 months). The mean preoperative LogMAR BCVA was 1.15 ± 0.53 (95 % CI: 0.81 - 1.49) and increased to 0.36 ± 0.32 (95 % CI: 0.15 - 0.56) at last medical visit (p < 0.001). The most frequent postoperative complication was posterior capsular opacification, which developed in 2 eyes (17 %). Other complications were mild fibrinous reaction in 1 eye (8 %). CONCLUSIONS: The outcomes of cataract surgery in patients with Behçet's disease were satisfactory. The great majority of the patients regained and retained a good visual outcome and had fewer postoperative complications.

[Postoperative endophthalmitis-a review of literature]. / Postoperative Endophthalmitis im Spiegel der Literatur.

Postoperative endophthalmitis is one of the most feared complications for ophthalmologists, and the number of infections after intraocular procedures have been increasing. Nonetheless, a prompt intervention can result in the recovery of vision. In the past, endophthalmitis after cataract surgery was accountable for the majority of cases but is becoming less frequent due to the progress of surgical techniques and demographic developments with a steadily increasing number of intravitreal injections. In this article, the different forms of postoperative endophthalmitis are assessed in terms of pathophysiology and their specific characteristics depending on their etiology.

[Pathophysiology of cataract formation after vitrectomy]. / Pathophysiologie der Katarakt-Entwicklung nach Vitrektomie.

Cataract formation is one of the most common complications after vitrectomy and cataract extraction in such cases will have to be performed under more difficult conditions. A knowledge of the different types of cataract, their frequency and causes may help to develop strategies to prevent this complication. In addition to a progressive nuclear opacification, which may occur after any type of vitrectomy, transient feathering of the lens often occurs after intraocular gas tamponade, while permanent subcapsular opacification may occur in silicone oil-filled eyes. Nuclear opacification after vitrectomy morphologically and histologically resembles age-related cataracts, but shows a faster progression: two years after vitrectomy half of the eyes require cataract extraction and there seems to be an age limit: the opacification progresses faster in patients over 50 years old. The main cause for nuclear cataracts most probably is oxidative stress. Oxygen in the avascular lens is provided by diffusion, meaning that the surrounding oxygen content is crucial for the oxygen content within the lens and thus for the formation of reactive oxygen species. In rabbits and also in humans the partial oxygen pressure is highly elevated in the vitreous cavity after vitrectomy and posterior to the lens since the vitreous is lacking as a diffusion barrier for the oxygen. The partial oxygen pressure might be additionally elevated by ventilation with oxygen and a high oxygen pressure in the infusion fluid during surgery. This elevated partial oxygen pressure may lead to increased oxygen stress and thus to lens opacification by oxidation of structural proteins. The key for the prevention of cataract formation therefore seems to be avoidance of oxidative stress, factors that might increase the protective or repair systems are so far not available. Ventilation with oxygen should be minimised as should be the partial oxygen tension in the infusion fluid. New hydrogels as vitreous substitutes might have a beneficial influence on intraocular partial oxygen tension.

[Current value of femtosecond laser-assisted cataract surgery]. / Aktueller Stellenwert der Femtosekundenlaser-assistierten Kataraktchirurgie.

After more than 10 years of experience with the femtosecond laser in cataract surgery, it can be concluded that the safety profile of femtosecond laser-assisted cataract surgery (FLACS) is comparable to that of conventional cataract surgery. This technique offers the possibility to perform incisions with a precision superior to that of any surgeon in the world, based on the connection of preoperative and intraoperative diagnostics. This results in new possibilities to revolutionize the surgical procedure of cataract surgery and to generate new therapeutic approaches for the treatment of cataracts. The combination of keratotomy for correcting astigmatism, intraocular lenses supported by capsulotomy and individually adapted fragmentation patterns is already a component of a personalized cataract surgery.

[Progressive maculopathy despite discontinuation of chloroquine treatment-multimodal imaging and review of the literature]. / Progressive Makulopathie trotz Absetzen der Chloroquin-Therapie ­ Multimodale Bildgebung und Review der Literatur.

This case report presents a pictorially well-documented case with multimodal images of a progression of maculopathy despite discontinuation of chloroquine treatment in a long-term follow-up over 6 years. Additionally, the current detection methods in screening for early recognition of maculopathy and their prognostic significance are reviewed.

[Vitreous substitutes as drug release systems]. / Glaskörperersatz als Möglichkeit zur protrahierten Freisetzung von Medikamenten im Glaskörper.

Despite major improvements of vitreo-retinal surgical techniques proliferative vitreoretinopathy (PVR) remains a major challenge. Surgical therapy alone may not be sufficient in complicated cases of PVR. A combination of standard techniques such as pars plana vitrectomy with a vitreous substitute and a simultaneous adjuvant pharmacological treatment for the suppression of undesired proliferation of retinal cells and retinal scarring may be a promising therapeutic approach. However, due to the narrow therapeutic range and the short biological half-life of most anti-proliferative or anti-inflammatory drugs in the vitreous cavity, intravitreal slow-release systems for extended drug delivery are desirable. Vitrectomy for PVR normally requires a vitreous substitute. Consequently, a vitreous substitute that could also serve as a slow-release system for anti-proliferative or anti-inflammatory drugs would provide several advantages. This review gives an overview of recent developments of slow-release systems that may also be suitable as vitreous substitutes. Even standard internal tamponades such as silicone oils or gases may serve as extended drug-release systems under certain conditions. In the mean time polymerised hydrogels have been developed, which apart from providing an adequate tamponade effect, may facilitate an extended intravitreal release of various anti-proliferative and anti-inflammatory drugs for several weeks.

[Heavy liquids as intraoperative instrument in retinal surgery]. / Schwere Flüssigkeiten als intraoperatives Instrument in der Netzhautchirurgie.

The introduction of perfluorocarbon liquids (PFCL) resuled in a significant change in vitreoretinal surgery. Even complicated retinal detachments could be treated reliably and successfully. The combination of vitrectomy with the use of PFCL was one of the decisive factors for the continuing success of pars plana vitrectomy (ppV) in addition to technical refinements. The PFCLs have become an established part of vitreoretinal surgery due to their wide range of application and the positive intraoperative influence. When applied correctly and intelligently, PFCL can serve as the third hand of a retinal surgeon. Contrary to the widespread scepticism, the currently discussed toxicity of PFCL is negligible for short-term use.

[LHON-Treatment option despite poor initial visual acuity?] / LHON ­ Behandlungsoption trotz schlechtem Ausgangsvisus?

A case of Leber's hereditary optic neuropathy is reported in order to draw attention to this rare mitochondrial disease in the differential diagnostics and to show current treatment options. In this case despite very poor initial visual acuity and late start of treatment an improvement of visual acuity relevant for the patient could be achieved.

[New developments in retinal detachment surgery]. / Neue Entwicklungen in der chirurgischen Therapie der rhegmatogenen Ablatio retinae.

The initial surgery is one of the most important factors influencing the anatomic and functional outcome of retinal detachment surgery. With the continual modifications in vitrectomy techniques, the strategy in primary vitrectomy surgery is also changing. Recent developments are the use of 25- and 23-gauge trocar systems and new surgical techniques without the use of perfluorcarbons or gas or silicone oil tamponade. In addition, heavy silicone oils are now entering routine clinical use, especially for proliferative vitreoretinopathy (PVR) redetachments of the lower fundus periphery. Regarding adjunct pharmacologic therapy, daunorubicin and 5-fluorouracil/low molecular weight heparin have been found to improve the results of patients with PVR or at risk for PVR.

[Optic atrophy subsequent to epiretinal triamcinolone deposits in an eye following inner limiting membrane peeling]. / Optikusatrophie nach epiretinalen Triamcinolon-Ablagerungen in einem Auge mit entfernter Membrana limitans interna.

BACKGROUND: Although current in vitro studies show local cytotoxicity of triamcinolone (TA) crystals if they are in direct contact with cells, a toxic effect of epiretinal TA deposits has not been reported yet clinically. For the first time, we present a case of potential cytotoxicity of epiretinal TA deposits in vivo. CASE REPORT: A 68-year old patient underwent a re-vitrectomy with peeling of a macular pucker and the internal limiting membrane (ILM) combined with an intravitreal injection of 25 mg TA due to a secondary macular pucker with cystoid macular edema. Postoperatively, pronounced epiretinal deposits of TA crystals were identified in the area of the posterior pole. Two months after the injection a consecutive optic atrophy with central visual field defect and severe reduction of the visual acuity to hand movements was apparent. CONCLUSION: Our case report indicates possible in-vivo toxicity of TA deposits in eyes subsequent to vitrectomy and peeling of the ILM. This is in accordance with previous in-vitro studies showing ILM and vitreous to be protective biological factors, but demonstrate pronounced cytotoxicity if TA crystals are allowed to directly adhering to denuded ganglion cells. Hence, we consider that TA injection should be carefully weighed in those patients with prior ILM removal.

[Scleromalacia associated with varicella-zoster virus]. / Varizella-zoster-Virus-assoziierte Skleromalazie.

BACKGROUND: Scleromalacia usually appears following vasculitis in systemic rheumatoid diseases, especially as a late symptom of rheumatoid arthritis. CASE REPORT: A 67-year-old woman was referred to our hospital for further evaluation with the diagnosis of a "fast-growing tumor" of the left eye. Sixteen months ago she had suffered from herpes zoster ophthalmicus-associated keratouveitis and trabeculitis in the same eye. Scleromalacia associated with varicella-zoster virus (VZV) was diagnosed after the biomicroscopic and gonioscopic examination of the eye was completed and a systemic disease had been ruled out. One week after beginning systemic application of acyclovir (5 x 800 mg daily) and prednisolone (30 mg daily), the anterior chamber inflammation regressed and a fibrosis seemed to appear in the atrophic scleral area. CONCLUSION: Although scleral atrophy mostly appears as a late sign of systemic rheumatoid diseases, it might also develop secondary to infectious diseases. Scleromalacia associated with varicella-zoster virus has been previously described only in a few cases. Scleromalacia is a vision-threatening complication of zoster ophthalmicus which responds well to combination therapy with systemic antiviral and anti-inflammatory agents.

[Suprachoroidal hydrogel buckling]. / Suprachoroidale Hydrogelplombe.

Suprachoroidal hydrogel buckling is a simple and safe procedure for the treatment of rhegmatogenous retinal detachment. The advantages of modern vitrectomy and classical buckling surgery are combined in this surgical approach. Suprachoroidal buckling can be performed as a stand-alone procedure or in addition to vitrectomy. Cross-linked hyaluronic acid with a resorption time of up to 8 weeks is a suitable agent for this technique. Further studies will help to establish suprachoroidal buckling as a surgical procedure for treatment of retinal detachment.

[Acute monocular loss of vision : Differential diagnostic considerations apart from the internistic etiological clarification]. / Akuter monokularer Visusverlust : Differenzialdiagnostische Überlegung abseits der internistisch-ätiologischen Abklärung.

We report the case of acute painless monocular loss of vision in a 53-year-old man. An interdisciplinary etiological evaluation remained without pathological findings with respect to arterial branch occlusion. A reevaluation of the patient history led to a possible association with the administration of phosphodiesterase type 5 inhibitor (PDE5 inhibitor). A critical review of the literature on PDE5 inhibitor administration with ocular participation was performed.

[Novel vitreous body replacement with hydrogel?] / Neuer Glaskörperersatz mit Hydrogel?

Although the surgical treatment of rhegmatogenous retinal detachment has advanced, there still is a significant risk of redetachment and a slow visual rehabilitation due to the use of endotamponades. Hydrophobic tamponades act via a buoyancy vector causing an accumulation of proinflammatory cytokines opposite the buoyancy vector. So far, the use of hydrophilic endotamponades is very promising because they represent a possible solution for the abovementioned problems of surgical ablation. This article presents the current developments in this field.

Surgical treatment of peripapillary choroidal neovascularisation.

OBJECTIVE: To report the functional and morphological outcome of surgical treatment of peripapillary choroidal neovascularisation due to age-related macular degeneration. METHODS: Consecutive interventional case series of eight patients with extensive peripapillary choroidal neovascularisation and accompanying haemorrhage who underwent subretinal surgery including extraction of the neovascular complex. Ophthalmic examination, including visual acuity testing, colour photography and fluorescein angiography, was performed at baseline and at 3, 6, 9 and 12 months, and then yearly. RESULTS: Mean follow-up was 26 months (12-60 months). Preoperative best corrected visual acuity (BCVA) ranged from logMAR (logarithm of minimum angle of acuity) 1.0 (20/200) to logMAR 0.0 (20/20), with a mean of logMAR 0.5 (20/63). Mean postoperative BCVA was logMAR 0.3 (20/40). BCVA improved in six patients, was stable in one patient and deteriorated in one patient. Two years after surgery, one patient developed recurrence of the CNV that was removed surgically. One patient showed retinal detachment 5 years after subretinal surgery. CONCLUSIONS: In this small case series of PPCNV, functional improvement was achieved after surgery in the majority of patients. Surgical extraction of the CNV represents an alternative treatment option in eyes with vision-threatening extensive PPCNV. Randomised controlled studies seem to be justified to evaluate further the beneficial effect and long-term functional outcome of this therapy approach.

Rapid development of band keratopathy of corneal graft associated with treatment with intracameral recombinant tissue plasminogen activator for postoperative fibrin reaction.

PURPOSE: To report a corneal transplant complication associated with intracameral recombinant tissue plasminogen activator (rTPA) treatment of postoperative fibrin reaction. METHODS: In a 71-year-old patient, a triple procedure was performed for perforated rheumatic ulcer and secondary cataract. RESULTS: A dense band keratopathy developed rapidly within 36 hours after the use of intracameral injection of rTPA for the treatment of a dense fibrin clot. CONCLUSIONS: This is the first report of rapid development of massive band keratopathy in a corneal graft after triple procedure and treatment with intracameral rTPA. Intracameral rTPA should be used with caution in patients with attenuated endothelium.