Semi-automated quantification of vitreal hyperreflective foci in SD-OCT and their relevance in patients with peripheral retinal breaks.

BACKGROUND: Retinal breaks (RB) are emergencies that require treatment to prevent progression of rhegmatogenous retinal detachment. Vitreal hyperreflective foci (VHF) representing migration of RPE cell clusters or interphotoreceptor matrix from the RB are potential biomarkers. The aim of this study is to investigate VHF in RB-patients using SD-OCT. METHODS: The retrospective cross-sectional study included RB patients from our Department of Ophthalmology, HSK Wiesbaden who underwent macular SD-OCT (SPECTRALIS®, Heidelberg Engineering, Germany) on both eyes. VHF, defined and quantified as foci that differ markedly in size and reflectivity from the background speckle pattern, were assessed for presence and frequency. The RB-affected eyes were the study group (G1), the partner eyes the control group (G2). RESULTS: 160 consecutive patients with RB were included. Age was 60 ± 10.2 years (52% female). 89.4% of G1 and 87.5% of G2 were phakic (p = 0.73). 94.4% (n = 151) were symptomatic. Symptom duration was 8.0 ± 10.1 days in G1, 94.4% (n = 151) showed VHF versus 5.6% (p < 0.0001) in G2, of which 75% (n = 6) showed asymptomatic lattice degenerations. Detectable VHF showed a strong association of OR = 320 (95% CI, 110-788, p < 0.0001)) with respect to symptomatic RB. Sensitivity and specificity were 94.7% and 94.7%, respectively. CONCLUSIONS: Most eyes with symptomatic RB show vitreal VHF in SD-OCT. Detected VHF are strongly associated with RB, and our semi-automated greyscale reflectivity analysis indicates that VHF likely originate from photoreceptor complexes torn out of the RB area that migrate into the vitreous cavity. The presence of VHF may indicate RB and should lead to a thorough fundus examination in both symptomatic and asymptomatic cases.

[Full depth imaging: a new imaging technique using optical coherence tomography (OCT)]. / Full Depth Imaging: neue Aufnahmetechnik mittels optischer Kohärenztomografie (OCT).

PURPOSE: The aim of this study was to evaluate the full depth imaging (FDI) mode as a new acquisition technique with spectral domain (SD) optical coherence tomography (OCT) from Heidelberg Engineering for illustrating vitreoretinal and choroidal structures with high contrast. METHODS: Patients with different diseases such as age-related macular degeneration, chorioretinopathia centralis serosa, diabetic retinopathy and epiretinal gliosis were examined with the FDI mode. For comparison, we also examined healthy probands with conventional OCT and the enhanced depth imaging (EDI) mode. FDI images were obtained with a manual acquisition technique. First, 100 conventional OCT scans of the vitreoretinal interface were averaged. After manual switching to the EDI mode the previous averaged image was overlayed with EDI images until vitreous, retina and choroid were projected in one comparably sharp image. RESULTS: The FDI mode enables SD-OCT images showing the vitreoretinal interface and deep choroid structures with a high contrast. The new acquisition mode has a few limitations: it is only possible to perform a single linear scan, a raster scan is not possible. The FDI mode is a manual acquisition technique and not automated yet. CONCLUSION: By a combination of averaged images of the vitreoretinal interface with the help of conventional SD-OCT scans with EDI OCT scans the FDI mode exhibits a simultaneous contrast image of the posterior vitreous, the retina and the choroid. Whereas the application of OCT was focused to evaluate the retina-retinal pigment epithel complex, the routine reinforcement of FDI scans could additionally show potential vitreous and choroidal pathologies. As the FDI mode is not an automated application yet it may be too complex to use for routine diagnostics at the moment.

[Primary intrastromal iris cysts]. / Primäre stromale Iriszysten.

BACKGROUND: Cysts of the iris are uncommon and most of them occur secondarily after surgery or penetrating injury. The minority of the iris cysts is primary without a reasonable cause. They are classified into the more common pigment epithelial cysts and the rare cysts of iris stroma ("intrastromal cysts"). These intrastromal iris cysts are generally diagnosed in children and often cause symptoms such as a decrease of visual acuity because of ingrowth into the optical axis. A diagnosis of stromal cysts in adults is very rare. Most of these patients remain without any symptoms and do not need treatment. The cellular origin is so far unknown. Mesoderm, neuroectoderm and surface ectoderm have been discussed in this context. CASE REPORTS: Two patients with primary intrastromal iris cysts are presented, a 5-year-old boy and a 65-year-old woman. In both cases, the cyst affected the optical axis and was removed by sector iridectomy. In histological and electron-microscopic examinations both cysts presented a typical epithelial structure. Immunohistochemical examination revealed positivity for epithelial markers and negativity for mesenchymal and neuroectodermal markers. CONCLUSION: Primary intrastromal iris cysts can occur in advanced age and may cause symptoms due to progressive growth. The cellular origin of primary intrastromal iris cysts is controversially discussed in the literature. On electron microscopy and immunohistochemistry, the iris cysts presented here showed characteristic features of surface ectodermal origin.

Treatment of peripapillary choroidal neovascularization with intravitreal bevacizumab.

PURPOSE: Peripapillary choroidal neovascularization (CNV) is an uncommon condition and often shows a growth tendency towards the fovea during spontaneous progression that threatens visual acuity. Treatment of peripapillary CNV is difficult. The authors report results of intravitreal bevacizumab therapy for peripapillary CNV. METHODS: Four patients with CNV located in the temporal or superior peripapillary area received intravitreal bevacizumab injections. Ophthalmologic examinations including OCT were performed at baseline and at 6-week intervals. Fluorescein angiography was performed at baseline and depending on clinical and OCT findings. The mean follow-up was 34+/-20 (22-69) weeks. RESULTS: The patients received an average of 3.5+/-3.1 (1-8) injections. In all patients fluorescein angiography showed inactivation of peripapillary CNV. No further increase in size was observed in any of the patients. The OCT showed a decrease of intraretinal and subretinal fluid. No intraocular or systemic side effects were observed. CONCLUSIONS: In this series of patients, intravitreal bevacizumab appears to be efficacious. A progression of peripapillary CNV could be prevented in all patients and the lesion was successfully inactivated. Anti-VEGF treatment with bevacizumab represents a promising therapy option for peripapillary CNV.

[Light exposition in vitreoretinal surgery. I. Basics]. / Lichtexposition bei vitreoretinaler Chirurgie. I. Grundlagen.

Due to its function of light perception, the eye is exposed to high levels of radiation of the optical spectrum. Most of the ultraviolet and infrared radiation is absorbed in the cornea and lens, and mostly only radiation of the visible spectrum can reach the retina. Visible light can cause retinal damage by photomechanical, photothermal, and photochemical mechanisms. The most important mechanism of light damage to the retina under daily conditions or when using ophthalmologic light sources is the photochemical light toxicity caused by light-induced chemical reactions. The extent of damage depends on several factors, such as wavelength, exposure time, and irradiance. Particularly the shorter portion of the visible light spectrum (blue light) is responsible for photochemical damage to the retina.

[Exposure to light during vitreoretinal surgery. II: Characteristics of endoilluminators]. / Lichtexposition bei vitreoretinaler Chirurgie. II. Physikalische Charakteristika von Endoilluminationssystemen.

PURPOSE: Light can cause phototoxic retinal damage. The aim of this study was to evaluate the risk of retinal hazard by endoilluminators during vitreoretinal surgery. METHODS: The spectra, radiance, and irradiance of six light sources with different associated fibre optics (20 G, 23 G, standard collimated, wide-angle diffuse) were measured and compared with thresholds published by international standardisation committees. RESULTS: The spectra of the endoilluminators differed significantly in the short wavelength band. The maximum radiance ranged from 15 mW to 190 mW and the calculated irradiance from 36 mW/cm2 to 1,130 mW/cm2 (distance 5 mm) and from 9 mW/cm2 to 376 mW/cm2 (distance 10 mm). Compared with published thresholds for surgery, time limits ranging from 0.7 min to 264 min (distance 5 mm) and 2.7 min to 1,052 min (distance 10 mm) seem to be safe. CONCLUSIONS: Light systems used for vitreoretinal surgery differ considerably in spectra, radiance, and irradiance; these differences have an impact on the maximum tolerable exposure times during surgery.

[Surgical treatment of lamellar macular hole]. / Operative Therapie bei Makulaschichtforamen.

PURPOSE: Vitrectomy and peeling in patients with lamellar macular hole was evaluated with regard to anatomical and functional outcome. PATIENTS AND METHODS: In a retrospective study, 10 patients with lamellar macular hole underwent vitrectomy, membrane-peeling (epiretinal membrane [ERM] and internal limiting membrane [ILM]) and gas (n=9) or silicone oil (n=1) endotamponade. In most patients (n=9), cataract surgery was also performed. Pre- and postoperative ocular coherence tomography (OCT) findings, visual acuity (ETDRS), and Birkhäuser near visual acuity were evaluated. RESULTS: Mean follow-up was 15+/-11 months after surgery with a minimum follow-up of 6 months. Best corrected visual acuity (BCVA) improved in all patients; the average BCVA gain was 3+/-2 lines. Preoperative mean BCVA was 0.35 (0.45+/-0.23logMAR), and postoperative BCVA was 0.64 (0.19+/-0.21logMAR). Eight of ten patients had a postoperative BCVA > or =20/40, and six patients had a postoperative BCVA > or =20/25. Mean near visual acuity was 0.5+/-0.26 (range 0.2-0.9). Postoperative OCT revealed a closed lamellar macular hole in six patients, with restored foveal contour in three of them. The other four patients showed a persistent inner retinal defect with an intact photoreceptor layer. CONCLUSION: Surgical treatment including vitrectomy, ERM-ILM-peeling and endotamponade appears to benefit patients with lamellar macular hole. All patients improved functionally. Surgical treatment can close the lamellar macular hole and restore foveal architecture.

[OCT-guided reinjection of 2.5 mg bevacizumab for treating macular edema due to retinal vein occlusion]. / OCT-Befund als Reinjektionskriterium für die 2,5-mg-Bevacizumab-Therapie bei venösen retinalen Verschlüssen.

BACKGROUND: Macular edema (ME) due to retinal vein occlusion can be successfully treated with intravitreal bevacizumab therapy. There is no common recommendation concerning time intervals and criteria for reinjection. METHOD: Sixty-three patients (follow-up 30+/-18 weeks) received intravitreal injections of 2.5 mg bevacizumab. Reinjection was performed only if optical coherence tomography (OCT) showed persistent or recurrent ME. Check-ups were performed every 6-8 weeks. RESULTS: There was complete resolution of macular edema in 31 patients after the first injection (improvement in visual acuity 3.7+/-3.7 lines); 65.2% of these patients developed recurrence of ME within 13.3+/-4.4 weeks, which completely resolved again after a second injection. Visual acuity gained the same level as after the first injection. Another relapse of ME in this group occurred in 69% of patients after another 13.4+/-5.4 weeks. Patients with persistent ME after the first injection (n=32) received a second injection, initially leading to resolution of ME in 33.3%, but all of these patients had a relapse within 13.9+/-4.1 weeks. CONCLUSION: OCT-guided reinjection leads to anatomic and functional stabilization or improvement even if transient recurrence of ME occurs.

[Intravitreal anti-VEGF therapy with bevacizumab for neovascular AMD]. / Intravitreale Anti-VEGF-Therapie mit Bevacizumab bei neovaskulärer AMD.

PURPOSE: To report on the efficacy of intravitreal bevacizumab as off-label therapy in different angiographic subtypes in neovascular age-related macular degeneration (AMD). METHODS: Seventy-five patients with neovascular AMD and recent disease progression were classified into different angiographic subtypes and were treated with intravitreal bevacizumab (1.25 mg/0.05 ml) at 6-week intervals. Patients with subfoveal classic choroidal neovascularization (CNV) also received photodynamic therapy. ETDRS visual acuity, ophthalmic exams, and optic coherence tomography (OCT) were performed before treatment, 1 week after treatment, and then on a 6-week basis. Fluorescein angiographies and medical check-ups were also done. RESULTS: Bevacizumab led to stabilization of visual acuity (loss of less than 15 letters) in all angiographic subtypes during a follow-up of 37+/-13 weeks. Patients with occult extrafoveal CNV (n=6) profited the most and gained 2+/-2 lines. Treatment with intravitreal bevacizumab was very well tolerated in all patients, with neither systemic nor intraocular side effects, with the exception of one retinal pigment epithelium tear. CONCLUSION: Intravitreal bevacizumab treatment is efficacious in all angiographic CNV subtypes and leads to reduction of macular edema and stabilization or improvement in visual acuity.

[Subcutaneous leiomyosarcoma metastatic to the eyelid]. / Lidmetastase eines subkutanen Leiomyosarkoms.

BACKGROUND: Metastatic eyelid lesions are rare. Most metastatic lesions to the eyelid are carcinomas. Leiomyosarcomas are soft tissue sarcomas arising most commonly in the uterus and gastrointestinal tract, whereas dermal leiomyosarcomas are less frequent. Dermal leiomyosarcomas metastatic to the eyelid have not been reported so far. CASE REPORT: A 28-year-old female patient presented with a rapidly growing tumor of her right lower eyelid. A subcutaneous leiomyosarcoma of the neck had been excised 21 months before with subsequent radiotherapy. Seven months later metastases to the lung, liver, and left upper arm were detected. The patient received chemotherapy. The eyelid tumor was completely excised. Histologically the lesion consisted of spindle cells arranged in fascicles with perinuclear vacuoles and myofilaments. There was a strong immunoreactivity for smooth muscle actin, and negative staining for cytokeratin and S100. CONCLUSION: Cutaneous and subcutaneous leiomyosarcomas occur at almost any age, but are most common between the 5th and 7th decades. They are more common in men and usually occur at the extremities. The prognosis of cutaneous/subcutaneous leiomyosarcoma correlates with the depth of the tumor. To our knowledge this is the first presentation of a subcutaneous leiomyosarcoma metastatic to the eyelid. Presumably, parenchymatous metastases of this tumor occur before dermal metastases arise.

[Central and branch retinal vein occlusion. Current strategies for treatment in Germany, Austria and Switzerland]. / Retinale Zentralvenen- und Venenastverschlüsse: Aktueller Therapiestand in Deutschland, Osterreich und der Schweiz.

BACKGROUND: The main object of this study was to find out what treatment methods are currently preferred for central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO) in Germany, Austria and Switzerland. METHODS: A questionnaire concerning the different medicamentous, surgical and laser treatments available for CRVO and BRVO was developed and sent out to the members of the German Retina Society. RESULTS: This analysis is based on 124 returned questionnaires. We found that 64% of our colleagues recommend isovolemic hemodilution in patients with CRVO. Pentoxyfyllin infusions are endorsed by 32% and 27%, respectively, for CRVO and BRVO. Panretinal photocoagulation is applied only if neovascularization is present by 39% of those responding, whereas 61% perform prophylactic photocoagulation when there is no visible neovascularization, depending on the degree of ischemia. In the case of macular edema due to BRVO 52% recommend macular grid photocoagulation. Sheathotomy is recommended by 51% for BRVO suggest, and 43% advise radial optic neurotomy (RON) for CRVO. Intravitreal injection of triamcinolone is performed for CRVO or BRVO by 58% and 56%, respectively, and para-bulbar injection of triamcinolone by 2% and 3%. Intravitreal anti-VEGF treatment is applied by 72% of respondents, the majority (94%) using bevacizumab for this purpose. CONCLUSION: Members of the German Retina Society apply widely differing treatments in patients with CRVO and BRVO. Further clinical studies to evaluate the different therapeutic options seem necessary in order to set up guidelines for the treatment of venous retinal occlusions.

[Bevacizumab for the treatment of macular edema secondary to retinal vein occlusion]. / Bevacizumab zur Therapie des Makulaödems infolge venöser retinaler Gefässverschlüsse.

BACKGROUND: Retinal vein occlusion often leads to macular edema as a result of an elevated level of intravitreal VEGF. We report on the anatomic and functional results after intravitreal bevacizumab injections in patients with retinal vein occlusion. METHODS: In a prospective study, 18 patients with central, and 22 patients with branch retinal vein occlusion, all of whom had persistent macular edema (>300 microm) received 2.5 mg intravitreal bevacizumab. ETDRS visual acuity, ophthalmic examination and stratus OCT were performed at baseline, 1 week after injection and then monthly. Further injections were given every 6 weeks in patients with persistent or recurring macular edema. RESULTS: The findings did not deteriorate in any of the 40 patients. The injections (mean of 2.6+/-1.4 injections/patient) were very well tolerated in all cases during a mean follow-up of 23+/-13 weeks. On the last visit, 73.3% of patients with central retinal vein occlusion and 76.5% of those with branch retinal vein occlusion were found to have significantly improved visual acuity (by at least 3 lines). Mean central retinal thickness had decreased from 921+/-264 to 239+/-66.2 microm in patients with central retinal vein occlusion, and from 678+/-221 to 236+/-78 microm in patients with branch retinal vein occlusion. CONCLUSIONS: Neither intraocular nor systemic side-effects were observed in this study after repeated intravitreal injections of 2.5 mg bevacizumab. Current results suggest that intravitreal anti-VEGF therapy is a promising option in macular edema secondary to retinal vein occlusion.

[Functional results after anatomically successful surgery for stage III/IV macular hole]. / Funktionelle Ergebnisse nach anatomisch erfolgreicher Makulaforamen-Stadium-III/IV-Chirurgie.

PURPOSE: To report the functional results after anatomically successful surgery for stage III/IV macular hole. METHODS: Follow-up examinations (ETDRS charts, Birkhäuser near visual acuity charts, OCT) were carried out in 29 patients 11+/-5 months after surgery for stage III/IV macular hole (hole size >400 microm); in all cases the foveal contour had been restored postoperatively . The surgery performed also included cataract surgery (n=26), vitrectomy, ICG-assisted ILM peeling (in which perfluorcarbon liquid was used to prevent ICG from coming in contact with the retinal pigment epithelium) and tamponade with intraocular gas (n=16) or silicone oil (n=13). Silicone oil had been removed by the time of the follow-up evaluation. RESULTS: Preoperative mean BCVA was 0.2 (0.64 logMAR+/-0.24) and postoperative BCVA, 0.5 (0.3 logMAR+/-0.19). None of the patients experienced any deterioration in sight; the average improvement in visual acuity was 3.5+/-2 lines. In 70% (n=20) of the patients the postoperative BCVA was > or =0.5. Visual acuity for near sight was 0.45+/-0.2. In 66% (n=19) a visual acuity of > or =0.4 was achieved for close work. The improvement in visual acuity was not related to the kind of endotamponade or to the size of the macular hole. Patients with macular hole diameters of 400-800 microm (n=20) gained 3.5+/-2.,4 lines, while in patients with macular hole diameters of 800-1135 microm the average gain was 3.6+/-1.3 lines. CONCLUSIONS: Anatomically successful macular hole stage III/IV surgery with ICG-assisted ILM peeling and protection of the retinal pigment epithelium from contact with ICG by perfluorcarbon liquid can yield good functional results.

[Radial optic neurotomy for central retinal vein occlusion -- how deep should it be?]. / Wie tief muss die radiäre Optikusneurotomie zur Therapie des retinalen Zentralvenenverschlusses sein?

PURPOSE: Most of the studies on radial optic neurotomy (RON) have not defined the depth of the incision. Complications following a deeper incision have been described. This histological study was performed to evaluate the required depth for RON. METHODS: Serial sections of the area of the optic nerve head were performed in 19 eye bank eyes. The distance between the inner surface of the optic disc and the outer limit of the cribriform plate was measured. Ten additional eye bank eyes underwent 2 mm deep experimental RON using the Spaide CRVO Knife (DORC, Netherlands). The cutting depth was assessed histologically by serial cuts. RESULTS: The distance between the inner surface of the disc and the outer limit of the cribriform plate measured 1.35+/-0.3 mm (shrinkage-revised value: 1.45 mm). The experimental RON showed cutting depths of 1.53+/-0.3 mm (shrinkage-revised value: 1.65 mm). CONCLUSION: Based on normal eyes, a cutting depth of 1.45 mm is sufficient to cut through the cribriform plate. This might change during central retinal vein occlusion because possible papillary edema due to central retinal vein occlusion has to be considered. Even under controlled experimental conditions RON leads to great variation in incision depths. The development of a knife with a fixed penetration depth would be helpful.

[Current strategies for macular hole surgery in Germany, Austria and Switzerland]. / Aktueller Stand der Makulaforamenchirurgie in Deutschland, Osterreich und der Schweiz.

BACKGROUND: Main aim of this study was to determine how macular hole surgery is currently being performed in Germany, Austria and Switzerland. METHODS: A questionnaire concerning the different aspects of surgery for stage 3 macular hole was developed and sent out to the 380 members of the German Retina Society. RESULTS: This analysis is based on 129 returned questionnaires from colleagues who perform macular hole surgery. A total of 95% (n=123) of the surgeons routinely perform vitrectomy with posterior vitreous detachment, peeling of epiretinal tissue and internal limiting membrane (ILM) peeling. Some 86% (n=106) stain the ILM, with 80% of these (n=85) using indocyanine green (ICG) in concentrations ranging from 0.005% up to 10%. Fourteen percent of ICG users perform a fluid-air exchange before applying the dye. Platelet concentrate is used by 8% of the surgeons with 97% (n=125) performing a gas tamponade using SF6 (53%), C3F8 (22%), C2F6 (16%) or just air (5%) (multiple answers: 4%). Simultaneous cataract surgery is routinely performed by 8%; by 73% only if there is significant cataract. CONCLUSIONS: There is common consent on the basic surgical steps, but several surgical details, e.g. ILM staining, are performed in substantially different ways.

[Neurodermatitis. A risk factor for the development of squamous cell carcinoma]. / Neurodermitis. Ein Risikofaktor für die Entstehung konjunktivaler Plattenepithelkarzinome.

Squamous cell conjunctival carcinomas (SCCC) are rare. We report on a 34-year-old patient with neurodermatitis and chronic conjunctivitis who presented with a therapy-resistant corneal ulcer induced by mechanical irritation diagnosed as SCCC. Chronic blepharoconjunctivitis seems to sustain the development of SCCC in patients with neurodermatitis because of their insufficient immune response.

[Solitary iris metastasis from breast cancer. Effective local therapy with electron beam irradiation]. / Solitäre Irismetastase bei Mammakarzinom. Wirksame lokale Therapie durch Elektronenbestrahlung.

BACKGROUND: The prevalence of intraocular metastases from breast cancer is approximately 4-5%. Solitary metastases of the iris are rare. We report on successful treatment of a solitary iris metastasis using electron beam irradiation. CASE REPORT: A 30-year-old patient presented with an amelanotic tumor of the iris and the anterior chamber angle of her right amblyopic eye. The patient had undergone left-sided breast-conserving surgery and lymph node dissection 3 years before followed by chemotherapy and radiotherapy. The iris tumor was considered a metastasis. Fractionated electron beam irradiation was performed applying a total dose of 50 Gy in fractions of 5 x 2 Gy/week, electrons (9 MeV). The iris metastasis was completely resolved 13 months after radiotherapy. Until now no signs of cataract have been detected and visual acuity has remained stable. CONCLUSION: Electron beam irradiation of this iris metastasis was an effective treatment for preserving visual acuity and ocular function with tolerable acute toxicity and so far no adverse side effects.

[Endogenous Candida lens abscess in a premature infant]. / Endogener Candida-Linsenabszess bei Frühgeborenem.

BACKGROUND: This case report describes an extremely rare Candida lens abscess in a premature infant (gestational age 24 weeks at birth). CASE REPORT: After birth the infant suffered from Candida sepsis which was successfully treated with an antifungal medication. The patient was referred at the age of 6 months because of greyish alterations in the pupils but an absence of other symptoms. The examination with the patient under general anesthesia revealed a grey pupillary membrane and behind it a whitish swollen lens. A lensectomy was performed. The vitreous body was inconspicuous. Candida albicans was identified microbiologically. CONCLUSIONS: In preterm infants dissemination of pathogens into the lens through the vascular coat of the lens is possible, which after regression of the coat is no longer accessible to systemic treatment and may thus be manifested as delayed abscess formation.