[Scleritis - Progress in Diagnosis and Therapy]. / Skleritis ­ Fortschritte zur Diagnose und Therapie.

Inflammation of the sclera includes a wide range of morphological changes, which often occur in association with systemic diseases. While episcleritis is mainly harmless, scleritis often proceeds and is characterised by a destructive course. This may lead to important complications, that present as ulcerative keratitis, uveitis or secondary increases in intraocular pressure. As this form of inflammation is severe and there are often underlying diseases, this contribution focusses on differential diagnosis and current therapeutic approaches.

European consensus-based (S2k) Guideline on the Management of Herpes Zoster - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 2: Treatment.

Herpes zoster (HZ, shingles) is a frequent medical condition which may severely impact the quality of life of affected patients. Different therapeutic approaches to treat acute HZ are available. The aim of this European project was the elaboration of a consensus-based guideline on the management of patients who present with HZ, considering different patient populations and different localizations. This interdisciplinary guideline aims at an improvement of the outcomes of the acute HZ management concerning disease duration, acute pain and quality of life of the affected patients and at a reduction in the incidence of postherpetic neuralgia (PHN) and other complications. The guideline development followed a structured and pre-defined process, considering the quality criteria for guidelines development as suggested by the AGREE II instrument. The steering group was responsible for the planning and the organization of the guideline development process (Division of Evidence-Based Medicine, dEBM). The expert panel was nominated by virtue of clinical expertise and/or scientific experience and included experts from the fields of dermatology, virology/infectiology, ophthalmology, otolaryngology, neurology and anaesthesiology. Recommendations for clinical practice were formally consented during the consensus conference, explicitly considering different relevant aspects. The guideline was approved by the commissioning societies after an extensive internal and external review process. In this second part of the guideline, therapeutic interventions have been evaluated. The expert panel formally consented recommendations for the treatment of patients with HZ (antiviral medication, pain management, local therapy), considering various clinical situations. Users of the guideline must carefully check whether the recommendations are appropriate for the context of intended application. In the setting of an international guideline, it is generally important to consider different national approaches and legal circumstances with regard to the regulatory approval, availability and reimbursement of diagnostic and therapeutic interventions.

European consensus-based (S2k) Guideline on the Management of Herpes Zoster - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 1: Diagnosis.

Herpes zoster (HZ, shingles) is a frequent medical condition which may severely impact the quality of life of affected patients. Different therapeutic approaches to treat acute HZ are available. The aim of this European project was the elaboration of a consensus-based guideline on the management of patients who present with HZ, considering different patient populations and different localizations. This interdisciplinary guideline aims at an improvement of the outcomes of the acute HZ management concerning disease duration, acute pain and quality of life of the affected patients and at a reduction of the incidence of postherpetic neuralgia and other complications. The guideline development followed a structured and predefined process, considering the quality criteria for guidelines development as suggested by the AGREE II instrument. The steering group was responsible for the planning and the organization of the guideline development process (Division of Evidence based Medicine, dEBM). The expert panel was nominated by virtue of clinical expertise and/or scientific experience and included experts from the fields of dermatology, virology/infectiology, ophthalmology, otolaryngology, neurology and anaesthesiology. Recommendations for clinical practice were formally consented during the consensus conference, explicitly considering different relevant aspects. The guideline was approved by the commissioning societies after an extensive internal and external review process. In this first part of the guideline, diagnostic means have been evaluated. The expert panel formally consented recommendations for the management of patients with (suspected) HZ, referring to the assessment of HZ patients, considering various specific clinical situations. Users of the guideline must carefully check whether the recommendations are appropriate for the context of intended application. In the setting of an international guideline, it is generally important to consider different national approaches and legal circumstances with regard to the regulatory approval, availability and reimbursement of diagnostic and therapeutic interventions.

[Anatomy and immunology of the eye]. / Anatomie und Immunologie des Auges.

The eye has all the mechanisms necessary for detection and processing (afferent immune reaction) as well as adequate initiation of an (efferent) immune response. Apart from the typical antigen-processing cells, locally present elements (e.g. glial cells and retinal pigment epithelium) can also be involved in the afferent reaction. For the efferent mechanisms a complex regulative system exists, which includes cellular and humoral responses and is essentially determined by surface molecules. In addition, the ocular environment is rich in immunosuppressive molecules that contribute to the regulation of immune cells. The adaptation of the anatomical and biochemical mechanisms for the creation of an immune-privileged microenvironment makes this sense organ unique. The purpose of this article is to highlight the specific features of the eye and to establish a reference to frequent ocular manifestations in rheumatic diseases.

[Bacterial Keratitis]. / Bakterielle Keratitis.

Worldwide inflammatory corneal diseases are considered to be one of the leading causes of monocular blindness. Bacterial infectious are still predominant and are found in 80 % of patients with ulcerative keratitis. In recent years, both changes in risk conditions and changes in the bacterial spectrum can be observed. Contact lenses and refractive surgery are factors that have increased in importance according to some studies. Microorganisms especially Pseudomonas spp. and atypical mycobacteria are detectable in these patients. In contrast, the bacterial keratitis is observed less frequently after trauma. The broad, often unsighted use of highly effective antimicrobial agents, especially of fluoroquinolones is assumed to be a factor in the transformation of the microbial spectrum. Due to the frequent course of keratitis and a targeted, effective therapy to initiate a pathogen is desirable. The possibilities of diagnostics have been expanded in recent years by molecular biological techniques, but cannot replace established methods. The aim of this paper is to provide a positioning on current aspects of bacterial keratitis.

[ChatGPT and the German board examination for ophthalmology: an evaluation]. / ChatGPT und die deutsche Facharztprüfung für Augenheilkunde: eine Evaluierung.

PURPOSE: In recent years artificial intelligence (AI), as a new segment of computer science, has also become increasingly more important in medicine. The aim of this project was to investigate whether the current version of ChatGPT (ChatGPT 4.0) is able to answer open questions that could be asked in the context of a German board examination in ophthalmology. METHODS: After excluding image-based questions, 10 questions from 15 different chapters/topics were selected from the textbook 1000 questions in ophthalmology (1000 Fragen Augenheilkunde 2nd edition, 2014). ChatGPT was instructed by means of a so-called prompt to assume the role of a board certified ophthalmologist and to concentrate on the essentials when answering. A human expert with considerable expertise in the respective topic, evaluated the answers regarding their correctness, relevance and internal coherence. Additionally, the overall performance was rated by school grades and assessed whether the answers would have been sufficient to pass the ophthalmology board examination. RESULTS: The ChatGPT would have passed the board examination in 12 out of 15 topics. The overall performance, however, was limited with only 53.3% completely correct answers. While the correctness of the results in the different topics was highly variable (uveitis and lens/cataract 100%; optics and refraction 20%), the answers always had a high thematic fit (70%) and internal coherence (71%). CONCLUSION: The fact that ChatGPT 4.0 would have passed the specialist examination in 12 out of 15 topics is remarkable considering the fact that this AI was not specifically trained for medical questions; however, there is a considerable performance variability between the topics, with some serious shortcomings that currently rule out its safe use in clinical practice.

[Present state of the art in topical and systemic immunosuppression after keratoplasty]. / Aktueller Stand der lokalen und systemischen Immunsuppression nach Keratoplastik.

Today MMF can be considered as standard treatment besides cyclosporin A for immunosuppression after high-risk perforating keratoplasty. The efficacy of systemic MMF for this indication has been documented in several clinical studies including multicentre designs. Whether or not MPA therapy offers further advantages is currently under discussion. Sirolimus and tacrolimus are effective but could not achieve clinical importance due to higher rates of side effects. An additional benefit of combination therapies is not proven by clinical studies up to date. Everolimus shows pre-clinically a promising immunosuppressive and antiproliferative effect. Topical preparations of immunosuppressants as monotherapy are obviously insufficient as alternatives for systemic immunosuppressive therapy. Whether or not topical combination therapies will become established as alternatives to systemic treatment has to be demonstrated in the following years.

[Ocular cicatricial pemphigoid - state of the art in clinic and therapy for a problematic disease]. / Das okuläre vernarbende Pemphigoid - aktuelle Aspekte zu Klinik und Therapie einer problematischen Erkrankung.

The ocular cicatricial pemphigoid (OCP) belongs to a family of chronically progressive autoimmune disorders, predominantly affecting mucous membranes (mucous membrane pemphigoids). It is an immunopathologically heterogeneous group of disorders with variable phenotypes that share the unique feature of a subepidermal blistering, through disruption of the adhesion between epidermis and dermis. A key feature is the chronically active inflammation with consecutive fibrosis, leading to a partial or complete loss of function of the affected organ. The ocular disease as a chronic cicatrising conjunctivitis is a common manifestation of the mucous membrane pemphigoid. The identification of the subtle pathology and the prompt initiation of an appropriate therapy are of pivotal importance. One purpose is to prevent further vision loss due to extensive corneal scarring and life-threatening systemic complications, such as the formation of oesophageal or tracheal strictures. So far there are no prospective, randomised studies, regarding the therapy guidelines with an evidence level more than III. The autoimmune nature of the disease implies that systemic immunosuppression is the only effective treatment option, most notably in extended stages. The aim of our study is to give a guideline for a stage adjusted therapy with conventional immunosuppressants and to give a perspective for alternative therapies, especially for recalcitrant disease.

[Diagnostics and treatment of ocular toxoplasmosis : Results of a survey]. / Diagnostik und Behandlung der okulären Toxoplasmose : Ergebnisse einer Umfrage.

BACKGROUND: Ocular toxoplasmosis (OT) is the most common infectious cause of posterior uveitis. This survey aimed to evaluate the current diagnostic and therapeutic approach to OT in Germany. MATERIAL AND METHODS: A detailed questionnaire with specific patient examples was sent in July 2021 to the members of the Uveitis Section of the German Ophthalmological Society (DOG) and the Retinological Society (RG). RESULTS: The questionnaire was answered by 53 (29 RG and 24 DOG) ophthalmologists. Of the respondents 16 (30%) work in private practice, 18 (34%) in a clinical facility and 19 (36%) in university hospital, 9 (17%) colleagues see < 50, 28 (53%) 50-200 and 16 (30%) more than 200 uveitis patients per year. The clinical results are still the gold standard (87%) for the diagnosis of OT and in cases of first manifestation 60% are supported by serological antibody investigations, while 10 out of 53 (19%) ophthalmologists rely on the clinical presentation only. An IgM test is requested by 25 (47%) respondents, 6 expected an increase in IgG titer (11%) and 1 the detection of specific IgA antibodies (2%). The majority (n = 28, 53%) of ophthalmologists would aim at confirming the diagnosis by an anterior chamber puncture, from which 20 (38%) prefer PCR, 3 (6%) determination of Goldmann-Witmer coefficients (GW) and 5 (9%) a combination of both methods. Clindamycin was most frequently used for treatment (n = 21, 40%), followed by pyrimethamine/sulfadiazine (n = 17, 32%) and trimethoprime + sulfamethoxazole (TMP/SMX) (n = 10, 19%); the latter was also used (n = 40, 75%) for secondary prophylaxis. CONCLUSION: The results show that apart from the clinical results as the gold standard for the diagnosis, there is no uniform approach to diagnosis and treatment of OT. The high request rate for serum IgM antibodies indicates a widespread uncertainty about the importance of serological findings. This should be viewed critically, given the continued high seroprevalence in Germany.

Evidence-based, interdisciplinary guidelines for anti-inflammatory treatment of uveitis associated with juvenile idiopathic arthritis.

Uveitis in juvenile idiopathic arthritis (JIA) is frequently associated with the development of complications and visual loss. Topical corticosteroids are the first-choice therapy, and immunosuppression is commonly used. However, treatment has not been standardized. Representatives from the German Ophthalmological Society, Society for Childhood and Adolescent Rheumatology, and the German Society for Rheumatology reached consensus on a standardized treatment strategy according to disease severity in the individual patient. The recommendations were based on a systematic literature analysis in MEDLINE and consensus expert meetings. Evidence and recommendations were graded, and an algorithm for anti-inflammatory treatment and final statements confirmed in a Delphi method. An interdisciplinary, evidence-based treatment guideline for JIA uveitis is presented.

[Ocular involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis]. / Okuläre Beteiligung bei Stevens-Johnson-Syndrom und Toxisch epidermaler Nekrolyse.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare severe reactions of skin and mucous membranes. They are considered as a single disease entity with differing severities and are mainly induced by drugs, less frequently by infections. In 50% of the patients ocular complications occur, which can lead to blindness in the absence of immediate ophthalmological treatment. The acute pattern, the unpredictable course and extreme variations in the manifestation of complications require an interdisciplinary treatment. Early diagnosis and initiation of an intensive lubricating and anti-inflammatory surface care are of utmost importance for the best visual outcome. This article is intended to help ophthalmologists towards a better understanding and interpretation of clinical signs of these conditions with the goal to achieve substantial improvements in visual outcome and of course the patient's quality of life.

[Inflammatory choroidal neovascularisations]. / Inflammatorische choroidale Neovaskularisationen.

Inflammation plays a key role in the induction of choroidal neovascular membranes (CNV). This explains why each form of posterior uveitis may lead to CNV formation. Diseases like presumed ocular histoplasmosis syndrome (POHS), multifocal choroiditis (MFC) or punctate inner choroidopathy (PIC) carry a high risk of CNV creation. Inflammatory processes mostly cause classical membranes. Because of the classical membrane form, smaller membrane size and the younger age of the patients' inflammatory membranes are often better treatable than membranes in AMD patients. In the times before VEGF inhibition inflammatory membranes were treated with argon laser coagulation and later with PDT. Nowadays better visual acuity results are achievable through VEGF inhibitor injections with or without PDT. This is proven by a few publications with greater numbers of patients because of the rarity of the diseases and several case reports in the literature. In addition to CNV treatment the control of intraocular inflammation should never be forgotten because it forms the leading CNV trigger.

[Physiology of the human corneal endothelium--new insights from electrophysiological investigations]. / Physiologie des humanen Hornhautendothels--neue Erkenntnisse durch elektrophysiologische Untersuchungen.

Currently, the identification of apoptotic or damaged human corneal endothelial (HCE) cells is limited to a morphological assessment and vital staining. Specific electrophysiological investigations may prospectively help to identify damaged HCE cells at an earlier stage. Besides calcium imaging, the so-called patch-clamp technique is an important test method enabling one to assay the effect of various substances on ion channels and receptors of the cell membrane. First electrophysiological pilot experiments with cultivated and freshly isolated HCE cells have revealed promising results. In this way, the expression of certain transient receptor potential channels (TRPs) could be demonstrated. However, the function of these channels is still not fully elucidated. In humans, TRPs play a crucial role in the sense of taste, pheromones, temperature and pain and are involved in osmolarity. This review summarises the current literature on the electrophysiology of the human corneal endothelium and deduces potential approaches to a sensitive vitality and function test under utilisation of the electrophysiological properties of HCE cells.

[Application possibilities of modern thermography--first experience with the new Tomey TG 1000]. / Anwendungsmöglichkeiten der modernen Thermografie--ste Erfahrungen mit dem neuen Tomey TG 1000.

Temperature is one of the fundamental characteristics of tissue metabolism and is certainly of major interest to investigate ocular physiology. Current instrumentation offers the potential to measure the ocular surface temperature (OST) with high accuracy and resolution. Potential applications of OST measurement may include any condition of the ocular surface. The present study gives a survey of the possible applications of thermography and describes our first experience with the new Tomey TG 1000.

[Intraocular inflammation with brolucizumab use : Patient management-diagnosis-therapy]. / Intraokulare Entzündungen bei Brolucizumab-Anwendung : Patientenmanagement ­ Diagnose ­ Therapie.

The anti-vascular endothelial growth factor (anti-VEGF) agent brolucizumab has been approved in the USA in October 2019 and in Europe in February 2020 for the treatment of neovascular age-related macular degeneration (nAMD). The approval was based on the randomized, double-blind phase III studies HAWK and HARRIER with a total of 1817 patients. Brolucizumab 6 mg (administered every 12 or 8 weeks depending on the activity of the disease) showed a non-inferior efficacy in terms of best-corrected visual acuity compared to aflibercept 2 mg (administered every 8 weeks). Initial reports on the use of brolucizumab after its approval in the USA indicated a safety signal of rare adverse events termed as retinal vasculitis and/or retinal vascular occlusion that may result in severe loss of vision. Typically, these events occurred in the presence of intraocular inflammation (IOI). A safety review committee (SRC) subsequently carried out an independent analysis of data from the pivotal studies. This article sets out the current state of knowledge and aims to provide users with orientation-from the authors' perspective-in treating brolucizumab-associated IOI. It appears mandatory to provide patients with information about possible symptoms of IOI. Even though the case reports and the SRC review of HAWK/HARRIER may not yet provide sufficient evidence for any final conclusions, it seems crucial to educate patients about signs and symptoms to ensure an early detection and diagnosis in cases of IOI. Once a patient is diagnosed with IOI, retinal vasculitis, and/or retinal vascular occlusive events, physicians should act promptly with an adequate and intensive anti-inflammatory treatment and brolucizumab treatment should be discontinued. It is important to note that these recommendations are primarily based on the authors' expert opinions and should be considered as guidance in managing these events rather than a formal protocol or guidelines.

[Diseases of the outer eye in rheumatoid arthritis]. / Erkrankungen des äusseren Auges bei rheumatoider Arthritis.

Eye involvement is a frequent finding in patients with rheumatoid arthritis and may represent the leading clinical manifestation of disease. In this context, all components of the visual organ might be affected. The main spectrum of eye involvement comprises keratoconjunctivitis sicca, episcleritis and scleritis as well as ulcerative keratitis. As with the underlying disease, autoimmune reactions based on a patient's genetic predisposition are assumed to be of significance in disease pathogenesis. Emerging evidence also points to additional morphological and physiological ocular characteristics in the pathogenesis of the various ocular pathologies. This article gives an overview of clinical aspects, pathogenetic background as well as therapeutic options for ocular involvement in rheumatoid arthritis.

[Diagnostic and therapeutic aspects of herpes virus associated uveitis]. / Diagnostik und Therapie der Herpesvirus-assoziierten Uveitis.

According to the World Health Organization, 60- 95 % of the population worldwide is infected by viruses of the herpes viridae family. Excellent adaptation of the organisms and host-related factors are probably predisposing for this global distribution. Herpes virus infections are probably the most common infectious cause of blindness in the Western world. Besides the well known manifestations of keratitis and anterior uveitis caused by HSV and VZV, new aspects have been discovered, in particular, in CMV-related disorders. Molecular biological methods have been instrumental to explore and discover herpes virus associated disorders and have provided new insights. Whereas keratitis and anterior uveitis are the most common clinical manifestations, more severe disorders such as posterior uveitis, panuveitis and acute retina necrosis syndrome have all been attributed to herpes virus infections. Since the therapeutic intervention greatly varies in these acute situations, identification of the causative agent is essential. Serology is rarely helpful, whereas analyses of aqueous humor or vitreous samples provide clues for the etiology. Aqueous humor antibody testing and PCR have demonstrated excellent diagnostic power with high sensitivity and high specificity. This review is intended to provide an overview on the diagnosis and differential diagnosis of this important disorder.

[Aqueous humor analysis: a diagnostic tool in intraocular inflammation]. / Kammerwasseranalyse in der Diagnostik intraokularer Entzündungen.

For the diagnosis of unclear intraocular inflammation, the collection of aqueous humor can provide substantial information. Specific procedures including microELISA, polymerase chain reaction (PCR) and cytokine analysis may provide essential diagnostic information. The correct indication and an adequate processing of ocular samples determine the quality and reliability of the laboratory results. This article describes the different considerations and processes that are important to ensure optimal results for these different diagnostic laboratory procedures.