Thinner temporal peripapillary retinal nerve fibre layer in Stargardt disease detected by optical coherence tomography.

PURPOSE: To evaluate peripapillary retinal nerve fibre layer (RNFL) thickness measured by spectral domain optical coherence tomography (OCT) in patients with Stargardt disease (STGD). METHODS: A cross-sectional, monocentric, observational case-control study. Twenty patients (39 eyes) with ABCA4 mutations graded according to the Fishman STGD classification were included. RNFL measurement was performed using Heidelberg Spectralis SD-OCT. RNFL thickness in STGD patients was compared to age-matched data of healthy individuals provided by the device's manufacturer. A manual readjustment of the optic disc-fovea angle was performed when needed. RESULTS: The mean age at first diagnosis of STGD was 22.9 years (range 9 to 50) and 39.1 years (range 18 to 74) at the time of examination. Thirty-nine percent of eyes (15 eyes) needed manual adjustment of the optic disc-fovea angle due to malfixation of the patients during OCT. The temporal quadrant corresponding to the macula showed a RNFL 16% thinner than controls (mean - 12 µm, 95%CI - 9 to -15 µm). However, global RNFL thickness did not differ from controls due to increased RNFL thickness of 12% in the nasal sectors. Duration and stage of STGD were not correlated to thinner RNFL. CONCLUSION: STGD seems to be associated with thinner peripapillary RNFL in the sector of axons projecting to the degenerated macular area. It is yet unclear as to whether this results from anterograde transneuronal degeneration of direct injury to retinal ganglion cells.

Side effects of topical atropine 0.05% compared to 0.01% for myopia control in German school children: a pilot study.

PURPOSE: Based on findings of the Asian low-concentration atropine for myopia progression study, a concentration of 0.05% has been proposed as a good compromise between safety and efficacy for myopia control. However, no data on side effects have been published so far in Caucasian children receiving this dose. METHODS: Prior to commencement of bilateral atropine treatment with 0.05% atropine, 19 myopic children aged 5 to 15 years were treated in only one eye at bedtime leaving the other eye as a control. Pupil size, accommodation amplitude and near visual acuity were measured at 10:00 a.m. the next day and compared to the untreated contralateral control eye. The results were then compared to a cohort of 18 children whose treatment with 0.01% atropine commenced in a similar fashion. RESULTS: Twelve children (63%) reported visual impairment or reading difficulties. Anisocoria was 2.9 ± 1.1 mm. In comparison, 0.01% atropine led to a significantly less anisocoria of 0.8 ± 0.7 mm (p < 0.0001). Accommodation was decreased by - 4.2 ± 3.8 D in 0.05% atropine treated eyes, whereas 0.01% atropine induced hypoaccommodation of - 0.05 ± 2.5 D (p < 0.01). Near visual acuity was not significantly reduced in eyes treated with 0.05% atropine compared to 0.01% atropine (p = 0.26). CONCLUSION: Compared to 0.01%, our data indicate stronger more relevant side effects of 0.05% topical atropine in young Caucasian children with progressive myopia as recently reported in Asian children, potentially compromising acceptance and compliance.

[Use of the Multidisciplinary Specialised Case Conference at the Freiburg Orbital Centre]. / Inanspruchnahme der multidisziplinären spezialisierten Fallkonferenz im Freiburger Orbitazentrum.

BACKGROUND: The treatment of tumors increasingly takes place in specialised interdisciplinary centres. Therapeutic decisions are usually made at case conferences. Ophthalmologists, oromaximillofacial surgeons, ENT physicians, neurosurgeons, as well as pediatricians, radiotherapists and radiologists are all involved in the treatment of orbital diseases. The aim of this article is to present the concept of a multidisciplinary case conference for orbital diseases and to analyse case numbers, indications, and the influence on the patient's therapy. METHODS: We analysed an anonymized data set of patients who presented in the case conference of the University Hospital Freiburg from 2008 to 2018 with regard to clinical diagnosis, histological diagnoses, number of surgical interventions, and number of interdisciplinary therapy decisions. RESULTS: From 2008 to 2018, 545 patients were presented in a weekly conference. Of these, 453 were available for anonymous evaluation. The median age was 56 years (quartiles 41; 69). The most frequent indication was an orbital tumour of unclear malignancy (n = 52; 11%). Further indications included Grave's orbitopathy (n = 39; 9%), orbital pseudotumour (n = 36; 8%), cranial nerve palsy (n = 22; 5%), and orbital lymphoma (n = 22; 5%). The most frequent histological diagnoses were B-cell lymphoma (n = 10; 2%), venous malformation (cavernoma, n = 8; 2%), marginal zone lymphoma (n = 8; 2%), and squamous cell carcinoma (n = 6; 1%). An interdisciplinary therapeutic approach was defined for 174 patients. CONCLUSION: A high demand for the interdisciplinary case conference was demonstrated. The high rate of primary or secondary interdisciplinary decisions indicates the value of such a conference. Hence, the patient is spared multiple examinations in the individual specialist areas and quick and effective therapy decisions can be achieved.

Little effect of 0.01% atropine eye drops as used in myopia prevention on the pattern electroretinogram.

PURPOSE: Daily administration of 0.01% atropine eye drops is a promising approach for myopia control. The mechanism of action is believed to involve the dopaminergic system of the retina, triggering an increased release of dopamine. Previous studies in psychiatric condition such as major depression suggest that pattern electroretinogram (PERG) amplitudes are modulated by changes in retinal dopamine. It is thus plausible that atropine eye drops could have an effect on PERG amplitudes. The present study was designed to test this, assessing the difference in amplitude between contrast levels and the ratio of amplitudes between check sizes as primary endpoints. METHODS: We included 14 participants with no more than ± 2 diopters of ametropia and visual acuity of at least 1.0. One eye was chosen randomly in each participant for atropine application (14 days, one drop of 0.01% atropine solution once daily before bedtime). We recorded two sets of steady-state PERG recordings: one with different contrasts (25% and 98%) and one with different check sizes (0.8° and 17°). Near-point distance, near visual acuity, and pupil diameter were measured additionally. RESULTS: The recordings to different contrasts did not show atropine-related changes of PERG amplitude. A small increase by 6% of the amplitude difference between contrast levels with atropine application was not significant (p = 0.08). Raw amplitudes in the check size condition increased with atropine by 17% (p < 0.01) and 10% (p < 0.03) for small and large checks, respectively, without a significant concomitant effect on the amplitude ratio. Pupil size was significantly affected (median increase 0.5 mm, p < 0.002). However, neither of the experimental conditions was associated with a significant correlation between pupil size and PERG effects. CONCLUSION: The effects on PERG primary endpoints after the 14-day period of atropine administration were small, especially compared to effect sizes in major depression, and statistically insignificant. Effects on raw amplitude were inconsistent. The present results suggest that retinal processing as reflected by PERG does not sizably change following a treatment regimen with atropine that is typical for myopia control.

Sirolimus-induced regression of a large orbital lymphangioma.

Microcystic lymphatic malformations are difficult to treat surgically, especially when located in the orbital apex. Recently, pharmacologic inhibition of the mTOR pathway by sirolimus was reported as a safe and efficacious treatment option for lymphatic malformations (also known as lymphangiomas). We report the case of a young male patient in which a unilateral, retrobulbar lymphatic malformation regressed to a large extent under treatment with 1 mg sirolimus given orally twice a day over a period of six months.

[Amblyopia and refractive error]. / Update Augenheilkunde ­ Amblyopie und Refraktionsfehler.

Myopia is on the increase worldwide and will become a major challenge over the next decades in terms of secondary ophthalmologic complications. There are effective therapeutic options available to slow or prevent the progression of myopia. So far, it has not been investigated whether there are possible additive effects of these interventions. Further investigations - especially in Caucasian populations - are necessary to verify the study results available from Asia. There is limited data on how long further progression of myopia is preventable. A therapy appears reasonable as long as a progression of myopia is detectable.Consistent childhood amblyopia screening provides a cost-effective measure for the prevention of visual disturbances over the course of life. How this can be best integrated into the existing system of "U-investigations", must be clarified by the cost-bearers and professional associations. This discourse should be supported by close interdisciplinary exchange and further studies on the prevalence of different degrees of amblyopia. In addition, sensitive and specific or even multi-stage tests should be developed in order to implement an early detection that is cost-effective and saves resources.

[Orbital decompression in Graves' orbitopathy-Experiences and results]. / Orbitadekompression bei endokriner Orbitopathie ­ Erfahrungen und Ergebnisse.

BACKGROUND: Graves' orbitopathy is the most frequent extrathyroidal manifestation of Graves' disease, affecting approximately 25-50% of patients. It leads to inflammation and swelling of orbital soft tissues. The treatment is mostly conservative. Surgical orbital decompression is indicated in severe cases with disfiguring exophthalmos or an acute steroid-refractive threat to vision, facilitating visual and cosmetic recovery. An important aspect in the quality of care is the avoidance of postoperative diplopia. OBJECTIVE: To report experiences and results from 100 cases of orbital decompression surgery performed on 62 patients at a multidisciplinary orbit center. Patients with signs of apical crowding were treated by pterional decompression. Patients without signs of apical crowding were treated either by deep lateral wall resection or pterional decompression. METHODS: A retrospective data analysis was carried out. RESULTS: The mean reduction in exophthalmos was 2.9 mm. Visual acuity improved by a mean of 2.2 lines in eyes with sight-threatening disease. In moderate to severe disease, visual acuity remained stable. The complication rate was 4%. New postoperative diplopia occurred after two interventions and one patient experienced a deterioration in visual acuity from 0.8 to 0.1. In nine cases, surgery led to a complete regression of previously reported double vision. CONCLUSION: Visual acuity gain, reduction of exophthalmos and complications in this collective are comparable to previously published results. The results of this study confirm the role of orbital decompression in the treatment of sight-threatening and severely disfiguring endocrine orbitopathy.

Pterional Orbit Decompression in Grave Disease with Dysthyroid Optic Neuropathy.

OBJECTIVE: The choice of surgical technique in sight-threatening Grave orbitopathy remains controversial. Available data are mostly derived from mixed cohorts with multiple surgical indications and techniques. The authors assessed predictors for visual outcome after standardized pterional orbital decompression for dysthyroid optic neuropathy. METHODS: Retrospective analysis of 62 pterional orbital decompressions performed on 40 patients with dysthyroid optic neuropathy. RESULTS: Visual acuity improved by an average of 3.8 lines in eyes with preoperative visual impairment (95% confidence interval [CI]: 1.8-5.8 lines, P < 0.001) and remained stable in eyes without prior visual impairment (95% CI -1.3 to 1 line, P = 0.81). Proptosis was reduced by an average of 3.1 mm (95% CI 1.8-4.3 mm, P < 0.001). Higher degrees of proptosis were predictive of worse visual outcomes (P = 0.017). New-onset diplopia developed in 2 patients, while previous diplopia resolved after surgery in 6 patients. CONCLUSIONS: This cohort is the largest series of pterional orbit decompressions and the first to focus exclusively on dysthyroid neuropathy. Complication rates were low. Decompression surgery was highly effective at restoring and maintaining visual acuity in patients with dysthyroid optic neuropathy.

Optic Nerve Head Volumetry by Optical Coherence Tomography in Papilledema Related to Idiopathic Intracranial Hypertension.

Purpose: Idiopathic intracranial hypertension (IIH) leads to optic nerve head swelling and optic atrophy if left untreated. We wanted to assess an easy to perform volumetric algorithm to detect and quantify papilledema in comparison to retinal nerve fiber layer (RNFL) analysis using optical coherence tomography (OCT). Methods: Participants with and without IIH underwent visual acuity testing at different contrast levels and static perimetry. Spectralis-OCT measurements comprised standard imaging of the peripapillary RNFL and macular ganglion cell layer (GCL). The optic nerve head volume (ONHV) was determined using the standard segmentation software and the 3.45 mm early treatment diabetic retinopathy study (ETDRS) grid, necessitating manual correction within Bruch membrane opening. Three neuro-ophthalmologists graded fundus images according to the Frisén scale. A mixed linear model (MLM) was used to determine differences between study groups. Sensitivity and specificity was evaluated using the area under the receiver-operating characteristic (ROC). Results: Twenty-one patients with IIH had an increased ONHV of 6.46 ± 2.36 mm3 as compared to 25 controls with 3.20 ± 0.25 mm3 (P < 0.001). The ONHV cutoff distinguishing IIH from controls was 3.97 mm3 (i.e. no patient with IIH had an ONHV below and no healthy individual above this value). The area under the curve (AUC) for ONHV was 0.99 and for the RNFL at 3.5 mm 0.90. The Frisén scale grading correlated higher with the ONHV (r = 0.90) than with the RNFL thickness (r = 0.68). ONHV measurements were highly reproducible in both groups (coefficient of variation <0.01%). Conclusions: OCT-based volumetry of the optic nerve head discriminates very accurately between individuals with and without IIH. It may serve as a useful adjunct to the rating with the subjective and ordinal Frisén scale. Translational Relevance: A simple OCT protocol run on the proprietary software of a commercial OCT device can reliably discriminate between normal optic nerve heads or pseudo-papilledema and true papilledema while being highly reproducible. Our normative data and OCT preset may be used in further clinical studies.

No evidence for an association of plasma homocysteine levels and refractive error - Results from the population-based Gutenberg Health Study (GHS).

PURPOSE: There is a strong association between severe hyperhomocysteinemia and myopia. Thus we studied the hypothesis that even moderately increased levels of homocysteine (Hcy) might be a potentially treatable risk factor for myopia. METHODS: The Gutenberg Health Study (GHS) is a population-based, prospective, observational cohort study in Germany, including 15,010 participants aged between 35 and 74 at recruitment. The baseline examination was conducted from 2007-2012. Refraction was measured using autorefraction (HARK 599, Carl Zeiss AG, Jena, Germany). Hcy was measured by an immunoassay. We included only phakic participants without a history of corneal surgery or corneal laser treatment. We used linear regression models to evaluate the potential association between Hcy and refraction at baseline, and between Hcy and change in refraction between baseline and 5-year-follow-up examination. We used generalized estimating equation models to account for the correlation between fellow eyes. RESULTS: We included 13,749 participants, categorized as having no myopia (spherical equivalent > -0.75 D, 65.2%), low myopia (-0.75 D--2.75 D, 21.5%), moderate myopia (-3.00 D- 5.75 D, 9.8%) and high myopia (≤ -6 D, 3.5%). Median Hcy levels were similar in all groups (µmol/l). We observed no association of Hcy with refraction or 5-year change in refraction in the models adjusted for age, sex and socioeconomic status. CONCLUSION: We found no evidence for an association of Hcy levels and refractive error.

A Pilot Study on the Efficacy and Safety of 0.01% Atropine in German Schoolchildren with Progressive Myopia.

INTRODUCTION: Although the interest is growing in topical low-dose atropine to control myopia in schoolchildren worldwide, its use in children of European ancestry remains controversial and solid evidence is sparse. The Oxford Centre for Evidence Based Medicine (OCEBM) classifies the evidence for this therapy as level I for East Asian populations, but only level IV in non-Asian populations. METHODS: Fifty-six children, aged a median of 11 years (range 6-17), were analysed after 12 months of topical treatment with 0.01% preservative-free atropine in both eyes at bedtime every day. Efficacy was assessed during treatment every 6 months. In a subset of 20 patients, treatment of the second eye was delayed by 1 day to enable a controlled safety assessment of side effects such as pupil dilation, hypoaccommodation, and near vision reduction. RESULTS: Prior to treatment, the mean myopic progression was estimated as 1.05 D/year; after 12 months of treatment with 0.01% atropine, it was 0.40 D/year (p < 0.0001). The only consistently measurable side effect was the induction of 1 mm pupil dilatation, which was only noticeable in comparison to the non-treated eye during the safety investigation. CONCLUSIONS: Topical low-dose atropine appears to be safe and efficacious also in a cohort of European schoolchildren. These data should motivate researchers to conduct more randomised clinical trials.

Characterisation of vascular changes in different stages of Stargardt disease using double swept-source optical coherence tomography angiography.

OBJECTIVE: To describe vascular changes in different stages of Stargardt disease (STGD) via double swept-source optical coherence tomography angiography. METHODS AND ANALYSIS: Prospective, cross-sectional case-control study. Twenty-three patients (45 eyes) with ABCA4 mutations graded according to the Fishman STGD classification and 23 controls (23 eyes) were included. Two independent investigators quantified the foveal avascular zone (FAZ) in the superficial and deep capillary plexus (SCP/DCP) and the areas presenting rarefied flow and complete vascular atrophy in the outer retina to choriocapillaris (ORCC) and choriocapillaris (CC) slab. RESULTS: The mean age at first diagnosis of STGD was 24.0 years (range 9-50) and 37.9 years (range 18-74) at the time of examination. Eleven patients were assigned to the Fishman STGD classification stage (S) 1, three to S2, eight to S3 and one to S4. The FAZ in SCP and DCP was increased in all stages compared with controls (p<0.01). Areas with rarefied flow signal and vascular atrophy were detected in the ORCC and the CC layer and grew with increasing stage of disease (p<0.01). The duration of disease correlated with the extent of the enlarged FAZ in the SCP/DCP and with the area of reduced flow in the ORCC and CC layer (p<0.01). Best corrected visual acuity correlated negatively with the extent of the enlarged FAZ in the SCP/DCP (p<0.0001), as well as with enlarged atrophic area in the ORCC and CC layer (p=0.026 and p=0.074). CONCLUSIONS: Patients with STGD reveal vascular changes in the retina and CC in all disease stages. The avascular zone in the SCP/DCP and areas with rarefied flow signal in the ORCC/CC increase with the duration and stage of disease, indicating progressive vascular decay most likely secondary to retinal pigment epithelium and neuronal loss. Furthermore, increased vascular damage is associated with decreased vision.

Treatment of optic neuritis with erythropoietin (TONE): a randomised, double-blind, placebo-controlled trial-study protocol.

INTRODUCTION: Optic neuritis leads to degeneration of retinal ganglion cells whose axons form the optic nerve. The standard treatment is a methylprednisolone pulse therapy. This treatment slightly shortens the time of recovery but does not prevent neurodegeneration and persistent visual impairment. In a phase II trial performed in preparation of this study, we have shown that erythropoietin protects global retinal nerve fibre layer thickness (RNFLT-G) in acute optic neuritis; however, the preparatory trial was not powered to show effects on visual function. METHODS AND ANALYSIS: Treatment of Optic Neuritis with Erythropoietin (TONE) is a national, randomised, double-blind, placebo-controlled, multicentre trial with two parallel arms. The primary objective is to determine the efficacy of erythropoietin compared to placebo given add-on to methylprednisolone as assessed by measurements of RNFLT-G and low-contrast visual acuity in the affected eye 6 months after randomisation. Inclusion criteria are a first episode of optic neuritis with decreased visual acuity to ≤ 0.5 (decimal system) and an onset of symptoms within 10 days prior to inclusion. The most important exclusion criteria are history of optic neuritis or multiple sclerosis or any ocular disease (affected or non-affected eye), significant hyperopia, myopia or astigmatism, elevated blood pressure, thrombotic events or malignancy. After randomisation, patients either receive 33,000 international units human recombinant erythropoietin intravenously for 3 consecutive days or placebo (0.9% saline) administered intravenously. With an estimated power of 80%, the calculated sample size is 100 patients. The trial started in September 2014 with a planned recruitment period of 30 months. ETHICS AND DISSEMINATION: TONE has been approved by the Central Ethics Commission in Freiburg (194/14) and the German Federal Institute for Drugs and Medical Devices (61-3910-4039831). It complies with the Declaration of Helsinki, local laws and ICH-GCP. TRIAL REGISTRATION NUMBER: NCT01962571.