Tintelnotia, a new genus in Phaeosphaeriaceae harbouring agents of cornea and nail infections in humans.

Phaeosphaeriaceae is a family in the order Pleosporales containing numerous plant pathogens, endophytes, lichenised fungi, and environmental saprobes. A novel genus, Tintelnotia is introduced containing two species, one of which caused an eye infection and several nail infections in humans. All species of Tintelnotia produce conidia in soft pycnidia with a wide ostiole. The generic type species is T. opuntiae causing necrotic spots on cactus plants. The isolates of the human opportunist T. destructans showed variable susceptibility pattern to a panel of common antifungal agents. The MICs of amphotericin B, voriconazole, posaconazole and itraconazole were 1 µg/mL, complemented by an in vitro MEC of 16 µg/mL against caspofungin; the MIC of terbinafine was 0.125 µg/mL. The latter compound contributed to the successful therapy in the ocular mycosis refractory to standard antifungal therapy, the benefit of terbinafine should be highlighted as a therapeutic option especially in difficult-to-treat fungal keratitis.

[Keratomycosis - Therapy Standards and New Developments]. / Keratomykose - Therapiestandards und aktuelle Entwicklungen.

Mycotic keratitis is a comparatively rare but serious ophthalmological disease, that can possibly lead to a severe loss of vision up to blindness. Over the last two decades an increase of cases with mycotic keratitis has been noticed, which is possibly caused by an increased use of soft contact lenses. This article gives an overview of the typical clinical signs and symptoms of keratomycosis, tried and tested diagnostics and therapy as well as new diagnostic and therapeutic developments and findings.

Benefit of polyhexamethylene biguanide in Fusarium keratitis.

PURPOSE: To report a series of 3 patients with soft contact lens-related Fusarium keratitis. Two of them were treated with the antiamoebic polyhexamethylene biguanide 0.02% (PHMB) in combination with antifungal drugs, and 1 patient was treated with PHMB as sole antifungal regimen. METHODS: Chart review of 3 patients treated with PHMB in Fusarium keratitis. Two of them were refractory to the commonly used therapy. The antifungal power of PHMB and propamidine isethionate was tested against the patients' isolates as well as against the clinical isolates from another 9 patients with ocular mould infections. RESULTS: An excellent outcome could be achieved in 2 patients with Fusarium solani keratitis refractory to common antifungal treatment by the additional use of PHMB 0.02%. In another patient PHMB alone was sufficient to resolve Fusarium proliferatum infection. The drug was well tolerated. In all patients repeated abrasion was done for better penetration of the drugs. PHMB revealed a marked in vitro antifungal activity for the three Fusarium isolates as well as for another 9 isolates of ocular infections from other patients including also the genera Scedosporium, Aspergillus and Rhizopus giving minimal inhibitory concentrations ranging from 1.56 to 3.12 µg/ml. CONCLUSIONS: Fusarium keratitis is a severe ocular infection. We report on the use of PHMB in 3 patients given additionally or as sole antifungal drug. We emphasize the benefit of PHMB 0.02% in Fusarium keratitis which might be considered as a therapeutic option especially in cases refractory to common antifungal therapy and possibly in keratitis due to other fungi.

[Giant cell arteritis (temporal arteritis, Horton's arteritis): clinical characteristics and management]. / Morbus Horton (Arteriitis temporalis, Riesenzellarteriitis): Klinik, Diagnostik, Histologie, Therapie.

Giant cell arteritis can cause diagnostic difficulties due to its heterogeneous symptomatology. Characteristic ophthalmic and systemic symptoms of Horton's disease are discussed. The clinical course is described on the basis of typical patients, which shows that generic symptoms do not have to coexist. The Horton's arteritis potentially represents a systemic vasculitis that requires early diagnosis and treatment in order to avoid dramatic ophthalmic consequences, in worst cases blindness. The erythrocyte sedimentation rate (ESR) represents the most important laboratory parameter. Although temporal artery biopsy remains the only confirmatory procedure for a definite diagnosis, imaging procedures such as sonography, magnetic resonance imaging, ultrasound biomicroscopy are useful in supporting the clinical diagnosis. Highly dosed corticosteroid therapy should always be indicated when suspicious clinical symptoms are present, even without any dramatic laboratory parameter changes. Initial high dosages are indicated up to 1 gram daily depending on the severity of the disease. Subsequently a slow ESR titrated reduction of the dose is necessary under control of inflammation values, symptomatology and side effects. Occasionally a lifelong immunsuppressive therapy is indispensable. The long-term treatment should take place in close cooperation with the general practitioner, rheumatologist, neurologist and if necessary further specialists.

[Prophylaxis and therapy of postoperative endophthalmitis. Criticism of the ESCRS study and the Early Vitrectomy study]. / Zur Prophylaxe und Therapie der postoperativen Endophthalmitis. ESCRS-Studie und "Early Vitrectomy Study" in der Kritik.

Postoperative endophthalmitis often leads to a substantial loss of vision and sometimes to loss of the eye. Occasionally this results in legal disputes during which medical studies will be consulted for reaching a verdict. Both the European Society of Cataract and Refractive Surgeons (ESCRS) study on prophylaxis and the Early Vitrectomy study on the therapy of postoperative endophthalmitis suffer from substantial deficits in essential areas. These studies cannot therefore be utilized as standard operating procedures and guidelines as well as in legal disputes.

[Retinotopic mapping of the human visual cortex with functional magnetic resonance imaging - basic principles, current developments and ophthalmological perspectives]. / Retinotope Kartierung des menschlichen visuellen Kortex mit funktioneller Magnetresonanztomografie - Grundlagen, aktuelle Entwicklungen und Perspektiven für die Ophthalmologie.

Since its initial introduction in the mid-1990 s, retinotopic mapping of the human visual cortex, based on functional magnetic resonance imaging (fMRI), has contributed greatly to our understanding of the human visual system. Multiple cortical visual field representations have been demonstrated and thus numerous visual areas identified. The organisation of specific areas has been detailed and the impact of pathophysiologies of the visual system on the cortical organisation uncovered. These results are based on investigations at a magnetic field strength of 3 Tesla or less. In a field-strength comparison between 3 and 7 Tesla, it was demonstrated that retinotopic mapping benefits from a magnetic field strength of 7 Tesla. Specifically, the visual areas can be mapped with high spatial resolution for a detailed analysis of the visual field maps. Applications of fMRI-based retinotopic mapping in ophthalmological research hold promise to further our understanding of plasticity in the human visual cortex. This is highlighted by pioneering studies in patients with macular dysfunction or misrouted optic nerves.

[Test-retest reliability of a web-based colour vision test]. / Untersuchungen zur Re-Test Reliabilität eines webbasierten Farbsehtests.

BACKGROUND: Screening tests should be simple, with high acceptance, low costs and offer a high sensitivity and specificity as well as high reliability. The test-retest reliability of a web-based colour vision test was evaluated. METHOD: The results of 386 subjects, who had performed the web-based colour vision test with 25 colour plates twice (available at http://www.farbsehtest.de), were analysed from an mySQL data base. Retests were performed spontaneously, normally on the same day, or through an email newsletter with a request to repeat the test. Test-retest reliability was assessed by calculating the kappa coefficient and the corresponding confidence interval. The McNemar test was used as a complementary procedure to detect the presence of systematic differences between test results. RESULTS: The kappa coefficient rises with increasing time interval between the first test performance and the test repetition. Thus it was 0.24 when the test was repeated within one hour (confidence interval 0.07 - 0.41, n = 63), it increases to 0.83 (confidence interval 0.75 - 0.92, n = 240) in the subjects who repeated the test at the earliest after two years. While the proportion of failed tests (< 3 mistakes) in the second test performance markedly decreases when the test is repeated in the short term within one hour (p < 0.001, McNemar), we were unable to identify any systematic differences (p = 0.602) for a time interval of more than one day. CONCLUSIONS: The web-based colour vision test is a reliable screening test with good reproducible results as well under uncontrolled examination conditions. Subjects must perform the test with serious intent and should not aim at a positive test result by training or manipulation because of self-delusion. Test results are reliable if the time interval between test and retest is more than one day.

[Herpes simplex keratitis. A short overview of the current therapy]. / Herpes-simplex-Keratitis. Ein kurzer Uberblick zur aktuellen Therapie.

In this review the current recommendations for the treatment of Herpes simplex keratitis are given - based on the literature, especially from 2000 till 2009. The medical treatment of epithelial, deep stromal keratitis, the prevention of recurrences and metaherpetic keratitis are discussed. Finally, a therapy scheme is presented.

[Rational antibiotic therapy in ophthalmology]. / Rationale Antibiotikatherapie in der Augenheilkunde.

Bacterial infections can affect all structures of the eye. In most cases, infections of the ocular surface are treatable with topical antibiotics, whereas intraocular infections need a combined treatment with intraocular and systemic antibiotics. Localisation, severity, expected microorganisms, and possible consequences of the infection lead to the appropriate therapy. Unwarranted use of antibiotic substances for prophylaxis or treatment of nonbacterial infection should be avoided, especially because of possible selection of multiresistant microorganisms.

[Keratomycosis: diagnosis and therapy]. / Diagnostik und Therapie der Keratomykose.

Diagnosis of fungal keratitis is only straightforward if it presents in its typical form with pyramidal-shaped hypopyon, prominent geographical corneal infiltration and satellites. However, in contact-lens wearers clinical presentation is untypical at early infection. Corneal debridement is therefore necessary, which simultaneously facilitates penetration of the antimycotic into the corneal stroma. At present, voriconazole is the medication of choice, if not changed after microbiological diagnosis to a specifically more potent substance - e.g. posaconazole or caspofungin. Amphotericin B may be used for repeated intracameral or intravitreal injection. Simultaneous application of steroids is useful.

Aqueous humor concentrations of topically administered caspofungin in rabbits.

BACKGROUND: The echinocandin caspofungin (CAS) is a novel antifungal drug with fungicidal in vitro activity against all Candida spp., which are the most frequent cause of fungal keratitis. Penetration of CAS through the cornea into the aqueous humor after topical administration was investigated. METHODS: A CAS solution with a concentration of 7 mg/ml was applied onto each rabbit's cornea. Drug application after corneal epithelium abrasion was processed in different time intervals: single application with aqueous humor sampling after 1 and 2 h. In addition, after continuous application of CAS every 30 min, aqueous humor concentrations of CAS after 1, 2 and 5 h were analyzed by liquid-chromatography tandem mass spectrometry. RESULTS: Topical administration of CAS without corneal epithelium abrasion resulted in no detectable amounts of the drug in the aqueous humor. However, with corneal abrasion, after a single application, levels of 2.16 +/- 1.57 microg/ml (n = 6) were reached after 1 h and then decreased to 1.76 +/- 0.88 microg/ml (n = 2) after 2 h. After serial application every 30 min, the following intracameral levels of CAS were detected: after 1 h, 2.11 +/- 1.09 microg/ml (n = 6); after 2 h, 4.94 +/- 1.80 microg/ml (n = 5), and after 5 h, 3.45 +/- 2.11 microg/ml (n = 6). CONCLUSION: In the aqueous humor, therapeutic drug levels can be reached that cover the MICs of most fungi after epithelial abrasion. To achieve a sustained high level of CAS as an effective antifungal therapy for corneal keratitis, CAS should be administered topically every 30 min after removal of the corneal epithelium.

[Contact allergy to topical ophthalmological drugs - epidemiological risk assessment]. / Kontaktallergien gegen ophthalmologische Lokaltherapeutika - eine epidemiologische Risikobewertung.

BACKGROUND: Contact allergies (CA) against active agents of topical ophthalmological therapeutics, causing inflammation of the conjunctiva and/or the lid, are usually not life-threatening, but occur not infrequently. As yet, the assessment of the CA-eliciting risk has been based on clinical data alone, while a valid epidemiological risk assessment is lacking. MATERIALS AND METHODS: The Information Network of Departments of Dermatology supplied information on diagnostic results obtained in 4,102 patients patch-tested for suspected CA to ophthalmic drugs between 1995 and 2004. Clinical prevalences were extrapolated to incidences at the German population level. These estimates served as numerator for a relative incidence (RI), which included the nationwide frequency of prescriptions collected by the WIdO, Bonn, in terms of a standardised defined daily dose (DDD) as denominator. RESULTS: The estimated annual incidence of CA ranges from 155 (atropine sulphate) to 2077 (gentamicin sulphate) and can thus be regarded as moderate. If incidence estimates are related to prescription frequencies, the highest risk was found for kanamycin and neomycin sulphate (RI > 8 / 100,000 DDD). In contrast, the RI of pilocarpine-HCl (0.3) was virtually negligible. CONCLUSIONS: The substance-specific risk of CA has been evaluated for the first time and found to differ between therapeutics (with a similar spectrum of application). CA risk should be considered in differential therapeutic decision-making.

[Biometry of the anterior segment using optical coherence tomography : Evaluation of different devices and analysis programs]. / Biometrie des vorderen Augensegmentes mittels optischer Kohärenztomographie : Evaluierung verschiedener Geräte und Analyseprogramme.

BACKGROUND: Digital visualisation of the anterior eye segment is becoming more and more important. Two commercially available optical coherence tomographs (OCTs) - Visante OCT (Carl-Zeiss Meditec Jena) and Slit Lamp-OCT (SL-OCT. Heidelberg Engineering) - were evaluated. Additionally, a manual and a semiautomatic analysis mode for the anterior segment biometry were compared using the SL-OCT. PATIENTS AND METHODS: Fifty eyes were examined by three ophthalmologists with complete eye status in a standardised fashion. Three anterior segment scans (horizontal and vertical) were performed using the Visante OCT and the SL-OCT. The manual integrated analysis mode of the Visante OCT was used. The best centred SL-OCT scan was analysed with a manual (EyelabGlobal/4Optics) and a semiautomatic procedure (HEYEX). Central corneal thickness (CCT), anterior chamber depth (ACD), pupillary diameter (PD) and chamber angle-angle distance (CAAD) were compared. RESULTS: Comparison of Visante OCT and SL-OCT: The horizontal CAAD was 11.65+/-0.47 mm for the Visante-OCT and 12.0+/-0.57 mm for the SL-OCT (p=0,002), vertical scans were comparable in 10 eyes only. The CCT was 568+/-61 microm with the Visante-OCT and 581+/-48 microm with the SL-OCT (n=35, p=0.03) in horizontal scans and 565+/-62 microm with the Visante-OCT and 568+/-51 microm with the SL-OCT in vertical scans (n=27, not significant). Deviation of the two measurement methods varied between -54.7 and 80.8 microm in horizontal scans and between -84.9 and 91.1 microm in vertical scans from the mean difference of the two methods. Comparison of the analysis programs: Horizontal scans: Manual analysis correlated with semiautomatic analysis in CCT as 581+/-51 microm vs. 572+/-53 microm (r=0.903), ACD 2.89+/-0.74 mm vs. 2.08+/-0.72 mm (r=0.98), PD 5.22+/-2.12 mm vs. 5.14+/-1.91 mm (r=0.917) and CAAD 11.59+/-1.02 mm vs. 11.79+/-0.6 mm (r=0.47). The manual and a semiautomatic analysis modes for CCT and ACD differed significantly (p<0.026). Vertical scan: Manual versus semiautomatic analysis modes correlated in CCT as 578+/-65 microm vs. 573+/-63 microm (r=0.593), ACD with 3.04+/-0.83 mm vs. 3.03+/-0.75 mm (r=0.92), PD with 5.28+/-1.99 mm vs. 5.45+/-2.00 mm (r=0.899) and CAAD with 11.75+/-0.66 mm vs. 11.82+/-0.6 mm (r=0.537). CONCLUSIONS: A near complete investigation of the cornea-anterior-chamber-iris segment is provided by the horizontal scan compared with the vertical scan. The noncontact OCT method is an easily handled tool for visualisation and biometry of the anterior eye segment. The investigated OCTs show a limited comparability. A complete analysis was possible in all eyes with the EyelabGlobal system in contrast to the HEYEX analysis software. Both analysis programs provided comparable measurements of the anterior eye segment. The semiautomatic biometrical mode may reduce the analysis time in qualitative excellent and well-centred scans to 10%.

[Intraocular injections of bevacizumab in rare indications--two cases]. / Intraokulare Bevacizumab-Injektionen bei seltenen Indikationen--zwei Kasuistiken.

Intravitreal anti-VEGF injections are currently the most effective treatment option for neovascular age-related macular degeneration. The anti-VEGF treatment of other, more common ocular diseases, such as diabetic retinopathy and vascular occlusions with neovascularization and retinal edema, is currently described in numerous studies and cases. Rare neovascular ocular diseases, such as Eales disease, presumed ocular histoplasmosis syndrome (POHS), retinopathy of prematurity, and idiopathic telangiectasia, may be future areas for anti-VEGF therapy. In our case report we describe intravitreal bevacizumab (Avastin) therapy for central serous chorioretinopathy and for pseudoxanthoma elasticum with angioid streaks and choroidal neovascularization. In both cases the intravitreal injection resulted in morphological and functional rehabilitation.

[Globe explosion due to intravitreal injection]. / Bulbusexplosion durch intravitreale Injektion.

An 83-year old female was given an intravitreal injection of 0.4 ml of triamcinolone acetonide (TA) by her local ophthalmologist for age-related maculopathy with a large choroidal neovascularisation in the left eye. During the injection, globe explosion occurred with nasal limbal rupture and extrusion of intraocular contents. Emergency primary wound repair was performed at the Eye Surgery Centre Erlangen-Mitte. During surgery, a 9 mm limbal rupture with prolapse of half of the iris and subconjunctival extrusion of the complete natural lens was discovered. After lens removal, anterior vitrectomy and iris repositioning, the wound was closed and the eye left aphakic. The further postoperative course was unremarkable and the patient retained her preoperative visual acuity of counting fingers. In this case, several factors may have contributed to the dramatic events: relative nanophthalmus (preoperative refraction + 5.0dpt), scleral weakness secondary to chemotherapy for leukemia, older age, and a relatively large volume of injected TA. The intravitreal injection of drugs may cause serious complications. Paracentesis or limited pars plana vitrectomy should be considered prior to intravitreal injection in high-risk cases to prevent such disastrous complications.