[Rho kinase inhibitors as new local therapy option in primary open angle glaucoma]. / Rho-Kinase-Hemmer als neue lokale Therapieoption beim primären Offenwinkelglaukom.

BACKGROUND: In 2014 in Japan and 2017 in the USA, the Rho-kinase inhibitors were approved as a new antiglaucomatous substance group and will now be launched in Europe. OBJECTIVE: On this occasion the current state of knowledge on Rho-kinase inhibitors is presented. METHODS: In intensive search in PubMed the relevant experimental and clinical literature on the Rho-kinase inhibitors ripasudil and netarsudil and the combination of netarsudil and latanoprost were selected and compiled for this review. RESULTS: The intraocular pressure lowering efficacy of ripasudil and netarsudil is in the range of the beta blocker timolol and the prostaglandin analogue latanoprost. In the fixed combination netarsudil/latanoprost the intraocular pressure reduction is greater than that of the single components and reaches a target pressure of below 15 mm Hg in 32%. Conjunctival hyperemia with 53-65% is the most common local side effect. Systemic side effects are very rare and so far there are no contraindications. CONCLUSION: The Rho-kinase inhibitors are an interesting new introduction for glaucoma therapy, as each new pressure-lowering therapy represents an additional chance to reach the individually defined target pressure level in a glaucoma patient with local therapy; however, many of the pleiotropic effects associated with Rho-kinase inhibitors have so far only been found experimentally and will require clinical confirmation in the future.

[Preoperative management of subconjunctival/sub-Tenon's glaucoma surgery with special consideration of the gel implant (XEN®)]. / Präoperatives Management bei subkonjunktivalen/subtenonalen glaukomchirurgischen Operationen unter besonderer Berücksichtigung des Gelimplantats (XEN®).

BACKGROUND: When using subconjunctival/sub-Tenon's ab interno glaucoma surgical procedures, patient selection and preoperative management are essential to reduce postoperative scarring of the bleb. OBJECTIVE: The aim of this study was to compile a list of risk factors that may have an unfavorable effect on the scarring process. METHOD: A literature search was carried out in PubMed with respect to the scarring process of the gel implant XEN®. RESULTS: Ophthalmological risk factors for conjunctivoscleral/Tenon's wound healing process include dry eye, allergies, use of eye drops containing preservatives and previous eye surgery. CONCLUSION: The preoperative administration of artificial tear substitutes, corticosteroids and the fundamental change to preservative-free eye drops can support the normalization of a chronic inflammatory altered conjunctiva and thus positively influence the wound healing process after surgery.

[Management of anticoagulants in ophthalmic surgery-a survey among ophthalmic surgeons in Germany]. / Umgang mit gerinnungshemmenden Substanzen in der Ophthalmochirurgie ­ eine Umfrage unter Ophthalmochirurgen in Deutschland.

INTRODUCTION: As our population ages and comorbidities rise, ophthalmic surgeons are increasingly faced with patients on anticoagulant therapy or with clotting disorders. The ophthalmic surgeon has to weigh the perioperative risk of haemorrhage when anticoagulation continues against the risk of thromboembolism caused by discontinuation or changing the patient's medication (bridging, switching, cessation). There are currently no guidelines or recommendations. METHODS: A survey was sent to the DOG (German Ophthalmologic Society) divisions and associated surgical organizations to determine the status quo. A questionnaire was sent out and filled out by the different groups of specialists. RESULTS: All four divisions of the DOG and four associated organizations returned completed questionnaires. Surgical interventions were listed that are carried out during anticoagulant therapy without exceptions, as well as interventions that were classified to require medical adjustment. Although the assessments varied, general consensus was achieved regarding interventions not requiring adjustments due to anticoagulants (i. e., intravitreal injection, cataract surgery, laser and corneal operations, simple muscle surgery), and those interventions requiring adjustments in medications (glaucoma operations, complex retina surgery, eye socket surgery, complex surgery of the lid). CONCLUSION: Main result of this survey was the specification of serious bleeding complications which are permanent vision loss and re-operation. They could serve as endpoint parameters for essential future investigations. Nevertheless, this survey makes clear that the decision about an adjustment of anticoagulant medication in ophthalmic surgery is currently made individually and not based on established standards.

[Suprachoroidal minimally invasive glaucoma surgery : Procedures and clinical outcome]. / Suprachoroidale minimalinvasive Glaukomchirurgie : Verfahren und klinische Ergebnisse.

The uveoscleral outflow route is via the ciliary muscles into the suprachoroidal spaces and then to the orbital blood and lymph systems. The main driving force behind this uveoscleral outflow is the high oncotic pressure in the choroidal vessels. Currently, the CyPass microstent is the only available suprachoroidal device for ab interno minimally invasive glaucoma surgery. The CyPass achieves a maximum reduction of intraocular pressure (IOP) to 16-17 mm Hg over 12-24 months and is approved for mild to moderate primary open-angle glaucoma. The CyPass is an easy to use minimally invasive glaucoma surgery stent operation and has few intraoperative as well as short and long-term complications. Postoperative management is unproblematic and the postoperative burden for patients is low, which leads to rapid recovery of patients; however, the correct selection of glaucoma patients is crucial for maintaining a sustainable success rate. Long-term studies are necessary to demonstrate the persistence of the IOP lowering effect.

[Structural and morphological changes in the eyes of arterial hypertensive patients with and without anti-CCP-positive rheumatoid arthritis]. / Strukturelle und morphologische Veränderungen am Auge bei Patienten mit arterieller Hypertonie mit und ohne Anti-CCP-positiver rheumatoider Arthritis.

INTRODUCTION: To investigate the additive systemic inflammatory process of rheumatoid arthritis (RA) in arterial hypertension patients, structural and morphological changes of the retina and optic nerve head were assessed by modern topographic technologies. Similarities of underlying vascular mechanisms between RA and arterial hypertension are interesting and have not been researched in depth. The aim of this study is to evaluate changes of RA and arterial hypertension with the optic coherence topography (OCT) and Heidelberg retina tomography (HRT III), to validate RA changes in comparison to arterial hypertension only patients and, finally, if these methods are useful to detect the chronic inflammatory influence of the RA on the eye. METHODS: In this prospective study design, data of 18 patients with RA and arterial hypertension (55.3 ± 4.31 years old), positive for antibodies against cyclic citrullinated peptides, 21 patients with arterial hypertension (54.2 ± 4.18 years old) and 19 healthy subjects (53.1 ± 3.25 years old) were included. Intensive ophthalmologic and internistic screening tests were carried out in all subjects. All participants were investigated for the retinal nerve fiber layer (RNFL) and macula thickness with the OCT (Carl Zeiss AG Germany) and for stereometric parameters of the optic nerve head with the Heidelberg Retina Tomograph III (Heidelberg Engineering Germany). The pachymetry was conducted by the Orbscan II system (Bausch & Lomb). Statistical data were assessed by SPSS, v20.0. RESULTS: No significant differences were found in visual function, diastolic and systolic blood pressure. RNFL, and macular thickness (Stratus-OCT) were almost consistent between the groups and even the main stereometric parameters measured with HRT III showed no significant differences. CONCLUSION: Contrary to our study hypothesis no structural and morphological changes could be detected in patients with arterial hypertension without RA compared to healthy subjects. Furthermore, no RA-specific effects could be shown in comparison with the hypertension group. Thus, the used examination techniques are not suitable to prove the systemic inflammatory influence of RA on the eye.

[Comparison of the Results of the Flicker Perimetry (Prototype versus Commercial Perimeter)]. / Vergleich der Ergebnisse der Flimmerperimetrie (Prototyp versus kommerziellem Perimeter).

Background: Analysis of the comparison of flicker perimetry with the prototype Pulsar and the new Octopus 600. Methods: Both eyes of 20 patients with primary open-angle glaucoma were studied with 30° visual field flimmer perimetry (dynamic strategy) at the perimeters Pulsar and Octopus 600 (Haag-Streit). The evaluation was based on the mean defect (MD = mean deviation) and the defect depth (square root of lost variance = sLV). Results: In the t test for paired samples, the Pulsar perimetry showed significantly higher values than the Octopus 600 perimetry: right eye MD 4.8 ± 3.6 src vs. 1.7 ± 2.9 src, p = 0.005; left eye MD 3.9 ± 3.6 src v. 1.4 ± 2.8 src, p = 0.018; both eyes MD 4.35 ± 3.62 src vs. 1.55 ± 2.80 src, p = 0.002. The sLV values with the Pulsar perimetry were significantly higher than the values with the Octopus 600 perimetry: right eye sLV 3.6 ± 1.6 vs. 2.3 ± 1.3 src, p = 0.006; left eye sLV 3.2 ± 0.8 vs. 2.0 ± 0.8 src, p < 0.0001; both eyes sLV 3.37 ± 1.28 src vs. 2.12 ± 1.05 src, p < 0.0001. The significances even persisted after the Bonferroni-Holm correction. Conclusion: The investigation results of flicker perimetry are not comparable, because there is a significant difference in MD and sLV. This mainly due to different light intensities, background brightness and varying colour scalings of the perimetric device.

[Aids for Patients with Glaucoma and Visual Impairment]. / Hilfsmittel für Patienten mit Glaukom und Sehbehinderung.

This article provides a broad overview of the existing medical aids and appliances for patients suffering from glaucoma and/or visual impairment. Furthermore, instructions for proper handling of eye drop therapy are given. There are many different public services to support patients with visual impairment and that aim to restore their mobility and autonomy in daily life. About 20,000 medical aids and tools are currently listed as refundable by insurances. The available supply ranges from magnifying reading aids to electronic aids and appliances to train patients' orientation, mobility and skills of every day life. Qualified professionals may be employed by organisations such as the DBSV e. V. and can accompany, support and counsel patients and their families with their specialised knowledge.

[Ocular blood flow regulation in glaucoma - examination with the ocular pressure flow analyzer (OPFA)]. / Okuläre Durchblutungsregulation beim Glaukom. Untersuchungen mit dem Ocular Pressure Flow Analyzer (OPFA).

BACKGROUND: The results of studies of ocular blood flow (BF) regulation of patients with primary open-angle glaucoma (POAG), normal-tension glaucoma (NTG) and ocular hypertension (OH) are presented. METHODS AND PATIENTS: Examinations were carried out with the "OPFA", a newly developed ocular pressure flow analyzer (producer: tpm Lüneburg) on 92 patients with newly diagnosed glaucomas, among whom 48 patients had POAG, 22 NTG and 22 OH, and compared with age-matched groups of healthy subjects. The OPFA uses pneumatic coupling through special scleral suction cups to record ocular pulses with highly sensitive transducers and a suction pump for simultaneously increasing intraocular pressure (IOP). Following local drop anaesthesia on both eyes, IOP is artificially raised to suprasystolic values. While continuously lowering IOP, the ocular pulse is then recorded with increasing ocular perfusion pressure. We obtain the relative ocular pulse blood volume by correlating the ocular pulse amplitudes with a calibration volume of 1 µl. This enables us to collect reproducible data on intra- and inter-individual pulse blood volume (PVoc). The ocular perfusion pressure pulse blood volume curve characterizes the respective individual ocular circulation as well as systolic and diastolic ocular perfusion pressures. RESULTS: In healthy subjects, the ocular pulse blood volume remains stable over a certain range of ocular perfusion pressure (ppoc) changes. After exceeding a critical point (CP), the ocular pulse blood volume drops. We refer to the difference between the CP and IOP as the autoregulatory capacity (AC). In patients with POAG and in patients with NTG, the AC was reduced significantly compared with the groups of healthy subjects. The mean AC of patients with OH remained within the normal range. The ROC curves showed at an optimal cut-off value for POAG a sensitivity of 75.0 % and a specificity of 97.9 %, for NTG a sensitivity of 77.3 % and a specificity of 100 %. In patients with POAG and OH, the ocular arterial pressures were elevated. In patients with NTG they remained unchanged compared with the healthy subjects. The ocular perfusion pressures did not change in POAG as well as in NTG and OH. CONCLUSIONS: In patients with POAG and in patients with NTG the ocular BF regulation was impaired and detected by the OPFA device with a high level of reliability. Ocular arterial blood pressures were increased as a result of vascular regulation to keep up the ocular perfusion pressure and to maintain ocular perfusion.

[Ambulatory 24-h blood pressure measurement in patients with glaucoma]. / Bedeutung des 24-Stunden-Blutdruckprofils beim Glaukom.

The arterial blood pressure is an important determinant for the development and progression of glaucoma. Some relevant information can be obtained only by ambulatory 24-h blood pressure measurement (ABPM). White-coat hypertension can be excluded by ABDM and the variability of blood pressure during 24 hours can be assessed. 24-h mean blood pressure should be < 130/80 mmHg. In contrast, diastolic blood pressure values below 60 mmHg during the night have been identified as a progression factor in glaucoma, as well as reductions of night-time systolic blood pressure of less than 10 % (non-dipper) and of more than 20 % (extreme dipper). The significance of the 24-h blood pressure profile for the cooperation of ophthalmology and internal medicine is discussed.

[Neurological disorders and glaucoma - an overview]. / Neurologische Erkrankungen und Glaukom - ein Überblick.

Due to the anatomic location of the N. opticus to the brain and its embryological development as a "bulging part of the brain", a close connection between the opticoneuropathy and certain neurological diseases exists. Glaucoma is a chronic neurodegenerative disorder and many cellular and molecular mechanisms of the chronic neurodegenerative diseases are common in the brain. For example, elevated levels of multiple biomarkers of Alzheimer's disease were found in the aqueous humor of patients with primary open-angle glaucoma. Also a decreased cerebrospinal fluid pressure (CSFP) has been demonstrated in patients with glaucoma and Alzheimer's disease. The resulting translaminar pressure difference is seen as one of the pathogenic mechanisms of the formation of the optic neuropathy in both diseases. Other hypotheses, such as the influence of oxidative stress, excitotoxicity, mitochondrial dysfunction, genetic factors and vascular factors play additional roles in the pathogenesis of the different diseases. Experimental studies have shown that dopaminergic amacrine cells are present in the retina. The dopamine in the retina is necessary for the light adaptation and the signal processing in the rods and cones. Parkinson's disease is characterised by a loss of dopaminergic neurons in the basal ganglia-substantia nigra pars compacta of the midbrain. These decreased levels of dopamine also have an effect on the eye and the afferent signal processing. So there are reductions in visual acuity, disturbances in colour vision and contrast sensitivity and reduction of the retinal nerve fiber layer in patients affected with Parkinson's disease. With the examples of Alzheimer's disease, Parkinson's disease and the chronic inflammatory disease multiple sclerosis, we demonstrate the association between the neurological diseases and the opticoneuropathy in primary open-angle glaucoma.

[Relevance of arterial hypertension in primary open-angle glaucoma]. / Die Bedeutung der arteriellen Hypertonie für das primäre Offenwinkelglaukom.

Primary open-angle glaucoma is a multifactorial disease with a lot of different risk factors. Beside the fact that intraocular pressure (IOP) is the most important risk factor, the reduction of IOP alone is in most cases not sufficient to stop the progression of glaucoma. Therefore, other risk factors play also an important role. One of them is arterial hypertension, the most common systemic disease in glaucoma patients. Arterial hypertension increases IOP slightly, but has an important negative effect on ocular perfusion. Especially the endothelial dysfunction with a disturbed retinal autoregulation plays an important role. Therefore, ischaemic and reperfusion effects alter the optic nerve head and have negative input to the glaucomatous optic neuropathy. In future glaucoma patients should be monitored by ophthalmologists as well as by general physicians/cardiologists to optimise their treatment and to stabilise their glaucoma as well as possible.

[Corneal endothelial cell density and its correlation with the severity of pseudoexfoliation]. / Hornhautendothelzelldichte in Abhängigkeit vom Schweregrad der Pseudoexfoliation.

INTRODUCTION: Pseudoexfoliation (PEX) syndrome is a common, age-related disease which is associated with the multifocal deposition of fibrillar PEX material in intra- and extraocular tissues. Subsequently among others second chronic open-angle glaucoma and corneal endothelial cell loss occurs. The present study analysed whether there is a correlation between the stage of the PEX process and corneal endothelial cell density (cECD), regardless of the non-existence or proof of secondary glaucoma. MATERIALS AND METHODS: One eye of 109 Caucasian subjects (mean age 71.7 years) was examined by slit-lamp microscopy and classified based on visible PEX deposits on the lens (mild and severe) and presence of glaucoma in 4 study groups. The control groups were healthy subjects and patients with primary open angle glaucoma (POAG). The cECD was measured with the endothelial cell mirror microscope (SeaEagle). RESULTS: All study groups and the POAG group showed a significant cECD reduction compared to the healthy control group: POAG: 6.0 %; PEX syndrome: mild 5.5 % and severe 11.0 %, PEX glaucoma: mild 7.7 % and severe 12.3 %. Further the cECD was significantly lower compared to the POAG group in severe PEX syndrome by 5.4 % and in severe PEX glaucoma by 6.8 %. cECD significantly decreased with increasing PEX stage independently of the presence of glaucoma. These differences remained statistically significant after Bonferroni-Holm correction. The analysis of the entire group of test subjects showed only a weak correlation between mean intraocular pressure and mean cECD. CONCLUSION: The results of this study showed a decreasing cECD with increasing PEX stage, regardless of whether glaucoma is present or not. The influence of the PEX process appears to be more pronounced than the influence of intraocular pressure.

[Supraciliary microstent for open-angle glaucoma: clinical results of a prospective multicenter study]. / Supraziliarer Mikrostent bei Offenwinkelglaukom: Klinische Ergebnisse einer prospektiven Multicenterstudie.

PURPOSE: The suprachoroidal CyPass micro-stent is designed to be implanted into the supraciliary space to facilitate aqueous outflow along the uveoscleral pathway in patients with open-angle glaucoma (OAG). This study assessed the safety of micro-stent implantation in patients undergoing cataract surgery. METHODS: In this multicenter study the CyPass microstent was implanted in patients with OAG undergoing cataract surgery. The implantation was performed using a minimally invasive, conjunctiva-sparing, ab interno intervention. Primary endpoints were safety aspects of the implant, secondary endpoints were the reduction of intraocular pressure (IOP) and topical medication. RESULTS: There were no severe adverse events during or after surgery in any of the patients. In patients with controlled glaucoma (IOP < 21 mmHg) the average IOP remained constant throughout the 24 month follow-up period but mean medication use decreased from 2.0 at baseline to 1.1 postoperative. In patients with IOP of ≥ 21 mmHg the pressure was reduced by 37 % postoperatively and mean medication decreased from 2.2 at baseline to 1.0. CONCLUSIONS: The safety profile of combined cataract surgery and CyPass microstent implantation is acceptable and patients also showed a decrease in IOP and medication use.

[Risk factors in the results of the colour vision test Roth 28-hue (E) desaturated in glaucoma patients]. / Einflussfaktoren auf die Ergebnisse des Farbpigmentprobentests Roth 28-hue (E) desaturiert bei Glaukompatienten.

BACKGROUND: Glaucoma is an ocular disease with typical progressive damage of the optic nerve. In the past it was postulated that glaucoma induces acquired colour vision disorders. Until now all studies about glaucoma and colour vision disorders did not include vascular risk factors. In the present study we determined several vascular risk factors concerning the results of the colour vision test Roth 28-hue (E) desaturated in glaucoma patients. PATIENTS AND METHODS: On the basis of an analysis of variance (ANOVA) we determined the influence of several risk factors, such as arteriosclerotic and vasospastic risk factors, on the results of the colour vision test Roth 28-hue (E) desaturated in glaucoma patients. 353 glaucoma patients were included in this study. RESULTS: We detected a strong influence of age and mean defect in perimetry and an additional effect of arteriosclerotic and vasospastic risk factors on the results of the colour vision test Roth 28-hue (E) desaturated in glaucoma patients. CONCLUSIONS: We suspect that arteriosclerotic and vasospastic risk factors independently to glaucoma have an influence on colour vision. In the future attention additionally has to be given to vascular risk factors in the colour vision testing of glaucoma patients.

[Immunoassay for matrix metalloproteinase-9 in the tear film of patients with pseudoexfoliation syndrome - a pilot study]. / Immunoassay für Matrix-Metalloproteinase-9 in der Tränenflüssigkeit bei Patienten mit Pseudoexfoliationssyndrom - eine Pilotstudie.

INTRODUCTION: Matrix-metalloproteinases (MMPs) are proteolytic enzymes released by irritated epithelial cells of the ocular surface. It has been established that the subtype MMP-9 can serve as an inflammatory marker within the tear film. MMP-9 is also attributed to have an effect on the PEX-glaucoma development. Recently, a rapid immunoassay for detection of MMP-9 in the tear film was developed to estimate inflammatory extent during dry eye disease. The aim of this study was to analyse the MMP-9 concentration in tear film in PEX-syndrome. In addition, an assessment of the feasibility, reliability and readability of the test was done. METHODS: We randomly selected 10 patients with PEX-syndrome and 10 healthy control patients and measured tear film MMP-9 of one eye with the RPS InflammaDry Detector™ (Rapid Pathogen Screening Inc., USA). RESULTS: We detected increased levels of MMP-9 in tear film in PEX-syndrome. 80 % of the PEX-patients and 20 % of the controls showed a positive test result (>or= 40 ng/mL MMP-9) indicating a test specificity and sensitivity of 80 %. This corresponds approximately to the published values for the dry eye (sensitivity 87 %, specificity: 92 %). The performance of the test is simple. The patients tolerated the inclusion of the test strips well. However, it is difficult to estimate whether enough tear film was used and in many cases, the intensity of the "indicator line" was weak. CONCLUSION: The rapid MMP-9-immunoassay is a novel, meaningful approach for the detection of inflammatory activity of the ocular surface. We have shown an up-regulation of the non-specific inflammatory marker MMP-9 in tear film in PEX-syndrome and suggest an association with a tear film disorder. However, an improvement in the estimation of the amount of collected tears and readability is desirable.

[Importance of perimetric differential diagnostics in patients with primary open-angle glaucoma]. / Stellenwert einer perimetrischen Differenzialdiagnostik beim primären Offenwinkelglaukom.

Functional deficits in glaucomatous optic neuropathy are, apart from other disturbances in the visual field, typically detected with achromatic perimetry as a well accepted gold standard. With the development of new perimetric devices and strategies (e.g. short wave perimetry, frequency doubling perimetry and flicker perimetry) individually different patterns of scotomas in the different perimetric devices could be recognized. The reasons for this could be a different sensitivity reaction of the ganglion cell subpopulations to an increased intraocular pressure as well as an influence of the underlying systemic diseases. To obtain a differentiated detection of the functional loss in the visual field in glaucoma, the use of different perimetric methods seems to be reasonable and helpful.