[Optic Nerve Head Diagnostics with Optical Coherence Tomography]. / Papillendiagnostik mithilfe der optischen Kohärenztomografie.

BACKGROUND: With a cooperative patient, examination of the optic nerve head using optical coherence tomography (OCT) is fast and easy to perform and facilitates identification and monitoring of different pathological changes in the optic nerve head. MATERIALS AND METHODS: Characteristic findings and scanning options are illustrated using case examples to simplify recognition of infrequent diseases of the optic nerve head and to facilitate treatment decisions using OCT results. RESULTS: Pathological changes and characteristic OCT findings are shown for glaucoma, for different anomalies of the optic nerve head, for non-glaucomatous optic atrophies and for optic disc swelling for different reasons. The most suitable OCT parameters and examination modes are listed to differentiate between specific pathological changes. CONCLUSION: Optic nerve head examination using the OCT facilitates rapid diagnosis of infrequent and hard to distinguish pathological changes, as well as exact monitoring of chronic progressive diseases of the optic nerve. Correct application and evaluation of results gathered using OCT examination of the optic nerve head facilitates accurate diagnosis and correct decisions.

Permeability shapes bacterial communities in sublittoral surface sediments.

The first interaction of water column-derived organic matter with benthic microbial communities takes place in surface sediments which are acting as biological filters catalyzing central steps of elemental cycling. Here we analyzed the bacterial diversity and community structure of sediment top layers at seven sites in the North Sea where sediment properties ranged from coarse-grained and highly permeable to fine-grained and impermeable. Bacterial communities in surface sediments were richer, more even and significantly different from communities in bottom waters as revealed by Illumina tag sequencing of 16S rRNA genes. Sediment permeability had a clear influence on community composition which was confirmed by CARD-FISH. Sulfate-reducing Desulfobacteraceae (2-5% of total cells), Flavobacteriaceae (3-5%) were more abundant in impermeable than in highly permeable sediments where acidobacterial Sva0725 dominated (11-15%). Myxobacterial Sandaracinaceae were most abundant in medium permeable sediments (3-7%). Woeseiaceae/JTB255 and Planctomycetes were major groups in all sediments (4-6%, 8-22%). Planctomycetes were highly diverse and branched throughout the phylum. We propose Planctomycetes as key bacteria for degradation of high molecular weight compounds and recalcitrant material entering surface sediments from the water column. Benthic Flavobacteriaceae likely have restricted capabilities for macromolecule degradation and might profit with Sandaracinaceae and Acidobacteria from low molecular weight compounds.

[Visual Snow Syndrome: Symptoms and Ophthalmological Findings]. / Das Visual-Snow-Syndrom: Symptome und ophthalmologische Befunde.

Background The symptom "visual snow" describes the continuous perception of tiny flickering dots within the whole visual field of both eyes. The diagnosis of a visual snow syndrome requires the appearance of typical additional visual symptoms and the exclusion of ophthalmological or neurological causes, or pharmacological influences. Patients and Methods Three male and four female subjects between 13 and 36 years of age referred with visual snow were investigated and asked about their symptoms. A complete ophthalmological investigation, including binocular fundoscopy, was performed in all patients. Furthermore, best corrected visual acuity, perimetry, binocular functions, colour vision (D15-test), full-field ERG, pattern-reversal VEP and SD-OCT images of macula and optic nerve (RNFL) were analysed. Results Visual acuity of at least 1.0 and normal findings for all further investigations were observed in all patients. The following additional visual symptoms were identified: illusionary palinopsia (n = 6), disturbance of night vision (n = 5), positive light phenomena (n = 7). A history of migraine with aura was reported in five patients. The intake of hallucinogenic drugs or centrally active pharmaceuticals was denied by all patients. The findings of available or initiated neurological investigations were normal. Conclusions The visual snow syndrome has to be regarded as a diagnosis of exclusion. Visual function parameters are not impaired. Apart from eye diseases, a persistent migraine aura as well as neurological diseases or the intake of hallucinogenic drugs must be excluded as possible causes of visual snow and palinopsia.

[Do We Still Need Electrophysiology in Ophthalmology?] / Brauchen wir noch Elektrophysiologie in der Augenheilkunde? Indikationsstellung für elektrophysiologische Untersuchungen.

Electrophysiological methods in clinical ophthalmology include the full-field electroretinogram (ERG) for assessment of outer and middle retinal layers, pattern ERG (PERG) for assessment of ganglion cell function, the electrooculogram (EOG) for assessment of retinal pigment epithelium function, as well as visual evoked potentials (VEP) for assessment of the visual pathway, including the optic nerve and visual cortex. Multifocal recording techniques for ERG and VEP are used for tests within selected areas of the visual field. Technical progress in ocular imaging, especially optical coherence tomography (OCT) and fundus autofluorescence (FAF), allows high-resolution imaging of subtle morphological changes of the retina and posterior fundus. Typical retinal diseases may then be diagnosed at an early stage, without conventional electrophysiological investigations (e.g. x-linked retinoschisis, Stargardt disease, vitelliform macular dystrophy). OCT outclasses electrophysiological methods in the quantification of optic atrophies. With newly developed optic techniques, peripheral retinal structures (wide angle optics) and subtle structures up to the photoreceptor level (adaptive optics) can be imaged with increasing quality. However, differentiation of central retinal disorders (e.g. macular dystrophy) from generalised retinal diseases requires electrophysiological diagnostic testing. The same applies to discrimination between different functional disorders in generalised retinal diseases (e.g. enhanced S-cone syndrome, congenital stationary night blindness, achromatopsia).

[Treatment options for nystagmus]. / Therapiemöglichkeiten bei Nystagmus.

The goal of treatment for nystagmus is to reduce or to abolish the typical symptoms associated with nystagmus. These are (i) reduction of visual acuity (and amblyopia in infantile nystagmus), (ii) abnormal head posture (with possible secondary changes of cervical spine) and (iii) oscillopsia (often connected with vertigo and disorders of gait and orientation). Treatment strategies include pharmacological treatment, surgical therapy and optical devices. Choice of treatment depends on the type of nystagmus and its characteristics. SURGICAL THERAPY: The following surgical procedures were successfully used as treatment of selected symptoms: (i) unilateral recess-resect surgery of the dominant eye in infantile esotropia with latent nystagmus for the relief of abnormal head posture, (ii) Kestenbaum operation of both eyes in infantile nystagmus syndrome with excentric null zone and abnormal head posture, (iii) recess-resect surgery to produce artificial exophoria in infantile nystagmus syndrome. PHARMACOLOGICAL TREATMENT: Depending on the pathophysiology of different types of nystagmus, several drugs were effective in clinical application (off-label use): (i) gabapentin (non-selective GABAergic and anti-glutamatergic effect): up to 2400 mg/d in infantile nystagmus, acquired pendular nystagmus and oculopalatal tremor, (ii) nemantine (anti-glutamatergic effect): dosage up to 40 mg/d in infantile nystagmus, also in acquired pendular nystagmus and oculopalatal tremor, (iii) baclofen (GABA-B-receptor agonist): 3 × 5-10 mg/d in periodic alternating nystagmus and in upbeat nystagmus, (iv) 4-aminopyridine (non-selective blocker of voltage-gated potassium channels): 3 × 5 mg/d or 1-2 × 10 mg Fampridin in downbeat nystagmus and upbeat nystagmus, (v) acetazolamide (carbonic anhydrase inhibitor): in hereditary episodic ataxia type 2. OPTICAL DEVICES: (i) Contact lenses are used in infantile nystagmus in order to overcome negative effects of eye glasses in abnormal head posture, lateral gaze, and higher refractive errors, (ii) spectacle prisms are useful to induce an artificial exophoria (base-out prisms) or to shift an excentric null zone (base in direction of head posture) of infantile nystagmus with abnormal head posture, (iii) low vision aids may be necessary and should be prescribed according to magnification requirements.

[Propranolol therapy for periocular and orbital infantile haemangiomas]. / Propranolol-Therapie bei infantilen Hämangiomen im Lid- und Orbitabereich.

In spite of the self-limiting natural course of infantile haemangiomas of the eyelids and orbit, the effects of amblyopia, compression of the optic nerve, and impairment of the aesthetic appearance may develop. Since the serendipitous discovery of the effects of propranolol, a non-selective beta-blocker, on infantile haemangioma in 2008, it has largely replaced the former standard treatments with corticosteroids, laser or surgical procedures. This review discusses the pathogenesis, classification, indication for treatment, and treatment options for infantile haemangiomas. In addition, the results of patients with infantile haemangiomas of the eyelids and orbit treated with systemic propranolol are shown. With additional confirmation of data, including a positive effect-risk-analysis, propranolol will potentially replace high-dose corticosteroids and surgery in the treatment of infantile haemangiomas in the eyelids and orbit. Further clinical studies are necessary to optimise the dosage, treatment period, and application modalities (oral or topical). In the future, propranolol accompanied with paediatric-cardiological monitoring should emerge as the first-line therapy for problematic infantile haemangiomas.

[Application of optical coherence tomography in paediatric neuroophthalmology]. / Einsatzmöglichkeiten der optischen Kohärenztomografie bei der Diagnostik von Erkrankungen der Makula und des Nervus opticus bei Kindern.

Optical coherence tomography (OCT) is a non-invasive imaging technique which provides the possibility to record transpupillarily cross-sectional scans of the retina and the optic disc. The exact localisation and reproducibility of the scans are ensured by the combination with a scanning laser ophthalmoscope. The outcome of this is the possibility to collect additional morphological data for the diagnosis of neuroophthalmological diseases particularly in children. OCT data allow for the differentiation of macular diseases from optic nerve pathology in unexplained visual loss. Various forms of optic neuropathies can be distinguished and quantitatively characterised with regard to their severity and clinical course. Serial assessment of papilloedema or optic atrophy over time gives valuable objective information about the prognosis of the underlying disease and the therapy planning.

[Driving competency after combined treatment with methylprednisolone and orbital radiotherapy for endocrine orbitopathy]. / Fahrtauglichkeit nach kombinierter Methylprednisolontherapie und Retrobulbärbestrahlung bei endokriner Orbitopathie.

OBJECTIVE: Graves' orbitopathy (GO) in its moderate to severe expression is a disfiguring and disabling disease that profoundly influences activities of daily living. Intravenous steroids and orbital radiotherapy are effective treatments for moderate to severe active GO. We examined the ophthalmological outcomes regarding daily life activities, such as driving competency. MATERIALS AND METHODS: In a retrospective case series, we evaluated the data for 21 consecutive patients with moderate to severe and active GO (14 women and seven men) treated with combined orbital radiotherapy (13 Gy) and intravenous methylprednisolone (500 mg weekly for 6 consecutive weeks and 250 mg weekly for consecutive 6 weeks). RESULTS: The pretreatment mean clinical activity score of 5.2 points (SD ± 0.9) decreased significantly to 2.7 points (SD ± 1.1) in the 12-month follow-up. Analysis of all ocular symptoms showed significant changes for four parameters with different time frames. Inflammatory eye signs--e.g., pain and pressure sensation, caruncle inflammation, and eyelid swelling, including exophthalmos--improved significantly within the first 3 months. Eyelid swelling was significantly reduced 6-12 months after therapy. However, there was no significant improvement of eye motility. Despite anti-inflammatory treatment, 11 patients (52.3%) were not fit to drive a car under binocular conditions. In eight of these patients, additional strabismologic therapy, including prisms or strabismus surgery, was successful. CONCLUSION: The combined therapy of intravenous corticosteroids and orbital radiotherapy reduced inflammatory ophthalmological signs in different time frames. In most cases, strabismologic intervention, including eye muscle surgery, was necessary to restore driving competency.

[23-gauge-lentectomy for the treatment of congenital cataract]. / 23-Gauge-Lentektomie zur operativen Behandlung einer angeborenen Katarakt.

BACKGROUND: Congenital cataract surgery can be performed using a pars plana/plicata approach if placement of an intraocular lens at the time of cataract removal is not a consideration. To prevent development of secondary cataract, we performed lens aspiration, anterior and posterior capsulotomy, and anterior vitrectomy via pars plana or pars plicata approach. Lentectomy in babies should be performed using a minimally invasive technique to prevent complications. Immediately after surgery, insertion of a contact lens should be possible. METHOD: The series consisted of 11 eyes of 8 consecutive children who suffered from congenital cataract and underwent pars plana/plicata lentectomy between April 2007 and September 2008. Age at operation ranged from 6 weeks to 13 months (median age 4 months). The inclusion criterion was congenital cataract affecting the visual axis. Lentectomy was performed via a pars plana or pars plicata approach using a special 23-gauge aspiration and irrigation system and a 23-gauge cutter. We performed lens aspiration, anterior and posterior capsulotomy, and anterior vitrectomy. RESULTS: Postoperatively the eyes showed only mild signs of inflammatory reaction. At the end of the operation, all eyes were provided with contact lenses. For all eyes, the surgical technique provided a clear visual axis during the follow-up period of 2-18 months. One eye developed secondary cataract. CONCLUSION: The use of 23-gauge instruments has advantages over standard 20-gauge equipment. Pars plana/plicata lentectomy using 23-gauge instruments is a safe, effective, and minimally invasive method for treating cataract in babies.

Effect of combined intravenous glucocorticoids and orbital radiotherapy in restoring driving competency in patients with Graves' orbitopathy.

Intravenous glucocorticoids and orbital radiotherapy are effective treatments for moderate-to-severe and active Graves' orbitopathy. We examined the ophthalmological outcome in daily life activities, such as driving competency. In a retrospective case series, 23 patients with moderate-to-severe and active Graves' disease (14 women and 7 men) were consecutively treated with combined orbital radiotherapy (13 Gy) and intravenous methylprednisolone (500 mg weekly for 6 consecutive weeks and 250 mg weekly for consecutive 6 weeks). The pretreatment Clinical Activity Score of 5.2 points (SD+/-0.9) decreased significantly to 2.7 points (SD+/-1.1) in the 12-month follow-up. Inflammatory eye signs, for example, pain and pressure sensation, caruncle inflammation, eyelid swelling, and exophthalmos decreased significantly. However, there was no significant improvement of eye motility. Despite anti-inflammatory treatment, 13 patients (61.9%) were not fit to drive a car under binocular conditions and additional stabismologic therapy including strabismus surgery was required. The combined therapy of intravenous glucocorticoids and orbital radiotherapy reduced inflammatory ophthalmological signs. In most cases strabismologic intervention including eye muscle surgery was necessary to restore driving competency.

Effects of unilateral ocular motor nerve palsies on smooth pursuit eye movements in adult patients.

AIM: The aim of this study was to investigate the influence of single ocular muscle weakness on smooth pursuit eye movements. METHODS: Infrared video recordings of horizontal and vertical eye movements were obtained from 14 adult patients with either unilateral abducens nerve palsy or trochlear nerve palsy. During the recordings, subsequent series of horizontal, vertical and oblique ramp stimuli of 10 degrees/s constant target velocity and +/-10 degrees amplitude were presented under monocular viewing conditions. RESULTS: In both forms of ocular nerve palsies, similar changes of pursuit eye movements were observed in the pulling plane of the paretic muscles. The movements of the covered paretic eye showed the lowest amplitude and gain values as well as the lowest numbers of catch-up saccades. The highest amplitude and gain values were calculated from the movements of the covered sound eye. The highest numbers of saccades, however, were produced by the fixating paretic eye. CONCLUSIONS: We conclude that the fixating paretic eye compensates for the paresis by raising the pursuit gain and the number of catch-up saccades. In the covered paretic eye, however, monocular adaptation is connected with a symmetric low pursuit gain and a reduced number of saccades in the pulling plane of the paretic muscle.

[Leucocoria in childhood]. / Leukokorie im Kindesalter.

BACKGROUND: There are a number of conditions in infants and young children which produce a white reflex in the pupillary area, termed leucocoria. In cases of leucocoria, retinoblastoma has to be excluded without delay. METHODS: We analysed data from consecutive children who were presented to our hospital because of leucocoria between January 1999 and June 2005. The analysis was performed by methods of descriptive statistics. RESULTS: Leucocoria was found in 83 eyes of 58 children. Leucocoria was caused in most cases by congenital cataract (35 %), followed by malformations (18 %) (persistent hyperplastic primary vitreous, coloboma, disc anomaly, combined developmental abnormalities), hereditary vitreoretinal disorders (13 %), retinopathy of prematurity (12 %), trauma-associated diseases (8 %). Five children suffered from retinoblastoma (6 %). Following in frequency were inflammatory disorders (5 %) and Coats' disease (2 %). DISCUSSION: Several ocular conditions of childhood can clinically cause leucocoria. Knowledge of the clinical features that serve to differentiate retinoblastoma from simulating lesions may assist the clinician in arriving at the correct diagnosis.

[The influence of geometric visual illusions on saccadic eye movements]. / Der Einfluss geometrisch-optischer Täuschungen auf sakkadische Augenbewegungen.

BACKGROUND: The aim of this study was to investigate whether visually perceived length differences of Mueller-Lyer figures result in amplitude differences of saccadic eye movements along the figures. METHODS: Video recordings of eye movements were obtained from 35 healthy volunteers (aged 18 - 30 years) when scanning the endpoints of Mueller-Lyer targets. RESULTS: Saccades between the ends of lines with inward-pointing arrowheads had significantly greater amplitudes than saccades between the ends of lines with outward-pointing arrowheads. This bias was observed for both horizontal and vertical target orientations, and was maintained with a smaller amplitude, after fixation periods were extended from 1 s to 4 s. CONCLUSIONS: Changes in length perception by visual illusions correspond with changes in the amplitude of saccadic eye movements. Therefore, recordings of saccadic eye movements offer the opportunity to assess changes in visual object perception based on changes of central image processing at the cortical level.

[Dynamics of the pupillary light reflex in unilateral Horner's syndrome]. / Die Dynamik der Pupillenreaktion bei einseitigem Horner-Syndrom.

BACKGROUND: The aim of this study was to characterise the changes of the dynamic pupillary light reflex in patients with unilateral Horner's syndrome by appropriate pupillographic parameters. METHODS: The dynamic changes of pupillary diameter in response to light flashes of 100 ms were recorded in darkness with two infrared video cameras in 15 patients. RESULTS: Significant changes in the pupillary light reflex of the affected side were observed only during the phase of redilatation. The decelerated redilatation was defined by the following parameters: (1) time parameters (percentage of redilatation after 4 s and after 5 s, time to reach 67% and 75% of redilatation) and (2) amplitude-adjusted velocity parameters (relative velocity at 67% and at 75% of redilatation). CONCLUSION: A slowed pupil redilatation in patients with Horner's syndrome can be detected also after short light flashes and is characterised by prolonged redilatation time parameters and reduced amplitude-adjusted redilatation velocity parameters.

[Diabolic injury with the localization of foreign bodies in the apex of the intraorbital region ]. / Diabolo-Verletzung mit Lokalisation des Fremdkörpers im Bereich der Orbitaspitze-ein Fallbericht.

BACKGROUND: Air-gun injuries with localisation of the pellet at the apex of the orbital cavity can cause difficult decisions in diagnostics and therapy, especially if you decide to retain the foreign body. METHODS: We report on a 14-year-old boy who was hit by an air-gun pellet. The foreign body went into the left orbit without damaging the globe or the optic nerve. RESULTS: The visual acuity was 1.0, the mobility was only slightly disturbed. A systemic therapy with antibiotics and corticosteroids could stop a series of relapses very well. CONCLUSIONS: Foreign bodies of the orbit can be retained if it is possible to deal with the surrounding reactions properly by conservative therapy.

Smooth pursuit eye movements in patients with ocular motor nerve palsies: a preliminary report.

The trajectories, velocity, and co-ordination of smooth pursuit eye movements were investigated in 30 patients with ocular motor nerve palsies (including palsies of cranial nerves III, IV and VI). The recordings of horizontal and vertical eye movements were obtained by video-oculography under monocular viewing conditions. During the recordings, horizontal, vertical, and oblique target movements of 10 degrees /s constant velocity were presented to the subjects in succession. In contrast to normal subjects, smooth pursuit eye movements in patients with ocular nerve palsies showed considerable differences in dependence on the fixating eye. The smooth pursuit gain of the paretic eye was reduced for eye movements in the pulling plane of the paretic muscle. When viewing with the paretic eye, the tracking of the target was achieved by a series of refixation saccades, which also occurred in the occluded normal eye. Consequently, the sound eye position overshot the target. The transition from a smooth to a saccadic pursuit pattern was accompanied by a spatial deviation of the eye movement trajectories from the path of the fixation target.

Influence of visual signals on the coordination of spontaneous eye and head movements in infant rabbits.

Horizontal angular movements of eye, head, and trunk were simultaneously recorded in spontaneously behaving unrestrained rabbits in the period after postnatal eye opening. The recordings were performed in daylight as well as in darkness. A crosscorrelation analysis of the velocities of eye in head and of head to trunk during periods of exploratory activity showed that the resulting crosscorrelation functions were mainly determined by the correlation of coupled saccadic movements of eye and head. Already at the end of the third postnatal week, the maxima of the crosscorrelation functions were higher and their time shifts were shorter for movements in light than for movements in darkness. These observations suggest that the stronger coupling of saccadic eye and head movement velocities in response to light reflects a light-induced increase in the activity of premotor neurons of the superior colliculus.

Spatial orientation of extraocular muscle EMG responses to tilt in the rabbit during postnatal development.

Unanaesthetized pigmented rabbits 2-45 days of age were gradually tilted (15 degrees steps) over 360 degrees around three orthogonal body axes. The multiunit electromyogram activity of superior rectus (SR) and superior oblique (SO) extraocular muscles was recorded with chronically implanted pairs of fine wire electrodes after each tilt step. The integrated EMG activity of the extraocular muscles in response to static tilt stimulation was trigonometrically related to tilt angle in all age groups. Each eye muscle was characterized by a typical locus of tilt positions which resulted in maximum integrated EMG activity. This locus was described by a vector of tonic vestibular activation (TVA) within the head coordinate system. The orientation of these TVA vectors within the coordinate system of the rabbit's head and, therefore, the coordination of tonic eye muscle activation in response to the position of the animal in the gravitational field did not change with postnatal age in the rabbit. Therefore, eye muscles are already capable of responding to static vestibular stimulation for the stabilization of gaze when visual information becomes available to the rabbit pups. The EMG responses to static tilt stimulation were principally determined by the scalar product of the gravity vector and the muscle's TVA vector. The response of the extraocular muscles to this effective gravitational stimulus was unchanged during the postnatal development of the rabbit: excitatory stimuli resulted in an approximately linear increase of the integrated EMG activity, inhibitory stimuli resulted in a smaller decrease to a minimum value. The correlation between the effective strength of excitatory gravity stimuli and the EMG activity of the extraocular muscles increased significantly at the time of postnatal eye opening. Since the strongest responses of SR and SO to static tilt were observed in intermediate roll-pitch positions that correspond closely to the planes of the vertical semicircular canals, a common reference frame for the cooperation of maculo-ocular and ampullo-ocular reactions is suggested.