[Polymyalgia rheumatica-A challenge in geriatrics : Interdisciplinary presentation of diagnostics and treatment]. / Polymyalgia rheumatica ­ eine Herausforderung in der Altersmedizin : Diagnostik und Therapie interdisziplinär dargestellt.

Polymyalgia rheumatica is the second most frequent inflammatory rheumatic disease in people aged over 50 years, after rheumatoid arthritis. It is characterized by pain and morning stiffness in the region of the shoulders, hip girdle and neck. It can be associated with giant cell arteritis (CGA). Treatment with glucocorticoids is indispensable. The duration of treatment varies and often exceeds 1 year. The additive administration of methotrexate is an option for saving glucocorticoids. The biologicals tocilizumab or secukinumab are very promising alternatives. The course of treatment should be closely monitored for inflammation parameters, glucocorticoid side effects, pain, visual acuity, depression, activities of daily living and especially related to functions of the upper extremities. The geriatric assessment plays an important role in the management of this condition.

[Polymyalgia rheumatica-A challenge in geriatrics : Interdisciplinary presentation of diagnostics and treatment]. / Polymyalgia rheumatica ­ eine Herausforderung in der Altersmedizin : Diagnostik und Therapie interdisziplinär dargestellt.

Polymyalgia rheumatica is the second most frequent inflammatory rheumatic disease in people aged over 50 years, after rheumatoid arthritis. It is characterized by pain and morning stiffness in the region of the shoulders, hip girdle and neck. It can be associated with giant cell arteritis (CGA). Treatment with glucocorticoids is indispensable. The duration of treatment varies and often exceeds 1 year. The additive administration of methotrexate is an option for saving glucocorticoids. The biologicals tocilizumab or secukinumab are very promising alternatives. The course of treatment should be closely monitored for inflammation parameters, glucocorticoid side effects, pain, visual acuity, depression, activities of daily living and especially related to functions of the upper extremities. The geriatric assessment plays an important role in the management of this condition.

Treatment of type I ROP with intravitreal bevacizumab or laser photocoagulation according to retinal zone.

AIMS: To investigate the outcome of intravitreal bevacizumab (IVB) compared with laser photocoagulation in type I retinopathy of prematurity (ROP). METHODS: Case records of 54 consecutive very low birth weight (VLBW) infants with type I ROP (posterior ROP, n=33; peripheral zone II, n=21) who were treated either with IVB (n=37) or laser photocoagulation (n=17) between 2011 and 2015 were retrospectively evaluated. RESULTS: Patients with posterior ROP displayed significantly faster regression of active ROP within 12 days (range 9-15 days) if treated with IVB compared with laser photocoagulation, where active ROP regressed within 57 days (range 28-63 days) (p>0.001). No difference was observed in peripheral zone II.Five of seven patients (12%) who developed a recurrence in both eyes after IVB required additional laser photocoagulation within a mean of 12.7 weeks (11.3-15.6 weeks) after the previous treatment. After laser photocoagulation one patient with posterior ROP developed macular dragging and another patient developed a temporary exudative retinal detachment in both eyes. 12 months after treatment the spherical equivalent was not statistically significant different between IVB and laser photocoagulation in posterior ROP patients. However, IVB lead to a significant lower spherical equivalent in infants with posterior ROP (+0.37 dioptres, range -0.5 to +1.88 dioptres) compared with peripheral zone II (+3.0 dioptres range +2.0 to +4.0 dioptres, p<0.001). CONCLUSIONS: IVB leads to faster regression of active ROP in infants with posterior ROP compared with laser photocoagulation. Spherical equivalent after 12 months was comparable in those treated with IVB and laser photocoagulation, but it was significantly lower in posterior ROP than in peripheral zone II.

[Ocular Hypotension: How the Retina Surgeon Sees the Causes and Therapeutic Options]. / Okuläre Hypotonie - Ursachen und therapeutische Möglichkeiten aus Sicht des Netzhautchirurgen.

Ocular hypotension is a result of a lack of production or a loss of intraocular fluid. Intraocular inflammation, drugs, or proliferative vitreoretinopathy (PVR) with overgrowth of the ciliary body can result in reduced secretion of intraocular fluid. Loss of intraocular fluid can result from external loss, such as in fistulating surgery or trauma, or internally, e.g. from cyclodialysis clefts or retinal detachment. In this review, we discuss the causal therapy of ocular hypotension: fixation of the ciliary body, removal of ciliary body membranes, surgery for PVR, choice of tamponade, possibilities and limitations of an iris diaphragm, and pharmacological options.

[Diagnostics and treatment of primary vitreoretinal lymphoma]. / Diagnostik und Therapie des primären vitreoretinalen Lymphoms.

BACKGROUND: Primary vitreoretinal lymphoma (PVRL) is a rare ocular lymphoid malignancy, mostly a diffuse large B-cell lymphoma. The PVRL, previously called primary intraocular lymphoma (PIOL), is a subset of primary central nervous system lymphoma (PCNSL). DIAGNOSIS: The diagnosis of PVRL is often difficult as it often mimics chronic intermediate or posterior uveitis; therefore, PVRL requires various procedures for the diagnostics, e.g. immunohistochemistry, cytology, pathology, molecular pathology and cytokine analysis (interleukin 10) after surgically obtaining ocular specimens. THERAPY: Treatment forms that are effective for systemic lymphomas have not been reliably successful for PVRL and PCNSL. Current management of PVRL consists of chemotherapy, such as methotrexate or rituximab, possibly combined with external beam radiation whereby both chemotherapeutic agents are administered systemically as well as intravitreally. Intravitreal treatment alone is recommended solely in the case of monocular PVRL, which is highly controversial. A PVRL usually responds well to initial treatment; however, relapse rates and CNS involvement are high, resulting in a poor prognosis and limited survival.

[Behcet's disease--ophthalmological and general aspects: Part 2: Therapy]. / Morbus Behçet--ophthalmologische und allgemeine Aspekte: Teil 2: Therapie.

Behcet's disease (also called Admantiades-Behcet syndrome) is a chronic vasculitis. The disease is characterized by exacerbations and remissions of symptoms and organ manifestations and may produce only mild mucocutaneous lesions, whereas ocular lesions can cause blindness. In addition, involvement of the gastrointestinal tract, central nervous system (CNS) and large blood vessels is sometimes life-threatening. Cyclosporin A is the only agent for treatment of ocular lesions registered in Germany; however, the neurotoxicity and nephrotoxicity restrict usage of the drug. In patients suffering from severe uveitis, biologics have been a breakthrough. Interferon (IFN) alpha therapy has shown significant efficacy for intraocular inflammation. Monoclonal antibodies to TNF-alpha and interleukin-1 have been successful in clinical trials and are approved in some countries. This article summarizes the current state of knowledge and emphasizes the important role of the ophthalmologist in the therapy of Behcet's disease.

[Behçet's disease - ophthalmological and general aspects part I : etiology, pathogenesis and diagnostics]. / Morbus Behçet - ophthalmologische und allgemeine Aspekte Teil I : Ätiologie, Pathogenese und Diagnostik.

Behçet's disease (also known as morbus Behcet or Admantiades-Behcet syndrome) is a chronic vasculitis mainly characterized by recurrent mucocutaneous lesions and sight threatening uveitis. It may also involve joints, vessels of all sizes and the central nervous system. Because of its severe morbidity and considerable mortality early diagnosis and treatment is important. Treatment and prognosis of this disorder have profited considerably in recent years following the introduction of biologic agents. This article summarizes the current state of knowledge and emphasizes the important role of the ophthalmologist in the diagnosis and therapy of Behçet's disease.

[Inflammatory choroidal neovascularisations]. / Inflammatorische choroidale Neovaskularisationen.

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

[Giant retinal tear detachment]. / Riesenrissamotio.

Giant retinal tears with possible tear inversion are a special group of rhegmatogenous retinal detachments. A good knowledge of the pathogenesis and surgical specifics is very important for the retinal surgeon to achieve the best anatomic results with a low PVR rate. The technical progress that was made since the 1960 s obviously led to better results in the therapy for giant retinal tears. To avoid a giant retinal tear of the second eye, a prophylactic treatment has to be discussed with the patient.

[Intravitreal implants: drug carriers and carriers of hope?]. / Intravitreale Implantate: Wirkstoff- und "Hoffnungsträger"?

Immunosuppressive agents are used for the therapy of noninfectious uveitis if intraocular quiescence and freedom from recurrences are not achievable with oral steroids at a low dosage. Partially, severe side effects are tolerated to preserve visual acuity even if the disease is limited to the eyes. Because of this a therapy would be desirable which is highly effective, limited to the eyes and with few side effects. For this fluocinolone acetonide and dexamethasone drug delivery systems were developed. Dexamethasone implants were already approved for the therapy of retinal vein occlusions and are used successfully. Diabetic macular edema would be another possible indication for dexamethasone implants.

[Janus-faced?: Effects and side-effects of interferon therapy in ophthalmology]. / Ein Januskopf?: Wirkungen und Nebenwirkungen der Interferontherapie in der Augenheilkunde.

Interferon alpha (IFN-α) and interferon beta (IFN-ß) are naturally occurring cytokines, which belong to the type I interferons and share the same receptor leading to very similar therapeutic effects. The immunomodulatory effect of type I interferons includes modulation of antibody production, inhibition of lymphocyte proliferation, inhibition of delayed-type hypersensitivity and enhancement of T-cell and NK-cell cytotoxicity. An increasing number of open clinical studies and case reports have demonstrated the efficacy of IFN-α for severe ocular inflammation in patients with Behçet's disease and of interferon-ß, which has been used mainly for the treatment of multiple sclerosis.

[Anti-TNF-α treatment for uveitis. Analysis of the current situation]. / Anti-TNF-Therapie bei Uveitis. Eine Standortbestimmung.

Biologicals are selectively acting proteins that demonstrated high efficacy in the treatment of chronic disorders. In particular, biologicals blocking tumor necrosis factor α (TNF-α), an essential cytokine in chronic inflammatory diseases, have demonstrated great promise. Experimental and clinical data indicate that TNF-α plays an important role in intraocular inflammation. Neutralization of TNF-α might therefore be a promising strategy for prevention and treatment of uveitis. Here we review the principle effects, therapeutic value, and potential side effects of anti-TNF agents in uveitis.

[Anti-VEGF inhibitors and their role in the treatment of diabetic macular oedema]. / Die Rolle der Anti-VEGF-Therapie in der Behandlung des diabetischen Makulaödems.

Diabetic macular edema (DME) and proliferative retinopathy are common causes for blindness in middle-aged patients. The gold standard for treatment has been laser coagulation. Limitations of this therapy are refractive DME, ischaemic diabetic maculopathy and complications after laser application. The need for a non-destructive and effective strategy has led to investigations regarding vascular endothelial growth factor (VEGF) inhibitors for reduction of vessel leakage and oedema formation. VEGF antibody fragments have been approved for age-associated macular degeneration (AMD) in different countries and have proved to be safe and effective. Trials for different anti-VEGF compounds are nearing completion or are completed. Published data show a superiority of anti-VEGF therapy compared to laser coagulation. In the present article, data regarding dose, injection scheme and practicable application form are reviewed.

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

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

Long time survival after reduced chemotherapy ina 15-year-old patient with AML and Candida krusei sepsis and eye involvement.

A 15-year-old boy with AML develops a fulminant candida krusei sepsis complicated by acute blindness due to enophthalmitis and subsequent bleeding during prolonged pancytopenia after induction therapy. Despite a low dose prophylaxis with oral nystatine and i. v. amphotericin B (ampho B) three times a week (0.8 mg/kg). Under an early intensified therapy with ampho B (1.5 mg/kg/d) combined with 5-flucytosin (160 mg/kg/d)the sepsis could be controlled and visual acuity slowly improved. A vitrectomy is due to the bleeding unavoidable. Despite a therapy delay of 4 weeks and omission of two cycles of the intensification treatment the patient is in continuous complete remission for longer than 10 years after diagnosis. If it is within the treatment protocols manageable to detect patients with increased sensitivity against cytostatic drugs and correspondingly highly sensitive leukemic cells, such complications could be avoided due to primary treatment adaptation.

TNFalpha-blocking agents or conventional immunosuppressive drugs in the therapy of children with uveitis? - an evidence based approach.

Treatment of childhood uveitis associated with juvenile idiopathic arthritis (JIA) is a challenge for both, ophthalmologists and pediatricians. In this study, we use the tools of evidence based medicine (EBM) to analyse studies concerning disease-modifying antirheumatic drugs (DMARD)/ immunosuppressive drugs and tumor necrosis factor alpha (TNFalpha) blocking agents. Most experience among DMARD's/ immunosuppressive drugs has been obtained with methotrexate (MTX) in juvenile idiopathic arthritis. However, controlled studies in uveitis are still missing, so that treatment with MTX and all other immunosuppressive drugs (ciclosporine A, azathioprine, mycophenolate mofetil) only reaches an evidence level III (expert opinion, clinical experience or descriptive study). Studies on TNFalpha-blocking agents reach an evidence level II-III, depending on the substance. In future, MTX will have to be examined in comparison to the new biological substance classes (e.g., tumor necrosis factor-alpha-blockers) for the treatment of uveitis in juvenile idiopathic arthritis. Controlled studies which have led to the approval of drugs for JIA are needed for uveitis in order to have the most effective and safe therapy for children with uveitis, who do not respond to conventional therapy with local and systemic steroids.

[MALT lymphoma of the orbit]. / MALT-Lymphom der Orbita.

MALT lymphomas of the orbit are rare orbital tumors; the differential diagnosis needs to exclude inflammatory pseudotumors of the orbit, but also benign lymphoproliferations, pseudolymphomas, and other orbital neoplasms. After histological confirmation of the diagnosis staging is necessary, and - as long as the disease is localized exclusively in the orbit - radiation therapy should be started. The clinical picture of MALT lymphoma and its differential diagnosis and treatment are discussed with reference to an actual case.