[Surgical therapy and pathogen detection in endogenous endophthalmitis : Analysis of data from five German eye hospitals]. / Operative Therapie und Keimnachweis bei endogener Endophthalmitis : Datenauswertung aus 5 Augenkliniken.

BACKGROUND: Endogenous endophthalmitis results from hematogenous spread of bacterial or fungal infection in severely diseased patients. Specific systemic and intraocular therapy is required. The basis for this treatment is causal pathogen detection in blood culture or vitreous sample. However, functional results are limited. OBJECTIVE: The current article provides practical hints for surgical therapy and pathogen detection in patients with endogenous endophthalmitis. METHODS: A retrospective analysis of anonymous data of 68 male and female patients from 2018-2023 from five ophthalmology clinics in Germany was performed. RESULTS: Mean age of affected patients was 71.4 years (31-96 years). Surgical therapy included pars plana vitrectomy (ppV) and intravitreal injection (IVOM). In 44 of 68 patients (65%), 1-3 surgeries were performed, 4-6 surgeries were required in 14/68 (21%) of patients, and 10 or more surgeries were required in 4/68 patients (6%). Pathogen detection was possible in 34% of vitreous specimens and in 11% of anterior chamber samples. Mean initial visual acuity was logMAR 1.5. After treatment and a mean follow-up of 2.5 months, mean visual acuity was logMAR 1.3. Preanalytical methods for specimen collection like the Freiburg endophthalmitis set to optimize pathogen detection are presented. CONCLUSION: Severe inflammatory intraocular reactions in endogenous endophthalmitis necessitate a combination of ppV and repeated IVOM. In addition to providing a vitreous sample, ppV also serves to remove inflammatory fibrin membranes. Early pars plana vitrectomy with specific antibiotic or antifungal therapy should be sought in addition to the focus search and systemic therapy.

[Ischemia and laser photocoagulation in retinal vein occlusion]. / Ischämie und Lasertherapie bei retinalen venösen Verschlüssen.

BACKGROUND: Retinal vein occlusions (RVO) are associated with retinal ischemia to a highly variable extent. An ischemic retina may lead to the development of neovascularization and further to secondary complications such as neovascular glaucoma, vitreous hemorrhage or tractional retinal detachment. Numerous factors such as vascular endothelial growth factor (VEGF) and other cytokines are produced in the ischemic area, which cause macular edema. Before the introduction of intravitreal drug injections (IVI), retinal laser photocoagulation was the leading form of treatment. Macular laser photocoagulation was applied in the form of focal laser or grid laser in patients with branch retinal vein occlusion (BRVO) to treat macular edema. In patients with ischemic RVO, panretinal laser photocoagulation (PRP) was recommended for treatment of secondary neovascular complications. The value of laser treatment in the management of patients with RVO changed after the introduction of IVI treatment. AIM: This article presents a review of the current study results and the recommendations for performing laser photocoagulation of the central and peripheral retina in patients with RVO. CONCLUSION: Conventional focal or grid laser photocoagulation has been replaced by IVI treatment in the management of macular edema secondary to BRVO; however, macular laser treatment can still be considered in patients with BRVO if the macular edema persists despite the use of available IVI drugs. The use of central laser photocoagulation in these cases is based on the findings of fluorescein angiography. Disseminated panretinal laser photocoagulation is still indicated in RVO patients who have large areas of nonperfusion, have developed neovascularization and/or late complications. Targeted laser photocoagulation of the peripheral areas of nonperfusion has recently been recommended by several authors and is expected to improve not only the visual outcome of IVI treatment, but more importantly to also reduce the duration of treatment and the number of re-injections needed. Clear evidence for targeted laser treatment is not yet available and is a focus of currently ongoing prospective randomized studies.

Influence of the Size of the Foveal Avascular Zone on Functional and Morphological Parameters in Patients with Early-Stage Diabetic Retinopathy.

Purpose: To correlate functional and morphological parameters with foveal avascular zone's (FAZ) size in diabetic patients with mild to moderate stage nonproliferative diabetic retinopathy. Methods: Monocentric and prospective study of a consecutive case series of diabetic patients. Medical history, best corrected visual acuity (BCVA), best corrected high/low contrast visual acuity (BChcVA/BClcVA), mean sensitivity (MS) and mean defect (MD) in central visual field testing, and FAZ size in fluorescein-angiography (FAG) were recorded. Macular thickness (central point thickness CPT, central subfield thickness CST) and volume measurements (central subfield volume CSV, total macular volume) were taken from SD-OCT (6x6mm ETDRS-grid). Groups were categorised as presenting FAZ sizes smaller (G1) or larger (G2) than 0.35mm2. Smallest (Q1) and largest quartiles (Q3) were also compared. Results: Thirty-six of 40 patients were included. MS differed significantly between G1 (n = 6) and G2 (n = 30), and BChcVA/BClcVA as well as TMV correlated significantly with FAZ size in correlation analysis. Mean HbA1c tended to be lower in G1 than G2. Patients in G1 were slightly older than in G2. Treatment period with insulin was shorter in G1/Q1 than in G2/Q3. CPT and TMV were lower in G1/Q1 than in G2/Q3. Our analysis of the FAZ in terms of patient age, HbA1c, disease duration and insulin therapy duration revealed no significance. That lack of significance also applies to BCVA, MS, MD, CPT, CST and CSV. Conclusion: As significantly associated, contrast sensitivity, central visual field parameters and potentially retinal thickness or volume seem to be suitable to detect early macular ischaemia. However, we failed to establish any correlation between FAZ and BCVA.

Diagnosing SARS-CoV-2 with Antigen Testing, Transcription-Mediated Amplification and Real-Time PCR.

This study was performed as a head-to-head comparison of the performance characteristics of (1) two SARS-CoV-2-specific rapid antigen assays with real-time PCR as gold standard as well as (2) a fully automated high-throughput transcription-mediated amplification (TMA) assay and real-time PCR in a latent class analysis-based test comparison without a gold standard with several hundred samples in a low prevalence "real world" setting. Recorded sensitivity and specificity of the NADAL and the LumiraDx antigen assays and the Hologic Aptima SARS-CoV-2 TMA assay were 0.1429 (0.0194, 0.5835), 0.7644 (0.7016, 0.8174), and 0.7157 (0, 1) as well as 0.4545 (0.2022, 0.7326), 0.9954 (0.9817, 0.9988), and 0.9997 (not estimable), respectively. Agreement kappa between the positive results of the two antigen-based assays was 0.060 (0.002, 0.167) and 0.659 (0.492, 0.825) for TMA and real-time PCR. Samples with low viral load as indicated by cycle threshold (Ct) values > 30 were generally missed by both antigen assays, while 1:10 pooling suggested higher sensitivity of TMA compared to real-time PCR. In conclusion, both sensitivity and specificity speak in favor of the use of the LumiraDx rather than the NADAL antigen assay, while TMA results are comparably as accurate as PCR, when applied in a low prevalence setting.

Risk Factors for Severe Bleeding Complications in Vitreoretinal Surgery and the Role of Antiplatelet or Anticoagulant Agents.

PURPOSE: To evaluate the influences and risk factors for severe bleeding complications during vitreoretinal surgery and to investigate the role of antiplatelet and anticoagulant agents. DESIGN: Prospective trial. PARTICIPANTS: Patients undergoing vitreoretinal surgery. METHODS: The procedures included were pars plana vitrectomy and scleral buckling. We developed a uniform classification to grade the bleeding severity. Bleeding was graded on an ordinal scale ranging from 0 to 5. Immediately after surgery and 1 day later, the incidence and the severity of bleeding events was documented on a standardized form. A grade of 3 or more was defined as severe bleeding. Furthermore, the influence of known systemic disorders before surgery, the type of anesthesia, type of surgical procedure, intraoperative blood pressure, and the use or change of antiplatelet or anticoagulant agents on intraoperative bleeding was analyzed. MAIN OUTCOME MEASURES: Incidence and risk factors for severe intraoperative bleeding events. RESULTS: Data from 374 eyes undergoing vitreoretinal procedures were included in our study (mean age, 67.6 ± 12.9 years). A severe intraoperative bleeding event was observed in 15 eyes (4%). We found that concomitant diseases such as diabetes mellitus and carotid artery stenosis, the presence of diabetic retinopathy, younger age, and scleral buckling combined with a transscleral puncture were associated significantly with severe bleeding events. By contrast, use of antiplatelet or anticoagulant agents, or both, had no significant influence on severe intraoperative bleeding events. CONCLUSIONS: Although external manipulations during buckling surgery (e.g., drainage of subretinal fluid) and concomitant diseases such as diabetes mellitus and carotid artery stenosis influences the risk of severe intraoperative bleeding events, we did not detect an increased risk related to coexisting antiplatelet or anticoagulant medication use, or both.

Reliability of Subjective Assessment of Spectral-Domain OCT Pathologic Features by Multiple Raters in Retinal Vein Occlusion.

Purpose: To examine the interrater and intrarater reliability of qualitatively and quantitatively assessed disorganization of retinal inner layers (DRIL) and disorganization of retinal outer layers (DROL) by multiple raters. Subjectively assessing these surrogate biomarkers can be challenging in daily routine, despite the high resolution of spectral-domain (SD) OCT scans. Design: Retrospective trial. Participants: Three hundred six pooled SD OCT scans of 34 patients treated for macular edema caused by retinal vein occlusion (RVO) between January 2016 and December 2017. Methods: SD OCT scans were assessed by 6 raters regarding presence of cystoid macular edema, subretinal fluid (SRF), vitreoretinal traction, and epiretinal membrane and extent of DRIL and DROL. Main Outcome Measures: Interrater and intrarater reliability were calculated applying κ statistics for qualitative assessment regarding each pathologic feature's presence in all evaluated OCT scans, and for quantified horizontal DRIL and DROL extent within each OCT cross-section. Results: Cystoid macular edema and SRF assessments revealed excellent inter- and intrarater reliability with almost perfect strength of agreement, whereas subjective DRIL and DROL evaluations yielded low κ statistics with slight to moderate strength of agreement. Furthermore, the presence of SRF remarkably compromised the reliability of DROL detection. Conclusions: Our data highlight the limited subjective assessibility of DRIL and DROL, underscoring the need for automated image analysis to improve the reliability of OCT biomarkers for clinical studies and daily practice.

There is no intraocular affection on a SARS-CoV-2 - Infected ocular surface.

PURPOSE: The presence of SARS-CoV-2 RNA in anterior chamber fluid and/or the vitreous in patients with SARS-CoV-2 RNA on the ocular surface is unclear. Knowledge about the infectious state of intraocular structures could influence the daily work of ophthalmic surgeons. OBSERVATIONS: We analyzed ocular samples from a patient who had succumbed to COVID-19 pneumonia for the prevalence of SARS-CoV-2 RNA. We detected viral RNA in the ocular-surface samples on one swab and in one excidate from the conjunctiva. Samples from the anterior chamber and vitreous revealed no SARS-CoV-2 RNA. CONCLUSIONS: SARS-CoV-2 can effectively be inactivated with standard disinfection agents. The now proven absence of SARS-CoV-2 in intraocular fluids could influence how ophthalmic surgeons work. Without having to account for the risk of a contagion via the anterior chamber and/or vitreous body, the surgical staff would require no additional, more elaborate protection.

[Diseases of the Lacrimal Gland]. / Erkrankungen der Tränendrüse.

Tear gland diseases are comparatively rare in daily ophthalmological practice. The aim of this article is on the one hand to present the necessary basic knowledge and on the other hand to draw a bow to important current publications on the subject in order to provide the reader with sufficient knowledge for daily practice after reading it.Inflammatory (acute and chronic specific dacryoadenitis, idiopathic dacryoadenitis), neoplastic (epithelial and nonepithelial) and structural (cysts etc.) are presented.Diagnostically, the importance of (open) biopsy has increased again in recent years. Only the pleomorphic adenoma of the lacrimal gland has to be removed in-toto in order to avoid a recurrence or malignant degeneration which is difficult to control curatively. Differential diagnostic aids are explained in detail.

Distance-Thresholded Intercapillary Area Analysis Versus Vessel-Based Approaches to Quantify Retinal Ischemia in OCTA.

PURPOSE: To develop and compare different analytic approaches for quantifying ischemia in OCT-angiography (OCTA), including vessel-based approaches and intercapillary area analysis. METHODS: En face OCTA (6 × 6) images of the superficial plexus of 20 healthy eyes and 20 eyes with different ischemic retinal diseases were analyzed retrospectively. Included retinal diseases were diabetic retinopathy (n = 9), central (n = 5) and branch retinal vein occlusion (n = 4), hypertensive retinopathy (n = 1), and occlusive retinal vasculitis in sarcoidosis (n = 1). Vessel-based approaches consisted of the mean gray scale, perfusion density, and vessel density. Intercapillary areas (ICAs) were analyzed measuring the distance of each intercapillary pixel from the surrounding vessels. In particular, we applied a vector method to measure the shortest, the mean, and the longest distance in eight predefined directions. Size of ICAs was determined applying different global or local distance thresholds. RESULTS: All approaches revealed significant differences between ischemic and healthy retinae (P < 0.001, with Bonferroni-Holm correction P = 0.001-0.025; Wilcoxon-Mann-Whitney test). Discrimination between the healthy and ischemic retinae based on ROC curves was best in the ICA analysis using a locally set threshold of the shortest distance. CONCLUSIONS: In the present study, ICA analysis was superior to vessel-based approaches in the quantification of retinal ischemia when defining a local or global distance threshold. TRANSLATIONAL RELEVANCE: In order to establish OCTA imaging in everyday clinical and scientific practice, standardized, device-independent image analysis methods are necessary.

Unilateral Vision Loss after a Dental Visit.

Intraoral local anesthetics are widely used for performing painless dental treatments; however, in some cases, they may cause ocular complications such as meiosis, diplopia, nystagmus, ophthalmoplegia, ptosis, and amaurosis. Mostly, the symptoms disappear after several hours; rarely, they have a prolonged character. We describe the case of a 38-year-old young man who had reduced vision in the left eye 5 days after having received intraoral local anesthesia. A diagnosis of cilioretinal artery occlusion with optic disc swelling was made. Ten weeks later, the patient's visual acuity had increased to 20/20, and the swelling of the optic disc had subsided. Although various possible mechanisms for ocular complications after intraoral local anesthetic administration were suggested in the literature, the exact etiology remains unclear. In this case, inadvertent intravascular injection is believed to be the cause.

Case report of a secondary macular hole closure after intravitreal bevacizumab therapy in a patient with retinal pigment epithelial detachment.

We describe a case of macular hole (MH) closure after intravitreal bevacizumab therapy for an underlying pigment epithelial detachment (PED) due to exudative age-related macular degeneration (AMD). The 73-year-old Caucasian female presented with reduced visual acuity (20/80) of the left eye and metamorphopsia for approximately 6 months. Spectral domain optical coherence tomography revealed a subfoveal PED due to AMD with an associated MH. To treat the exudative component of the pathology, we started intravitreal bevacizumab therapy, consecutively leading to reduction of the height of PED and allowing closure of the MH. Detachment recurred during further follow-up, but the MH remained closed. MHs and exudative AMD are common diseases, which rarely occur simultaneously. To the best of our knowledge (search via PubMed for "MH," "PED," "age-related macular degeneration"), no other case with the persistent closure of an MH associated with PED during intravitreal antivascular endothelial growth factor therapy and despite recurrent PED has been published to date.