[Importance of fluorescein angiography for differentiating between early papilledema and papillitis]. / Stellenwert der Fluoreszenzangiographie zur Differenzierung zwischen einer frühen Stauungspapille und einer Papillitis.

BACKGROUND: Optic disc swelling poses a diagnostic challenge due to its multiple underlying pathological causes. This study aimed to investigate the use of fluorescein angiography (FLA) in combination with optical coherence tomography (OCT) as a diagnostic tool for differentiating between papilledema and papillitis in cases of optic disc swelling. MATERIAL AND METHODS: A total of 12 patients were included in the study in whom both FLA and OCT of the optic disc were performed to evaluate the optic disc swelling in cases of papilledema (7 patients, 14 eyes) and papillitis (5 patients, 7 eyes). The fluorescence behavior of the optic disc during late phase FLA was examined in relation to papillary thickness measured by OCT. RESULTS AND DISCUSSION: In the papilledema group OCT revealed a mean papillary thickness of 873 µm. In 6 patients FLA detected a ring-shaped papillary hyperfluorescence with papillary thicknesses ranging from 611 µm to 972 µm. Another patient with chronic and marked papilledema exhibited bilateral panpapillary leakage in FLA and papillary thicknesses of 1287 µm (right eye) and 1526 µm (left eye). In the papillitis group FLA showed panpapillary leakage in all cases. The mean papillary thickness was 865 µm (range 632-1195 µm). CONCLUSION: In acute optic disc swelling and a papillary prominence less than 1000 µm in OCT, a difference in FLA was noticeable between papilledema and papillitis. While acute and mild papilledema exhibited a ring-shaped hyperfluorescence, papillitis showed a panpapillary leakage in late phase FLA in the examined cases. This difference could not be seen in the case of papilledema with chronic and severe swelling.

On the Current Care Situation and Treatment of Ocular Mucous Membrane Pemphigoid in Germany. / Zur Versorgungssituation und konservativen Therapie des okulären vernarbenden Schleimhautpemphigoids in Deutschland.

BACKGROUND: Ocular involvement in mucous membrane pemphigoid (MMP) is relatively rare, with a prevalence of 25 cases per million population, equating to approx. 2,100 patients throughout Germany. Diagnosis can be difficult - especially in cases of isolated ocular involvement - and treatment can be complex and lengthy. Immunosuppressants or immunomodulatory drugs are often used. Due to the complexity of diagnosis and treatment, MMP patients are usually referred to specialized centers. The aim of this project was to evaluate the current care situation of patients with ocular MMP in Germany. METHODS: A paper-based survey was designed and sent to all university eye clinics and other specialized centers in Germany in April 2020. The survey asked about the existence of a specialized outpatient service, the total annual number of patients with MMP, the annual number of newly diagnosed patients, any interdisciplinary collaboration for diagnostic or therapeutic purposes, as well as the local and systemic therapy used. RESULTS: Of a total of 44 clinics, 28 (64%) responded, reporting a total average of 27 ± 42 (0 - 200) patients and 3.6 ± 2.2 (0 - 10) new cases per year. This corresponds to a total of 741 patients. Only nine (32%) of the responding clinics offer specialized MMP clinics. 93% of the centers collaborate with the local dermatology department. 79% perform serological and histological diagnostics in-house. About half of the centers (n = 16) apply a standardized treatment regime. Systemic glucocorticoids (66.7%) are most commonly used, followed by mycophenolate mofetil and dapsone (57.1%), rituximab (33.3%), azathioprine and cyclophosphamide (28.6%), as well as methotrexate (19.0%). The least frequently used treatment is intravenous immunoglobulin (14.3%). CONCLUSION: This survey of German ophthalmology departments obtained data from about one third of the estimated total cohort of all patients with MMP in Germany. These are presumed to be exclusively patients with at least one ocular involvement. The complex care of these patients is usually provided in collaboration with a dermatologist and with the use of systemic anti-inflammatory medication. Currently, an ophthalmological MMP register is being established to better record the epidemiology and care situation of this rare disease in Germany and to improve it in the long term.

Novel Bleb Classification Following Ab Interno Implantation of Gel-Stent Using Anterior Segment Optical Coherence Tomography.

PRCIS: A novel qualitative tomographical classification for bleb after implantation of XEN-Gel-Stent using ab interno approach is presented. Association of anatomic patterns to intraocular pressure (IOP) and success rates (SR) illustrates that anterior segment optical coherence tomography can be useful tool in clinical guidance. PURPOSE: To present a novel classification of bleb resulting from ab interno implantation of XEN-Gel-Stent and report association of tomographical patterns with IOP and SR. MATERIALS AND METHODS: A cross-sectional 1-armed study of patients receiving XEN-Gel-Stent. Tomographical changes in the bleb area were studied using swept-source optical coherence tomography in an early (d 29-90 postsurgery) and late (starting from d 91 postsurgery) phase. Frequency of patterns and their association with IOP and SR (defined as IOP<18 mmHg without medications) were studied. RESULTS: One hundred eleven examinations of 49 blebs (49 patients) were included. Three tomographical patterns at conjunctival, 4 at tenons capsule, and 2 at episcleral level were characterized. Most frequent conjunctival pattern was subconjunctival spaces (56.3% and 53.2% in the early and late phase, respectively) and associated with lower IOP (13.0±6.0 mmHg) and higher SR (89%) but only in the early phase compared with other conjunctival patterns ( P <0.05). At tenons capsule level, the hyporeflective pattern was most frequent (50% and 51.9% in early and late phase) followed by the cavernous pattern. Both patterns associated with lower IOP and higher SR compared with hyper-reflective or loss of tenon changes ( P <0.005). Most blebs showed no episcleral lake (87.5% and 89.9% in early and late phase). No difference of IOP and SR was noted compared with those showing an episcleral lake. CONCLUSION: A practical and clinically relevant novel classification system is proposed to tomographically describe and classify blebs after implantation of XEN-Gel-Stent. Certain patterns were associated with lower IOP and higher SR.

[Bleb morphology using optical coherence tomography : After primary implantation of XEN gel stent and open conjunctival revision]. / Morphologie des Sickerkissens mittels optischer Kohärenztomographie : Nach primärer Implantation von XEN-Gel-Stent und offener Bindehautrevision.

BACKGROUND: The implantation of a XEN gel stent is an innovative method for filtration surgery using an ab interno approach. The morphological evaluation of the resulting bleb is decisive for surgical success. Bleb revision is frequently needed after XEN implantation and might affect the bleb morphology. Aim of this study was to examine bleb morphology using anterior segment OCT (AS-OCT) and analyze the morphological differences of blebs after primary XEN implantation and after bleb revision. MATERIAL AND METHODS: Included were eyes that underwent XEN implantation (Pr-X) or bleb revision after XEN (Re­X group). An AS-OCT of blebs was performed and images were classified using a novel classification system (the Jenaer bleb grading system, JBGS). Frequency of different tomographic patterns (M) and their correlation with intraocular pressure (IOP) were analyzed. RESULTS AND DISCUSSION: A total of 69 eyes (40 in the Pr­X and 29 in the Re­X groups) were included. At the conjunctival level, the most common M in both groups was subconjunctival spaces (M-C2) followed by intraconjunctival cysts (C1) and no conjunctival changes (C0). No differences of frequencies between the two groups or of IOP between the three Ms were seen. At the tenon level, the most commonly seen Ms in the Pr­X group were hyporeflective and cavernous changes (M-T2, T3) followed by no changes (M0) and hyperflective changes (T1). In the Re­X group, the M­T1 and T2 were most commonly seen followed by T3 and T0. The M­T2 and T3 in the Pr­X group and the M­T1 and T2 in the Re­X group correlated with lower IOP. An episcleral lake (M-ES1) was seen significantly less frequently in the Pr­X group compared with Re­X group where it correlated with lower IOP CONCLUSION: The hyperreflective changes at the tenon level and the presence of an episcleral lake were seen more frequently following bleb revision compared with primary XEN implantation and correlated with lower IOP. The interpretation of bleb morphology using AS-OCT should only be done considering the surgical approach used.