Intravitreal fluocinolone acetonide implant for chronic postoperative cystoid macular edema - two years results.

PURPOSE: We report visual and anatomical outcomes of chronic postoperative macular edema treated with a fluocinolone acetonide intravitreal implant. METHOD: Retrospective study of chronic, post-surgical CME treated with a fluocinolone acetonide intravitreal implant. Best registered visual acuity (BRVA), central retinal thickness (CRT), and Goldmann tonometry intraocular pressure (IOP) were assessed over 24 months. The need for IOP lowering treatment, top-up therapy during follow-up, and complications were also assessed. RESULTS: We analyzed 16 consecutive eyes of 16 patients with chronic, post-surgical CME treated with fluocinolone acetonide intravitreal implant. Surgical indications included cataract surgery, vitrectomy plus membrane peeling and combined phaco-vitrectomy. Baseline mean BRVA of 0.8 ± 0.65 logMAR improved to 0.60 ± 0.4 logMAR (p = 0.02) at 12 months and to 0.7 ± 0.5 logMAR (p = 0.32) at 24 months. At month 12, BRVA improved in 11 eyes, stabilized in 4 eyes, and decreased in 1 eye. At month 24, VA remained improved in 5 eyes, remained stabilized in 5 eyes, and decreased in 1 eye. Mean CRT decreased from 524 ± 132 µm at baseline to 389 µm at month 3, 347 µm at month 6, 355 ± 106 µm (p = 0.0003) at month 12, and 313 ± 83 µm (p = 0.0001) at month 24. At 12 months, CRT improved in 13 eyes and remained unchanged in 2 eyes. At 24 months, CRT improved further in 8 eyes, and stabilized in 3 eyes. Increased IOP (≥21 mmHg) was observed only in 4 eyes, all successfully managed with topical medication. No further side effects were observed in any patient. CONCLUSION: Visual and anatomic improvements were achieved by a single fluocinolone acetonide implant with few side effects up to 24 months in CME eyes with a long and heavy prior treatment history.

[Regression of idiopathic epiretinal membrane-Case report and consideration of the possible mechanism]. / Regression einer idiopathischen epiretinalen Gliose ­ Kasuistik und Überlegungen zum Mechanismus.

In the presence of a symptomatic epiretinal gliosis, pars plana vitrectomy with membrane peeling to remove the membrane is usually indicated in clinical practice. According to common clinical experience, almost no independent regression of such an epiretinal membrane and thus healing of the pathology alone exists. Therefore, the unusual case of bilateral independent regression of idiopathic epiretinal gliosis and formation of a lamellar macular hole in a 73-year-old male patient is described. Considerations of the possible mechanism are presented based on the existing literature. These include separation of inflammatory versus noninflammatory membranes, possible separation of individual layers depending on the status of the posterior vitreous limiting membrane and also the possible action of proteolytic systems in the posterior vitreous region. Finally, the question arises, whether patients have to be informed about this fact before possible surgery.

[Proliferative vitreoretinopathy (PVR) minimal: same, same but different. Characteristics and surgical treatment of PVR-associated macular pucker]. / Proliferative Vitreoretinopathie (PVR) minimal: "Same same, but different". Besonderheiten und chirurgische Therapie des PVR-assoziierten Makula-Puckers.

BACKGROUND: Epiretinal membrane formation resulting in a macular pucker is among the typical complications associated with proliferative vitreoretinopathy (PVR) in retinal detachment and has a major impact on the functional outcome after surgical treatment. METHODS: A literature search was carried out in PubMed. RESULTS: Approaches to the surgical treatment of PVR-associated macular pucker include complete membrane removal within the vascular arcades aimed at relieving retinal traction at the posterior pole and peeling of the internal limiting membrane (ILM). As a further option it has been suggested that primary ILM peeling in rhegmatogenous retinal detachment repair may reduce or even prevent postoperative epiretinal membrane formation. In addition, correct timing of surgery is a factor that may contribute to successful treatment. DISCUSSION: Due to the particularly strong adhesion and the frequent occurrence of concurrent retinal detachment, the surgical approach to PVR-associated macular pucker is particularly challenging. As with idiopathic epiretinal membranes, surgical removal has the potential to improve functional outcomes; however, visual improvement depends largely on whether the macula was involved in the original retinal detachment.

[Proliferative vitreoretinopathy (PVR) surgery: Scar Wars : Five steps to successful treatment of PVR detachment]. / Proliferative Vitreoretinopathie(PVR)-Chirurgie: "Scar Wars" : Fünf Schritte zur erfolgreichen Therapie der PVR-Amotio.

BACKGROUND: After initially successful surgery of retinal detachment, proliferative vitreoretinopathy (PVR) is the most common cause of renewed retinal detachment. With an incidence of 5-20% it represents a frequent surgical challenge based on a pronounced epiretinal, subretinal and intraretinal scar formation. MATERIAL AND METHODS: The five most important steps leading to a successful repair of a PVR retinal detachment are described. RESULTS: 1. The basic prerequisite is the complete removal of the vitreous body in order to remove the substrate for proliferation of pathological cells. 2. Furthermore, the complete removal of all tractional PVR membranes is necessary. Subretinal PVR membranes that show no traction can be left in place. 3. The professional care of the macular is still important. As approximately 12% of all patients who undergo surgery for retinal detachment develop an epiretinal gliosis/macular pucker, peeling of the internal limiting membrane (ILM) is obligatory in cases of PVR. 4. Particularly in PVR detachment the mentioned surgical procedure is facilitated by the selection of suitable modern instruments, including wide-angle optics, such as the binocular indirect ophthalmomicroscope (BIOM), chandelier lights, perfluorocarbons (PFCL) and silicone oil. 5. Last but not least, the credo as much as necessary, as little as possible is of essential importance, as PVR eyes have usually been previously operated on and any further surgical intervention leads to subsequent inflammation and a persisting stimulation of the PVR reaction and further damage. CONCLUSION: Following a few decisive rules and tips is a prerequisite for a successful reattachment in cases of PVR retinal detachment.

[Current situation of allocation of academic medical personnel in ophthalmology departments in Germany]. / Zum Status der Personalplanung für den ärztlichen Dienst in ophthalmologischen Hauptabteilungen in Deutschland.

BACKGROUND: At present minimum nursing staff numbers have been defined and are being implemented. In December 2019 the German Medical Association asked the German professional associations about their general experience with planning of medical personnel in hospital departments. As no structured data were available on this subject, the German Ophthalmological Society (DOG) founded a working group in March 2020 to answer this request. METHOD: In the course of several consensus meetings, the working group on personnel planning for physicians in hospitals of the DOG prepared a questionnaire on previous experiences in personnel planning of eye hospitals, which was sent to the heads of all university eye hospitals and departments of ophthalmology in Germany. The questionnaire consisted of individual items with fixed choices and free answers regarding the procedure and current situation of staffing as well as the range of tasks and organization of the medical service. RESULTS: Out of 104 departments 53 (51%) responded, of which 25 were from university departments (64% response), 23 from departments of other public or non-profit ownership (46%) and 5 from departments with private hospital ownership (33%). Of these 49% stated that there was no transparent basis for calculation of the number of medical positions in their hospital. Of the surveyed departments, outpatient tasks, services and revenues were considered in the calculations in only 47%. There was a statistically significant higher ratio of full-time personnel to the numbers of beds in university departments compared to private and publicly owned non-profit institutions (p < 0.001, t­test). All departments have to cope with multiple additional tasks in addition to clinical patient care, which are taken into account only to a limited extent in the staffing. Approximately 70% of the departments provide a 24 h/7 day (24/7) medical on-call service on site, 91% have a 24/7 surgery on-call service and 34% have a cooperation with emergency services run by the Association of Statutory Health Insurance Physicians. CONCLUSION: The results show how heterogeneously and nontransparent German departments of ophthalmology are staffed in terms of medical doctors. On average, university departments have higher personnel resources per hospital bed to cope with additional tasks in research and teaching. Outpatient tasks, which contribute significantly to the revenues of an eye department, and multiple other tasks are often not taken into account in the personnel calculation. A transparent and uniform basis for calculation of the medical staff of the departments is desirable in order to achieve a sufficient personnel staffing for a patient and employee-oriented working environment.

[Real-time optical coherence tomography-assisted high-precision vitreoretinal surgery in the clinical routine]. / Echtzeit-optische Kohärenztomographie-assistierte Hochpräzisionsvitreoretinalchirurgie in der klinischen Routine.

The complete integration of spectral domain optical coherence tomography (SD-OCT) into an operating microscope now enables targeted, high-resolution imaging-guided vitreoretinal surgery. This provides real-time visualization of retinal layers, vitreous body and instrument-tissue interactions, which can be used for intraoperative decision making. Compared to conventional surgical microscopes, intraoperative OCT enables a greatly enhanced precision of vitreoretinal surgical maneuvers and is an essential prerequisite for the implementation of real-time guided surgical techniques at the micrometer level.

[Vitrectomy for endophthalmitis : Incubation time and prognosis following intravitreal injection vs. cataract surgery]. / Vitrektomie bei Endophthalmitis : Latenzzeit und Prognose nach IVOM vs. Kataraktchirurgie.

BACKGROUND: Bacterial endophthalmitis is a rare but devastating complication following intraocular surgery. Guidelines on the diagnostics and treatment are based mainly on experience of endophthalmitis treatment following cataract surgery. OBJECTIVE: In this study we analyzed infectious endophthalmitis cases following either intravitreal operative drug injection (IVOM) or cataract surgery for possible differences in the clinical course and prognosis. MATERIAL AND METHODS: All cases of endophthalmitis from January 2013 through December 2017 retrieved from our electronic database were examined and analyzed according to the type of intervention, time elapsed until diagnosis, pathogen detection, postinterventional visual acuity and the presence of comorbidities. RESULTS: A total of 29 cases were included, 11 secondary to IVOM and 18 secondary to cataract surgery. Symptoms for all cases presented at a mean of 6.8 days, with a significant difference between patients following IVOM (5.5 days) and patients following cataract surgery (4.1 days, p < 0.05). Patients with endophthalmitis following cataract surgery had a significantly better visual outcome 1 year after treatment compared to patients with endophthalmitis following IVOM (p < 0.05). The most commonly isolated pathogen was Staphylococcus epidermidis. CONCLUSION: Knowledge of the typical clinical course in the development of endophthalmitis following IVOM or cataract surgery is a critical prerequisite for the timely diagnosis and initiation of adequate treatment measures. Our results point towards a significantly delayed clinical manifestation of endophthalmitis following IVOM, possibly also caused by the anatomical origin of the infection. In an era of increasing numbers of IVOM this clinical observation could be helpful for a careful follow-up control beyond the previous traditional timepoints.

[Prevalence of Elevated Lipoprotein (a) Levels in Patients < 60 Years of Age with Retinal Vein Occlusion]. / Prävalenz erhöhter Lipoprotein(a)-Spiegel bei unter 60-jährigen Patienten mit venösen retinalen Gefäßverschlüssen.

BACKGROUND: The potential impact of elevated Lipoprotein (a) [Lp(a)] levels on retinal venous occlusive (RVO) diseases with regard to age and various risk factors has not been studied extensively. PATIENTS AND METHODS: In a retrospective case-control study, thrombophilia data of 106 young patients (< 60 years at the time of the RVO or a previous thromboembolic event) with RVO and 76 healthy subjects were evaluated. RESULTS: Elevated Lp(a) plasma levels were significantly more prevalent among RVO patients (29.2 %) than among controls (9.2 %; p = 0.0009). Lp(a) levels were found to be significantly (p = 0.012) different between patients and controls. Moreover, we found that an unusual personal or family history of thromboembolism was a strong predictor of elevated Lp(a) (p = 0.03). We observed a significant correlation between elevated Lp(a) and other coagulation disorders (p = 0.005). Multivariate analysis showed that elevated lipoprotein(a) levels (OR: 3.5; p = 0.003) were an independent risk factor for the development of RVO. CONCLUSIONS: Elevated plasma levels of Lp(a) are associated with the development of RVO. Selective screening of young patients and subjects with a personal or family history of thromboembolism may be helpful in identifying RVO patients with elevated Lp(a).

[Multiple thrombophilic risk markers in patients ≺65 years of age with retinal vein occlusion]. / Multiple thrombophile Risikomarker bei Patienten ≺65 Jahre mit venösen retinalen Gefäßverschlüssen.

BACKGROUND: The potential impact of multiple thrombophilic defects on retinal venous occlusive (RVO) diseases with regard to age and various risk factors has not been studied extensively. MATERIALS AND METHODS: In a retrospective, multicenter study, thrombophilia data of 128 patients <65 years of age with RVO and 110 healthy subjects were evaluated. The main measure outcome was the prevalence of multiple thrombophilic disorders. RESULTS: Multiple thrombophilic defects were significantly more prevalent among RVO patients (18.0%) than among controls (1.8%; P < 0.0001). We identified factor VIII elevation, elevated lipoprotein(a) plasma levels and resistance to activated protein C as the most prevalent combined disorders. Factor XII deficiency and prothrombin mutation G20210A were found to be isolated thrombophilic risk factors. Multiple thrombophilic defects were significantly associated with RVO recurrence (P = 0.008). CONCLUSION: Multiple thrombophilic disorders are associated with the development of RVO among patients younger than 65 years of age. Moreover, our results suggest that patients with RVO associated with underlying combined thrombophilic defects are at increased risk for RVO recurrence. Further studies are required to analyze whether the diagnosis of combined thrombophilic defects among RVO patients could be a predictor for RVO recurrence.

[Intraoperative real-time OCT in macular surgery]. / Intraoperative Echtzeit-OCT in der Makulachirurgie.

BACKGROUND: Spectral domain optical coherence tomography (SD-OCT) has become a standard diagnostic tool in the surgical management of vitreomacular interface disorders. The high-resolution cross-sectional information obtained from SD-OCT is a perfect complement to vitreoretinal surgery. It provides detailed intraoperative anatomical views that are not possible with a microscope. OBJECTIVE: To investigate the value of intraoperative real-time OCT with respect to improvement of surgical techniques in the management of vitreomacular disorders. METHODS: A review of the current literature was conducted and an analysis of own systematically evaluated data was included to provide a comprehensive overview of potential applications for the clinical use of intraoperative real-time OCT in macular surgery. RESULTS: Intraoperative real-time OCT can provide detailed visualization of epiretinal membranes and help to identify whether complete membrane removal has been achieved following surgery. In addition, it can provide qualitative and quantitative information that has previously not been available and assist in surgical decision-making. Intraoperative real-time OCT allows membrane peeling to be performed in selected cases without using retinal dyes, whereas it is not ideal for accurately guiding the surgeon while performing maneuvers. CONCLUSION: Intraoperative real-time OCT provides high-resolution visualization of the effects of surgical maneuvers on the microarchitecture of the retina and surrounding tissues and will fill a gap in the understanding of the pathophysiology and prognostic factors of vitreomacular disorders; however, with currently available systems, accurate intraoperative real-time guidance of surgical maneuvers is hindered by several limiting factors.

[Intraoperative optical coherence tomography in retinal detachment]. / Intraoperative optische Kohärenztomographie bei Ablatio retinae.

BACKGROUND: Using intraoperative optical coherence tomography (iOCT) can be advantageous during macular surgery and lamellar keratoplasty. It is yet unknown if there is a distinct benefit in its application in retinal detachment surgery. OBJECTIVE: What can be shown using iOCT during retinal detachment surgery? Can therapeutically relevant decisions be made and do they have a prognostic implication on postoperative results? METHODS: Based on already published (11 patients/eyes) and our own new data (23 patients/eyes),findings by iOCT during retinal detachment surgery are presented. RESULTS: Outer retinal corrugations are a frequent feature in iOCT in retinal detachment. These corrugations persist during the application of heavy liquids. Even when the retina seems clinically reattached under the use of perfluoroctane, there is significant subfoveal fluid. Using perfluordecaline, there seems to be less subfoveal fluid. In patients with retinal detachment and macula off situation, subclinical full thickness macular holes seem to be more common than assumed. It is unclear if their incidence is influenced by the use of heavy liquids. They appear to have a negative predictive value regarding postoperative visual acuity. CONCLUSION: Even if there are no obvious benefits in using iOCT in retinal detachment surgery, this new technique offers deeper insights into the microarchitecture of the detached retina. Further investigations in more patients will show if the use of the iOCT will result in a better prognosis for our patients.

[Intravitreal dexamethasone implant for treatment of persistent postoperative macular edema after vitrectomy]. / Intravitreales Dexamethason-Implantat zur Behandlung des persistierenden postoperativen Makulaödems nach Vitrektomie.

BACKGROUND: To date, there is no consensus about the management of persistent cystoid macular edema (CME) following vitrectomy. The aim of this study was to evaluate the efficacy and safety of intravitreal dexamethasone implants for the treatment of postoperative CME following vitrectomy. MATERIAL AND METHODS: In this multicenter study we retrospectively reviewed the data of 24 patients (25 eyes) who had been treated with intravitreal dexamethasone (Ozurdex®) for the management of persistent postoperative CME following pars plana vitrectomy. The main outcome measure was central retinal thickness (CRT in µm) as assessed by spectral domain optical coherence tomography (SD-OCT). Secondary outcome measures included change in best corrected visual acuity (BCVA) and the presence of metamorphopsia. RESULTS: All 19 eyes which were postoperatively examined within 4-8 weeks after implantation showed a significant decrease in CRT (mean 564 µm to 315 µm) and a reduction of metamorphopsias. Within the same period of time the BCVA improved in 15 out of 19 eyes (79%) which corresponds to an average visual improvement from 0.69 logMAR to 0.46 logMAR (P <0.0001). In eyes examined after 10-16 weeks a slight increase in the average CRT of 351 µm was observed, whereas the BCVA improved to 0.28 logMAR. After 4 months a decrease in average BCVA was noted. Out of 25 eyes 12 required further dexamethasone implantations between 1 and 4 times within the investigation period. The first repeat injections were performed an average of 7.3 months after the initial treatment. CONCLUSION: Our results suggest that intravitreal dexamethasone is a safe and effective treatment option for persistent CME following vitrectomy.

[Massive subretinal hemorrhage and anticoagulants. An unfortunate combination?]. / Submakuläre Massenblutung und Gerinnungshemmer. Eine unglückliche Kombination?

Exudative age-related macular degeneration (ARMD) is one of the conditions which has been shown to be associated with a risk of massive subretinal hemorrhage. Patients with thick submacular hemorrhage complicating ARMD typically have a poor visual prognosis. Antiplatelet therapy with aspirin, clopidogrel or ticlopidine has significant benefits in the secondary prevention of fatal and non-fatal coronary and cerebrovascular events. Anticoagulation is frequently used in this elderly age group for a variety of other comorbidities including prosthetic heart valves, atrial fibrillation, ischemic heart disease, cerebrovascular disease and venous thromboembolism. However, it is a well established observation that the longer patients remain on anticoagulant therapy, the higher the cumulative risk of bleeding. Over the past years, there has been a rapidly growing body of literature concerning the risk of hemorrhagic ocular complications with ophthalmic surgery in patients receiving anticoagulant therapy. By contrast, there are still little data on the relationship between anticoagulation or antiplatelet therapy and spontaneous ocular hemorrhages and only few reports have focused on patients with ARMD. Just recently, several authors reported a strong association of anticoagulants and antiplatelet agents with the development of large subretinal hemorrhages in ARMD patients. Moreover, arterial hypertension is a high risk factor for large subretinal hemorrhages in ARMD patients receiving anticoagulants or antiplatelet agents. Physicians should be aware of an increased risk of extensive subretinal hemorrhage in ARMD patients when deciding on the initiation and duration of anticoagulant and antiplatelet therapy.

[Choroidal tumor with exsudative retinal detachment?]. / Aderhauttumor mit exsudativer Amotio retinae?

We present the case of a 41-year-old female patient with acute onset of nyctalopia, xanthopsia and impairment of visual field. The ophthalmologic examination revealed peripheral choroidal elevation with accompanying retinal detachment. Due to the the presence of a nanophthalmic eye without any evidence of inflammation or malignant growth, the diagnosis uveal effusion syndrome could be made.

[Thrombophilic and systemic risk factors in patients with retinal vein occlusion]. / Thrombophiliediagnostik und Abklärung systemischer Risikofaktoren bei Patienten mit venösen retinalen Gefässverschlüssen.

Over the past years there has been a dramatic increase in the number of identifiable causes of thrombophilia. However, as retinal vein occlusions (RVO) have a strong pathogenic correlation with the presence of hypertension or arteriosclerosis and the average age of affected patients is usually within the sixth or seventh decade of life, thrombophilia screening of RVO patients poses a particularly difficult diagnostic challenge. It is clear that to use medical resources appropriately and improve the level of interdisciplinary patient care in RVO, subgroup analysis is required. Just recently, some studies have demonstrated the significant role of coagulation disorders in specific subgroups of RVO patients and have provided recommendations for clinical practice. These results indicate that thrombophilic risk factors are significantly more prevalent among patients equal or less than 45 years of age at the time of RVO or a previous thromboembolic event, among patients with a remarkable family history of thromboembolism prior to the age of 45 years, or among patients without cardiovascular risk factors. According to these data, thrombophilia screening should be considered in these selected subgroups.

[Ophthalmologic diagnostic procedures and imaging of retinal vein occlusions]. / Ophthalmologische Diagnostik und Bildgebung bei venösen retinalen Gefässverschlüssen.

Retinal vein occlusions are a common vascular disease of the eye. Ophthalmological diagnostic procedures and imaging are important for the prognosis of the disease, as are the systemic work-up and therapy. Besides routine ophthalmic tests (visual acuity, slit lamp examination, funduscopy) a work-up for glaucoma such as intraocular pressure, visual field or 24 h IOP profile is useful as a diagnostic procedure. Furthermore, new diagnostic and imaging tests such as central corneal thickness and optic nerve head imaging by Heidelberg retina tomography or optical coherence tomography (OCT) should be considered for glaucoma evaluation. Optical coherence tomography also plays a major role in treatment monitoring of macular edema secondary to retinal vein occlusions. Fluorescein angiography is well established and can provide information with regard to size and extent of the occlusion, degree of ischemia, areas of non-perfusion and neovascularization, as well as macular edema.

Coagulation disorders and the risk of retinal vein occlusion.

Over the past years, there has been a dramatic increase in the number of identifiable causes of thrombophilia. However, to date, there are no large, prospective studies to assess an optimal, cost-effective approach with regard to screening and case finding for thrombophilic risk factors in patients presenting with retinal vessel occlusion. Two hundred twenty-eight patients with retinal vein occlusion (RVO) and 130 age-matched healthy controls were prospectively screened for thrombophilic risk factors. Both cohorts were divided into three subgroups, depending on the patients' age at the time of the RVO or a previous thromboembolic event. Patient age < or =45 years was associated with a high prevalence of coagulation disorders (p<0.0001). Among patients < or =45 years and >45 to < or =60 years, a family history of thromboembolism was strongly associated with the presence of thrombophilic disorders. The absence of cardiovascular risk factors was found to be a strong predictor for the presence of coagulation disorders in all patient groups (< or =45 years, p=0.003; >45 to < or =60 years, p=0.0008; >60 years, p=0.001). Multivariate analysis revealed the presence of resistance to activated protein C (p=0.014), antiphospholipid antibodies (p=0.022), and deficiency of the anticoagulant proteins (p=0.05) as independent risk factors for the development of RVO among patients < or =45 years. Our results indicate that thrombophilic disorders are associated with the development of retinal vein occlusion in patients < or =45 years by the time of the RVO or a previous thromboembolic event, in patients with a family history of thromboembolism, or in patients without cardiovascular risk factors.

[Perioperative conversion of oral anticoagulants to heparin (bridging) in ophthalmic medicine]. / Perioperative Umstellung von oralen Antikoagulanzien auf Heparin in der Augenheilkunde (Bridging).

Since topical anesthesia was introduced in ophthalmic surgery, anticoagulation therapy can often be used in patients with thromboembolic risk. But some surgical procedures with an increased risk for intraoperative bleeding necessitate changing a patient's Coumadin therapy to heparin. To reduce intraoperative bleeding and perioperative thromboembolic complications, ophthalmologists and referring general practitioners should cooperate closely.