[Keratitis - Infectious or Autoimmune?]. / Keratitis - infektiös oder autoimmun?

Histopathological evaluation of ocular tissues is important in differentiating between infectious and autoimmune disease. Inflammation, necrosis and keratolysis are common to most forms of keratitis. Histopathology can be of great help in identifying the causative organism, establishing a final diagnosis and/or managing the patient with herpes simplex virus keratitis, mycotic keratitis, acanthamoeba keratitis or microsporidia keratoconjunctivitis. Important pathogenetic knowledge with therapeutic relevance has been gained from histopathological studies in nummular keratitis after epidemic keratoconjunctivitis and atopic keratoconjunctivitis.

[ChatGPT and the German board examination for ophthalmology: an evaluation]. / ChatGPT und die deutsche Facharztprüfung für Augenheilkunde: eine Evaluierung.

PURPOSE: In recent years artificial intelligence (AI), as a new segment of computer science, has also become increasingly more important in medicine. The aim of this project was to investigate whether the current version of ChatGPT (ChatGPT 4.0) is able to answer open questions that could be asked in the context of a German board examination in ophthalmology. METHODS: After excluding image-based questions, 10 questions from 15 different chapters/topics were selected from the textbook 1000 questions in ophthalmology (1000 Fragen Augenheilkunde 2nd edition, 2014). ChatGPT was instructed by means of a so-called prompt to assume the role of a board certified ophthalmologist and to concentrate on the essentials when answering. A human expert with considerable expertise in the respective topic, evaluated the answers regarding their correctness, relevance and internal coherence. Additionally, the overall performance was rated by school grades and assessed whether the answers would have been sufficient to pass the ophthalmology board examination. RESULTS: The ChatGPT would have passed the board examination in 12 out of 15 topics. The overall performance, however, was limited with only 53.3% completely correct answers. While the correctness of the results in the different topics was highly variable (uveitis and lens/cataract 100%; optics and refraction 20%), the answers always had a high thematic fit (70%) and internal coherence (71%). CONCLUSION: The fact that ChatGPT 4.0 would have passed the specialist examination in 12 out of 15 topics is remarkable considering the fact that this AI was not specifically trained for medical questions; however, there is a considerable performance variability between the topics, with some serious shortcomings that currently rule out its safe use in clinical practice.

[In vivo confocal microscopy--correlation to histology]. / Konfokale In-vivo-Mikroskopie--Korrelation zu histologischen Befunden.

In vivo confocal microcopy is a fascinating technique to obtain rapidly and non-invasively histological/cytological sections of the ocular surface, and observe long-term changes. It allows classification of corneal findings, facilitates the diagnosis of conjunctival lesions, and has broadened our understanding of lid margin disease. To correctly interpret in vivo confocal scans, profound knowledge of microscopic anatomy and histopathology are crucial. To reduce inter-observer variability and allow comparison of scientific studies, in vivo confocal-histopathological correlations have to be investigated, and standards for the interpretation of in vivo confocal microscopic findings must be established. In suspicious lesions of the ocular surface an excisional biopsy and histopathological examination are still the gold standard.

[Bacterial conjunctivitis--diagnosis and therapy update]. / Bakterielle Konjunktivitis--Update zu Diagnose und Therapie.

Acute bacterial conjunctivitis is a common health-care issue for the general practitioner and the ophthalmologist. Signs and symptoms usually allow a correct diagnosis without conjunctival swab. Primary microbiological investigations are recommended in newborns, immunocompromised patients and cases of hyperacute conjunctivitis. Of concern are methicillin-resistant Staphylococcus aureus strains which have been isolated with increasing frequency in the last few years. Studies have demonstrated the faster clinical and microbiological cure of acute bacterial conjunctivitis with topical antibiotics. However, the development of resistance of the typical germs to all of the antibiotic groups is alarming and should influence therapeutic behaviour. Fluoroquinolones show good activity in the treatment of acute bacterial conjunctivitis but should be saved for severe infections due to its broad spectrum of activity. Antibiotics such as gentamycin, tobramycin, and azithromycin should be preferred. Considering the high spontaneous healing rate of acute conjunctivitis, delayed topical antibiotics in case of persistence after 3-4 days, or treatment without antibiotics using artificial tears and eye bathings may be considered. Additive anti-inflammatory drugs are generally not recommended. Chronic-recurrent follicular conjunctivitis necessitates testing for Chlamydia, and in case of a positive result, systemic antibiotic treatment of patient and sexual partner.

[Linear IgA disease with ocular involvement associated with ulcerative colitis]. / Lineare IgA-Dermatose mit Augenbeteiligung in Assoziation mit Colitis ulcerosa.

The association of linear IgA disease (LAD), ulcerative colitis and scarring ocular involvement is very rare and represents a considerable therapeutic challenge. We report a 48-year-old male diagnosed with ulcerative colitis in 1995, who received long-term methylprednisolone therapy. Later, he developed ocular inflammation with conjunctival scarring and synechiae formation as well as episodes of vesicles. Although azathioprine was added to his regimen, the disease was not controlled. After the diagnosis of LAD was established, dapsone was added. With this therapy, the ocular inflammation decreased significantly and the methylprednisolone dose could be successfully tapered slowly without reappearance of vesicles.

[Clinical presentation of zoster ophthalmicus]. / Klinik des Zoster Ophthalmicus.

BACKGROUND: Zoster ophthalmicus (ZO) is a common disease, in particular in elderly and immunocompromised patients. In addition to the characteristic dermal lesions and to the postherpetic neuralgia, the clinical appearance may include very different forms of eye involvement. METHODS: This article reviews the clinical features of ZO as well as the typical eye complications and therapy. RESULTS: 50 % of ZO patients have eye involvement. The acute phase of ZO is characterised by lid exanthema, conjunctivitis and epithelial keratitis (up to 65 %). In the late phase, stromal keratitis (up to 25 %), anterior uveitis (up to 50 %), and acute retinal necrosis (ARN) may occur. Typical complications are eyelid malposition, neurotrophic keratopathy (up to 25 %) and glaucoma. The diagnosis is usually based on the characteristic dermal lesions. In atypical cases, immunohistochemistry and PCR are tools for virus detection. All ZO patients should immediately receive systemic antiviral therapy. Corticosteroid therapy is essential for the management of the concomitant immune reaction that is relevant for the long-term prognosis, especially in stromal keratitis, uveitis, scleritis and ARN. CONCLUSIONS: All patients should receive systemic antiviral treatment to avoid complications and visual impairment. With appropriate medical and surgical therapy the prognosis is usually good. Postherpetic neuralgia is often the major issue in the later course. For the prevention of ZO and its complications, a vaccination is useful.

[Wound healing following amniotic membrane, limbal stem cell and corneal transplantation]. / Wundheilung nach Amnionmembran­, Limbus- und Hornhauttransplantation.

Knowledge of wound healing processes involved in amniotic membrane, limbal stem cell and corneal transplantation enables an assessment of clinical findings and a targeted treatment. The amniotic membrane serves as a basal membrane substrate or temporary transplant in corneal epithelial wound healing. It has an anti-inflammatory effect, supports corneal wound healing and counteracts scar formation. Amniotic membranes are integrated intraepithelially, subepithelially, or intrastromally in the course of healing. Limbal epithelial stem cells express multiple genes necessary for corneal wound healing. The rho-associated, coiled-coil containing protein kinase (ROCK) inhibitor Y­27632 can improve the proliferation of limbal epithelial cells and therefore represents a new therapeutic option for limbal stem cell deficiency. Wound healing following penetrating keratoplasty involves fibroblasts, type III and IV collagens, proteoglycans, and chondroitin-6-sulfate. A certain inflammatory reaction seems to be necessary for final corneal wound closure.

[The situation of ophthalmic pathology in Germany: the current status]. / Zur Situation der Ophthalmopathologie in Deutschland: eine aktuelle Bestandsaufnahme.

BACKGROUND: Ophthalmic pathology with its 150 year-old tradition is a subspecialty which since its beginning has contributed substantially to progress in ophthalmology. Nevertheless, deactivation or even termination of ophthalmopathological laboratories has occurred in the past years mainly due to economic pressure. In order to evaluate the situation and future perspectives of the existing, active laboratories in Germany and to ask for the kind of support desired from the Section for Ophthalmic Pathology of the German Ophthalmological Society (DOG) a survey was carried out using a questionnaire. RESULTS: The main results were as follows. 1. Specialised ophthalmic pathology is performed in Germany almost exclusively in laboratories integrated in university eye clinics. 2. There is close cooperation with institutes for pathology and dermatopathology. 3. The main focus is placed on the cornea, tumours of the eye and its adnexae, and the conjunctiva. 4. The number of ophthalmopathological specimens investigated per year is generally below 1000 and often below 500. 5. The diagnostic spectrum and equipment of the laboratories is generally good. 6. There are some deficits concerning ophthalmopathological education and the status of ophthalmic pathology within the clinics. 7. A considerable number of scientific publications is generated by the members of the laboratories. 8. At present there is only minimal fear that the own laboratory will be eliminated in the near future. 9. Ophthalmic pathology is established as an integral component of ophthalmology in patient care and, even more, in ophthalmic research. 10. The DOG-Section "Ophthalmic pathology" is requested to initiate stays in foreign laboratories, to initiate scientific multicentre studies, and to support activities dedicated to preserve the ophthalmopathological laboratories. DISCUSSION: For the first time valid data concerning the situation of ophthalmopathological laboratories in Germany have been collected. The information gathered can and should be used as an argument for the preservation and, if possible, even expansion of the occupation with normal and pathologic eye morphology at eye hospitals in and beyond Germany.

[Clinical picture and diagnosis of neurotrophic keratopathy]. / Klinik und Diagnose der neurotrophen Keratopathie.

BACKGROUND: Neurotrophic keratopathy is characterized by corneal surface alterations, persistent corneal epithelial defects and/or corneal ulcerations associated with corneal sensory abnormalities. Due to the variable clinical picture neurotrophic keratopathy is often overlooked or diagnosed too late in the course of the disease. OBJECTIVE: Discussion of the clinical picture of neurotrophic keratopathy and recommendations for correct diagnosis. MATERIAL AND METHODS: Analysis of the existing literature and discussion of basic recent publications. RESULTS: Neurotrophic keratopathy is defined as a disease related to alterations in corneal nerves leading to impairment in sensory and trophic function with consequent breakdown of the corneal epithelium affecting health and integrity of the tear film, epithelium and stroma. It can occur with infections, autoimmune diseases, after trauma or ocular surgery, with intracranial neoplasia, in systemic diseases and genetic syndromes. It is classified into three stages: mild (epithelial changes without epithelial defects), moderate (epithelial defects) and severe (stromal involvement). The clinical hallmark is reduced or absent corneal sensation. Therefore, corneal sensitivity testing is essential in the diagnosis of neurotrophic keratopathy along with the patient history, clinical examination and diagnostic tests, such as vital stains and, if possible, in vivo confocal microscopy. CONCLUSION: The correct diagnosis and classification of neurotrophic keratopathy enable a stage-adapted step-ladder therapeutic approach with subsequent reduction of progression and complications of the disease.

[Intense pulsed light (IPL) as a therapeutic option for Meibomian gland dysfunction]. / Pulslichttherapie ("intense pulsed light") als Therapieoption bei der Behandlung der Meibom-Drüsen-Dysfunktion.

Meibomian gland dysfunction (MGD) is a common cause of dry eye disease. Intense pulsed light (IPL) treatment is a new and approved therapeutic option for MGD. The treatment consists of 2-4 sessions where light impulses are applied to the lower lid and temporal lid margin. The IPL technique is a safe form of treatment when the required safety precautions are followed. Current studies document an improvement of patients' subjective symptoms and objectively measured clinical parameters.

[The German keratomycosis registry : Initial results of a multicenter survey]. / Das Deutsche Pilz-Keratitis-Register : Erste Ergebnisse einer multizentrischen Erhebung.

BACKGROUND AND PURPOSE: Mycotic keratitis is a serious but relatively rare disease. No targeted data collection in Germany existed until the foundation of the German Pilz-Keratitis Register in 2015. PATIENTS AND METHODS: The inclusion of retrospective and prospective patients was carried out. INCLUSION CRITERIA: diagnosis confirmed by the polymerase chain reaction (PCR), culture, histology or confocal microscopy (IVCM). Collected parameters: date of symptom onset, date and method of diagnosis, risk factors, visual acuity and findings at admission and at follow-up, conservative and surgical treatment. RESULTS: By January 2018, a total of 102 eyes from the years 2000-2017 were reported from 16 centers (64.3% female, mean age 52 years, range 18-95 years). The initial diagnosis was made correctly in only 20.6% of cases. The mean time to correct diagnosis was 31.7 ±â€¯46.9 (0-296) days. The diagnosis was confirmed in cultures in 74.5%, histologically in 30.4%, by PCR in 38.2% and IVCM in 27.4%. Fungal species identified were: 36.7% Fusarium spp., 35.8% Candida spp., 6.4% Aspergillus spp. and 21.1% other. The most important risk factor was the use of contact lenses. The most commonly used antifungal agent was voriconazole (64.7%) followed by amphotericin B (37.2%). Penetrating keratoplasty was performed in 65.7% of the cases and 8.8% of the affected eyes had to be enucleated. The visual acuity of the entire study population increased from the initial 0.16 ±â€¯0.25 (0.001-1.0) decimal to 0.28 ±â€¯0.34 (0-1.0) decimal. CONCLUSION: The correct diagnosis of fungal keratitis is often significantly delayed. The treatment can be very difficult and keratoplasty is often necessary. In order to gain a better understanding of this disease, to recognize previously unknown risk factors and, if necessary, a change in the spectrum of pathogens and to identify approaches to treatment optimization, the fungal keratitis registry will be continued.

[Novel current and future therapy options for treatment of dry eye disease]. / Neue aktuelle und zukünftige Therapieoptionen in der Behandlung des trockenen Auges.

Dry eye disease was redefined by the dry eye workshop (DEWS II) in May 2017. According to the new definition "dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film and accompanied by ocular symptoms". The current definition encompasses etiological factors, such as instability and hyperosmolarity of the tear film, ocular surface inflammation and damage as well as a new aspect compared to the former definition, neurosensory abnormalities. Recent and future therapeutic options for dry eye focus on treatment of the aforementioned pathogenetic events. New tear substitutes, medications and devices to stimulate tear production, innovative anti-inflammatory treatment, medications to influence corneal innervation and new methods for treatment of Meibomian gland dysfunction are already available or will be available in the near future.

[Diagnosis of dry eye disease]. / Diagnostik des trockenen Auges.

Dry eye disease (DED) is one of the most common ophthalmological diseases with an increasing prevalence in recent years. Numerous general and ocular risk factors exist for the development of DED. The pathogenesis of DED is multifactorial and complex, characterized by a loss of homeostasis of the tear film, inflammatory mechanisms at the ocular surface, hyperosmolarity of tears and neurosensory abnormalities. DED is classified into the two sub-categories, aqueous deficient dry eye and evaporative dry eye. Apart from a detailed patient history, basic and complementary diagnostic tests are necessary to enable an individualized and efficient therapy. Moreover, subjective symptom questionnaires and interdisciplinary cooperations are beneficial in a thorough work-up of these patients.

[Osmoprotection as a new therapeutic principle]. / Osmoprotektion als therapeutisches Prinzip.

Dry eye syndrome is one of the most common disorders encountered in daily ophthalmological practice. New pathophysiological concepts have been developed over the last few years. Hyperosmolarity of the tear film is one of the key pathogenetic factors in the development of a - commonly subclinical - inflammation of the ocular surface, the lacrimal gland and the tear film in dry eye syndrome. Osmoprotective agents act through compatible solutes to prevent - at least in theory -a hyperosmolar tear film from damaging the ocular surface.

Cost utility for penetrating keratoplasty in patients with poor binocular vision.

PURPOSE: Cost-utility and cost-effectiveness analyses are of increasing importance to clinicians and health policy experts. This study determines the costs in Germany and other countries in relation to gain of utility for patients with bilateral poor vision owing to corneal disease undergoing penetrating keratoplasty (PK) in 1 eye. DESIGN: A cost-utility analysis was performed using retrospective clinical data and high-level evidence-based data. PARTICIPANTS: Sixty patients (mean age, 46.3 years) with bilateral poor vision who underwent PK for corneal disease. METHODS: Visual acuity and utility values were obtained before and 1 year after PK and after suture removal. A 10-year graft survival rate of 80% was assumed. Expenses included costs for the corneal transplant and surgery, medication, and optical rehabilitation. A discount rate of 5% was applied for costs and quality-adjusted life years (QALYs). Cost-utility analysis encompassed a 10-year period after surgery. MAIN OUTCOME MEASURES: The number of QALYs was calculated for the study group undergoing PK. This was divided into the cost of the procedure to get the number of euros spent per QALY gained. RESULTS: Median binocular preoperative visual acuity was -log mean angle of resolution (-logMAR) 0.91+/-0.53 (Snellen equivalent 20/160) yielding a utility value of 0.67. After suture removal and optical rehabilitation, binocular visual acuity increased to median -logMAR 0.36+/-0.36 (20/46) with a utility value of 0.79. Over the 10 years after surgery and considering graft survival and discounting, a cost utility of 9551 euros per QALY was gained (equivalent to US11,557 dollars). One-way sensitivity analysis yielded a range from 7706 euros to 12874 euros per QALY, highlighting the robustness of the model. CONCLUSIONS: Although an expensive procedure, PK is cost effective in patients with bilateral poor vision.

Ocular manifestations of keratitis-ichthyosis-deafness (KID) syndrome.

OBJECTIVE: Keratitis-ichthyosis-deafness (KID) syndrome is a rare congenital ectodermal dysplasia characterized by the association of hyperkeratotic skin lesions, moderate to profound sensorineural hearing loss and vascularizing keratitis. Mutations in the GJB2 gene coding for connexin 26, a component of gap junctions in epithelial cells, have been observed in several KID patients. Variable ocular manifestations of the disease in 3 patients with molecular genetically confirmed KID syndrome are reported. DESIGN: Retrospective case series. METHODS: Clinical examination and molecular genetic analysis for mutations in the GJB2 gene were performed in 3 patients with KID syndrome ages 5, 13, and 41 years. RESULTS: Visual acuity ranged from normal to severe visual loss. The ocular signs included loss of eyebrows and lashes, thickened and keratinized lids, trichiasis, recurrent corneal epithelial defects, superficial and deep corneal stromal vascularization with scarring, keratoconjunctivitis sicca, and, in one patient, presumed limbal insufficiency. Whereas ocular surface integrity could be maintained with artificial tears in one patient, and an epithelial defect healed under conservative treatment in the second patient, multiple surgical procedures including superficial keratectomies, limbal allograft transplantation with systemic immunosuppression, amniotic membrane transplantation, lateral tarsorrhaphies, and lamellar keratoplasty could not preserve useful vision in the third patient. CONCLUSIONS: KID syndrome may affect the ocular adnexae and surface with variable severity independent of the age of the patient. Lid abnormalities, corneal surface instability, limbal stem cell deficiency with resulting corneal complications, and dry eye are the main ocular manifestations.

[Ocular allergies]. / Okuläre Allergien.

Recent developments indicate that ocular allergy is more than an IgE-mediated allergic conjunctivitis. Ocular allergy is a disease affecting the entire ocular surface including conjunctiva, lids, cornea, lacrimal gland and tear film. Besides an IgE-mediated reaction, a complex chronic inflammation is involved in the pathogenesis of many ocular allergies. According to their pathogenesis and clinical picture, ocular allergies are classified into mild forms, such as seasonal and perennial allergic conjunctivitis as well as giant papillary conjunctivitis, and chronic, potentially blinding forms such as atopic keratoconjunctivitis and vernal keratoconjunctivitis. New therapeutics act on the entire inflammatory process or try to modulate the allergic reaction early and specifically. The association with non-ocular allergic symptoms requires an interdisciplinary approach.

[What's new in ocular surface disease?]. / Neue Erkenntnisse zu Erkrankungen der Augenoberfläche Trockenes Auge, okuläre Allergie, infektiöse Konjunktivitis.

The 76th meeting of the Association for Research in Vision and Ophthalmology (ARVO) was held in Fort Lauderdale, Florida on 25-29 April 2004. The congress focused on the latest developments in clinical and laboratory research in ophthalmology and the treatment of ocular disease. In this article the authors review new insights into dry eye, including recent treatment developments, discuss current advances in the field of ocular allergy and highlight new findings in the area of ocular infection presented at the ARVO meeting.

Referral patterns of uveitis in a tertiary eye care center.

OBJECTIVE: To analyze the referral patterns and diagnosis of uveitis during the past decade in a large tertiary eye center. DESIGN: The records of 1237 patients with uveitis referred to the Immunology Service of the Massachusetts Eye and Ear Infirmary from 1982 to 1992 were classified and analyzed. Data regarding sex, race, nationality, referral site, ages at presentation and onset of uveitis, ocular involvement, clinical characteristics, ocular condition, and systemic disease associations were obtained. RESULTS: The mean age at onset of uveitis was 37.2 years; the male-to-female ratio was 1:1.4. Most patients were white (85.8%), born in the United States (83.1%), and referred from within New England (84.7%). Anterior uveitis was most common (51.6%), followed by posterior uveitis (19.4%), panuveitis (16.0%), and intermediate uveitis (13.0%). Chronic (58.3%), nongranulomatous (77.7%), and noninfectious (83.1%) were the most frequent types of uveitis. The most common entities included idiopathic (34.9%), seronegative spondyloarthropathies (10.4%), sarcoidosis (9.6%), juvenile rheumatoid arthritis (5.6%), systemic lupus erythematosus (4.8%), Behçet's disease (2.5%), and the acquired immunodeficiency syndrome (2.4%). CONCLUSION: The appearance of new uveitic entities, such as the acute retinal necrosis syndrome, multifocal choroiditis and panuveitis, birdshot retinochoroidopathy, and acquired immunodeficiency syndrome-related uveitis, and the reemergence of the classic infectious causes of uveitis, tuberculosis and syphilis, have changed the way we approach the diagnosis and management of posterior and panuveitis at the Massachusetts Eye and Ear Infirmary.

Vasculitic peripheral ulcerative keratitis.

The onset of peripheral ulcerative keratitis in the course of a connective tissue disorder, such as rheumatoid arthritis, relapsing polychondritis, or systemic lupus erythematosus, may reflect the presence of potentially lethal systemic vasculitis. Moreover, peripheral ulcerative keratitis may be the first sign of systemic necrotizing vasculitis in patients with Wegener's granulomatosis, polyarteritis nodosa, microscopic polyangiitis, or Churg-Strauss syndrome. Although the exact pathogenesis of this severe corneal inflammation and destruction is not well understood, evidence points to a dysfunction in immunoregulation with immune complexes formed in response to autoantigens or to some unknown microbial antigen depositing in scleral and limbal vessels. These events lead to changes that are mainly responsible for the resulting tissue damage. In pauci-immune vasculitides positive for antineutrophil cytoplasmic antibodies, cell-mediated cytotoxicity may play an important role in the pathogenesis of peripheral ulcerative keratitis. Untreated systemic conditions such as those mentioned above may carry a grave prognosis for the eye and may also be life-threatening. Immunosuppressive therapy with corticosteroids and cytotoxic agents is, we believe, mandatory in the treatment of these multisystem disorders associated with vasculitic peripheral ulcerative keratitis.