[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.

[Trabeculectomy Ab Interno in Primary Open Angle Glaucoma and Exfoliative Glaucoma]. / Trabekulotomie ab interno (Trabectome) - Kumulierte klinische Ergebnisse eines großen Glaukomkollektivs.

BACKGROUND: To assess the outcome of routine trabectomy surgery in the treatment of primary (POAG) and secondary open angle glaucoma. PATIENTS/METHODS: 296 eyes of 296 patients with diagnosed open angle glaucoma and exfoliative glaucoma were analysed from June 2012 until June 2014. IOP readings (intraocular pressure) and the number of antiglaucoma medications was evaluated at every follow-up visit. For statistical analysis, 4 study cohorts were built (cohort 1 = trabectomy in POAG, cohort 2 = trabectomy in exfoliative glaucoma (PEX), cohort 3 = trabectomy + IOL in POAG, cohort 4 = trabectomy + IOL in PEX glaucoma). RESULTS: Mean IOP before trabectomy surgery was 19.8 ± 5.9 mmHg and 23.7 ± 9.5 mmHg in cohorts 1 and 2, respectively. At 1 year follow-up, IOP was reduced to normal level for cohorts 1 and 2 (14.8 ± 3.2 mmHg (p = 0.001) and 14.0 ± 3.3 mmHg (p = 0.046), respectively). The number of topical antiglaucoma medications changed to 2.1 ± 1.2 (p = 0.004) and 2.4 ± 1.2, respectively (p = 0.593) at one year follow-up, respectively, for POAG and exfoliative glaucoma. In study cohort 3 and 4, mean IOP before trabectomy surgery was 19.2 ± 4.0 mmHg and 23.2 ± 9.2 mmHg, respectively. At 1 year follow-up, IOP was reduced to normal levels in cohorts 3 and 4 (11.8 ± 3.1 mmHg (p < 0.01) and 12.6 ± 1.1 mmHg, respectively (p = 0.043)); the number of topical antiglaucoma medications changed to 2.3 ± 1.4 (p = 0.469) and 1.4 ± 0.8, respectively, (p = 0.102) at 1 year follow-up. A significant difference in IOP reduction could be demonstrated in POAG between the trabectomy + IOL group and the trabectomy cohort 1 year postoperative (p = 0.017); in the PEX trabectomy + IOL versus PEX trabectomy cohort no statistically significant difference (p = 0.678) could be demonstrated. No serious postoperative complications were recorded. CONCLUSION: Trabectomy surgery seemed to be a reliable and effective tool for the management of mild and moderate primary and secondary open angle glaucoma with uncontrolled IOP in daily routine. One year follow-up showed a significant reduction in intraocular pressure in all cohorts.

Long-term (4 years) results of choroidal hemangioma treated with proton beam irradiation.

BACKGROUND: The aim of this retrospective study was to determine the efficacy of proton beam irradiation in choroidal hemangioma in a long-term follow-up. PATIENTS AND METHODS: A total dose of 20 Cobalt Gray equivalent (CGE) was administered to 50 eyes of 50 patients from September 1998 to September 2010. All treated patients presented with a symptomatic tumor. Nine patients were pre-treated by photodynamic therapy (PDT). Visual outcome, tumor regression, and complications resulting from radiation were investigated. RESULTS: The mean follow-up was 55.4 months (range 13-132). Tumor thickness decreased in all patients. Retinal re-attachment was achieved without evidence of tumor leakage. Visual acuity improved by two lines after one year in 43.4 % of patients and after two years in 36.8 % of patients. During the 55.4 months of long-term follow-up the visual acuity improved from 6/15 to 6/12 after proton therapy. Twenty-three patients (46.0 %) developed radiation retinopathy. According to the Finger classification of 2004, 21 patients (42.0 %) showed a stage 1 or 2 (functionally not relevant) retinopathy, and two patients (4.0 %) presented a stage 3 or 4 (functionally relevant) retinopathy. Further complications included sicca syndrome in nine cases, cataract formation in 10 cases, and radiation optic neuropathy in four cases. CONCLUSION: Proton therapy with 20 CGE is an efficient primary therapy in choroidal hemangioma and is very effective as a secondary treatment after PDT.

[Surgery for age-related macular degeneration. Still an option in the age of pharmacotherapy?]. / Chirurgie der altersbedingten Makuladegeneration--Ist das im Zeitalter der Pharmakotherapie noch eine Option?

This review assesses the relevance of surgical approaches for age-related macular degeneration (AMD) with respect to the pathophysiology of AMD and the current pharmacological possibilities. We discuss the different surgical approaches such as subretinal membrane excision, cell transplantation (IPE and RPE) and transplantation of retina and choroid (PATCH), as well as translocation surgery. Peeling of epiretinal membranes in patients with drusen as well as vitrectomy before epiretinal brachytherapy (VIDEON system) are the final topics. While overall pharmacotherapy has displaced surgical approaches, surgery is worthy of consideration in selected cases. For these patients surgical options need to be maintained in the armamentarium of retinal surgeons.

[Retinal Arterial Macroaneurysms (RAM)--pathology, differenzial diagnoses, and therapy]. / Retinale arterielle Makroaneurysmen (RAM)--Pathologie, Differenzialdiagnose und Therapie.

Retinal arterial macroaneurysms (RAM) are unilateral, solitary, acquired saccular or fusiform dilatations of the large arterioles of the retina, usually within the first three orders of bifurcation. They are associated with systemic vascular conditions such as hypertension and arteriosclerotic disease and occur most commonly in elderly women. Cases of simple RAM are predominated by the vascular ectasia. These macroaneurysms regress without treatment and without causing decreased visual acuity and will usually remain undetected. Complex RAM often go along with vision loss due to haemorrhage or oedema affecting the macula. Poor visual outcome may occur secondary to foveal exudates and subfoveal haemorrhage, the latter appear as pre-retinal, intra-, and subretinal haemorrhage. This overview discusses conservative and surgical therapeutic options for complex cases.

[Endothelial cell loss after retropupillary iris-claw intraocular lens implantation]. / Endothelzellverlust nach retropupillar fixierter Irisklauen-Linse.

BACKGROUND: The aim of this study was to evaluate the indication, visual and refractive outcome, endothelial cell loss and complication rate after implantation of a posterior iris-claw aphakic intraocular lens (IOL). PATIENTS AND METHODS: This retrospective study comprised 62 eyes of 56 patients without adequate capsular support undergoing posterior iris-claw aphakic IOL implantation (Verisyse™/Artisan®) between 2006 and 2012. Mean follow-up was 34 months (range from 13 to 78 months). RESULTS: The IOLs were inserted during primary lens surgery in 11 phakic eyes (17.8 %), during an IOL exchange procedure for dislocated posterior chamber IOLs in 34 eyes (54.8 %), and as a secondary procedure in 17 aphakic eyes (27.4 %). The final best spectacle-corrected visual acuity (BSCVA) in logMAR (mean 0.24 ± 0.45) improved significantly (p < 0.001) compared to the preoperative BSCVA (mean 0.61 ± 0.65). The mean spherical equivalent improved from preoperative 7,25 ± 5,04 diopters (D) (range - 10.25 to + 16.0 D) to - 0.21 ± 1.01 D (range - 4.0 to 3.0 D) postoperatively. Mean central endothelial cell density was 1844 ± 690 cells/mm(2) preoperatively. After surgery mean endothelial cell density decreased statistically not significant with a loss of 5.5 % to 1743 ± 721 cells/mm(2) (p > 0.05) at last follow-up visit. Complications included cystoid macular oedema in 4 eyes (6.4 %), early postoperative hypotony in 2 eyes (3.2 %), pupil ovalisation in 2 eyes (3.2 %), traumatic iris-claw IOL disenclavation in 2 eyes (3.2 %) and spontaneous IOL disenclavation in one eye (1.6 %). CONCLUSIONS: Retropupillar iris-claw IOL provides good visual and refractive outcomes with a low endothelial cell loss and can be used for a wide range of indications in eyes without adequate capsular support.

Alterations in basement membrane immunoreactivity of the diabetic retina in three diabetic mouse models.

BACKGROUND: The mouse retina contains three kinds of basement membrane (BM) structures; the inner limiting membrane (ILM), Bruch's membrane (BrM), and the BM surrounding the capillaries. We aimed to investigate possible variations of individual BM components and to detect effects caused by diabetes in three different diabetic mouse models. METHODS: After 4 and 6 months of diabetes (defined by blood glucose > 250 mg/dl), we analyzed by immunohistochemistry the laminin, collagen IV, and nidogen-1 and nidogen-2 protein composition of the BMs obtained from diabetic and non-diabetic Leptin-receptor deficient (db/db) mice and insulin receptor (IR)/insulin receptor substrate-1 (IRS-1) double heterozygous knockout mice. In addition, C57BL/6 J mice were rendered diabetic by intraperitoneal injections of streptozotocin (STZ). RESULTS: All analyzed BM proteins were detected in all of the three BMs with the exception of collagen IV, which was not detectable in the ILM of db/db mice and IR/IRS-1 mice. We present the first analysis of nidogen expression in diabetic BM. The staining patterns did not differ between the type-1 diabetic model (STZ) or the type-2 diabetic models (db/db and IR/IRS-1) and the wild-type controls, with only one exception: both the db/db mice and the IR/IRS-1 mice but not the STZ mice showed a decreased nidogen-1 immunoreactivity in the BrM after 4 months of diabetes, but not after 6 months. CONCLUSIONS: The BMs in the three mouse strains differ with regard to protein immunoreactivity in the inner limiting membrane. Changes in BM composition may affect both the assembly and the function of the retinal BM. However, there are no marked differences in the BM composition between type-1 and type-2 diabetes. These results provide evidence for BM remodelling during diabetic retinopathy.

Comparison of functional and morphological diagnostics in glaucoma patients and healthy subjects.

PURPOSE: To evaluate the diagnostic value of microperimetry (MP), blue-on-yellow perimetry (B/YP), confocal scanning laser ophthalmoscopy (Heidelberg Retina Tomograph, HRT, III) and optical coherence tomography (OCT) in discriminating eyes with early glaucoma from healthy subjects. MATERIAL AND METHODS: Prospective examination of 22 eyes of subjects with early primary open-angle glaucoma and 24 eyes of healthy control subjects. After a complete ophthalmological examination, B/YP, MP, OCT and HRT III were determined. Morphological and functional parameters were analysed. RESULTS: Mean sensitivity threshold values obtained with B/YP and MP did not show significant differences between glaucoma patients and the control group (p = 0.321 and p = 0.281). Retinal nerve fibre layer (RNFL) thickness was significantly decreased in patients with glaucoma with both HRT III and OCT (p = 0.018 and p < 0.001). CONCLUSIONS: While B/YP and MP had no ability to discriminate between subjects with early glaucoma and healthy subjects, RNFL thickness measured with HRT III and OCT showed a significant difference. In early primary open-angle glaucoma, morphological changes like RNFL thickness seem to occur prior to functional defects in the visual field.

[Childhood retinal detachment: ROP and myopia]. / Kindliche Ablationes: ROP und Myopie.

This article reviews the cause and treatment options for retinopathy of prematurity (ROP)-related tractional detachment and detachments in ROP residuals during childhood and early adulthood. Retinal vascularisation is incomplete after premature birth. Phase I of ROP consists of a delayed retinal vascular growth and vessel loss after premature birth resulting in hypoxia, phase II results in hypoxia-induced vascular proliferation and as a consequence to vitreoretinal traction. The anatomic and functional outcome of tractional detachment in ROP is determined by the previous treatment (e.g., laser to the avascular periphery or anti-VEGF). While the literature reports re-attachment rates > 70 % in ROP IV a, functional and anatomic outcome in the later stages is limited. ROP residuals may cause rhegmatogenous rather than tractional detachments in childhood or early adulthood. Myopia is associated with ROP and may further complicate the retinal situation and the risk for rhegmatogenous detachment. The retinal changes due to ROP warrant lifelong controls.

[Retinal exudative disease in childhood: Coats' disease and familial exudative vitreoretinopathy (FEVR)]. / Retinal exsudative Gefäßerkrankungen im Kindesalter: Morbus Coats und familiär exsudative Vitreoretinopathie (FEVR).

This article reviews the pathophysiology of retinal vascular disease with emphasis on Coats' disease and familial exudative vitreoretinopathy (FEVR). Both Coats' disease and FEVR demonstrate vascular abnormalities and associated exudation. Coats' disease manifests as teleangiectasia and aneurysms. Exudative subretinal lipid deposits can be extensive. Coats' disease is in 90 % unilateral and affects predominantly otherwise healthy young males. If the retina is attached, laser and cryocoagulation are the method of choice. Vitreoretinal surgery is only rarely indicated in advanced cases after a retinoblastoma has been excluded prior to surgery. FEVR inheritance is 56 % dominant (FZD4 und TSPAN12) and 44 % recessive (LRP5 und NDP). Temporal dragging of the vascular arcades and heterotopia of the macula are characteristic for FEVR. Subretinal exudates are indicators for progression of the disease with visual loss due to subsequent exudative or tractive retinal detachment. Exudative forms require treatment and reduction of peripheral ischaemia with laser photocoagulation and cryopexia. In cases of tractive detachments vitreoretinal surgery is necessary. Coats' disease and FEVR are both progressive diseases requiring lifelong follow-up and therapy.

[Diagnosis of and therapy for choroidal melanoma]. / Diagnostik und Therapie choroidaler Melanome.

BACKGROUND: Prognosis evaluation of patients with choroidal and ciliary melanoma has experienced recent progress through tumour sampling and cytogenetic analysis of metastatic risk. By allocating tumor extension, height and linear basal diameter to defined TNM stages, an estimation of prognosis can also be made without invasive tissue sampling. METHODS: Therapeutic strategies of organ preserving irradiation using different sources have clearly come to the forefront. RESULTS: Due to microscopic haematogenous spreading of tumour cells prior to treatment, the metastatic risk following radiation of any form is not influenced in comparison to primary enucleation. CONCLUSION: However, metastatic disease still remains a fatal condition which currently may only be influenced by early detection and treatment of uveal melanomas.

[Retinal angiomatous proliferations]. / Retinale angiomatöse Proliferationen.

Retinal angiomatous proliferations, also known as type 3 neovascularisation, are a common entity amongst patients with age-related macular degeneration. Their prevalence is being estimated at around 12-15% in this group of patients. Certain funduscopic signs like an extravofeal, intraretinal haemorrhage, cystoid macular oedema or a retinal anastomosis of the lesion are considered to be pathognomonic. Verification of the diagnosis should be based on ICG angiography, although OCT is gaining popularity. Interestingly, RAP lesions seem to have distinctive demographic characteristics and respond differently to established therapies, differentiating them from regular type 1 or type 2 neovascularisation. Current therapies of choice are VEGF inhibitors. Nonetheless, combination therapies, combining different approaches like anti-VEGF treatment and photodynamic therapy, have received more attention recently.

[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.

[Myopic traction maculopathy - vitreoretinal traction syndrome in high myopic eyes and posterior staphyloma]. / Traktive myope Makulopathie - vitreoretinales Traktionssyndrom bei hoher Myopie und hinterem Staphylom.

The pathology of the posterior pole in high myopic eyes is characterised by scleral thinning and staphyloma associated with structural changes of the retina. Epiretinal membranes and epiretinal traction together with partial separation of the ILM result in myopic foveoschisis and posterior tractional detachment with myopic macular holes. Foveal detachment and retinoschisis in highly myopic eyes may resolve after vitrectomy with ILM peeling: however, there is a considerable risk for the development of macular hole formation. Skleral buckling surgery is currently regaining interest and allows one to reduce the tractional forces in selected cases. While reading visual acuity is usually not regained after macular hole development, prophylactic measures should be considered for the fellow eye. Vitreous surgery might have a rationale as prophylactic treatment for highly myopic eyes at high risk of macular hole development; however, this needs to be weighed against possible surgical complications.

[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.

[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.

[Heavy tamponades--background and future perspectives]. / Schwere Tamponaden - Hintergrund und Zukunftsperspektiven.

Proliferative vitreoretinopathy in the inferior retina remains clinically challenging. Heavier-than-water intraocular tamponades have been developed to improve inferior tamponading properties. The parameters of an optimal intraocular tamponade are defined and the influences of the specific gravity, buoyancy, interfacial tension, and viscosity are discussed. Perfluorocarbon liquids and partially fluorinated alkanes were associated with tamponade emulsification, intraocular inflammation, and rises in intraocular pressure that were less prominent in admixtures of these substances with silicone oil (heavy silicone oils). Two recently developed heavy silicone oil tamponades, Oxane HD and Densiron 68, are well tolerated and have entered clinical practice. The side effects are associated with the chemical properties of the tamponading agent and seem comparable to those seen with conventional silicone oil. Heavy silicone oil tamponade improves inferior tamponade and may be considered as a new generation of intraocular tamponades.