[Diagnostic and Therapeutic Management of Episcleritis and Scleritis]. / Diagnostisches und therapeutisches Management der Episkleritis und Skleritis.

While episcleritis is a benign disease only affecting the episclera, scleritis is an ocular inflammation with typically severe pain and not rarely affecting adjacent tissue.Scleritis is classified into anterior and posterior forms. Anterior scleritis is further subdivided into diffuse, nodular, necrotizing with inflammation, and necrotizing scleritis without inflammation (scleromalacia perforans). A systemic disease such as rheumatoid arthritis or granulomatosis with polyangiitis is associated with up to 50% of all patients with scleritis or episcleritis, consequently a systemic work-up with blood sampling and imaging as well as collaboration with internists are necessary.Differentiating these two entities is of high importance for planning the treatment: episcleritis has a self-limited course, whereas treatment of scleritis is obligatory to protect patients from irreversible visual loss, organ damage, and furthermore reduce the risk of mortality.Treatment depending of subtype and associated systemic disease may involve non-steroidal anti-inflammatory drugs, corticosteroids, and disease-modifying anti-rheumatic drugs.

Biologics in the Treatment of Uveitis. / Therapie der Uveitis mit Biologika.

GOAL: To provide an overview of biologics that are used to treat noninfectious uveitis, including their different targets, modes of actions, and indications. MATERIAL AND METHODS: A review of recent and well-established literature was used to present the biochemical and pathophysiological background of biologics and to provide an account of evidence-based decision making for their use, not only in noninfectious uveitis in general, but with special regard to indications for their use in particular types of uveitis. RESULTS: Extensive clinical data for adalimumab shows that it is currently the only approved biologic for the treatment of uveitis. However, there is sufficient evidence to argue that many other biologics, notably TNF-α inhibitors, certain Interleukin inhibitors, Interferons, and B cell and T cell inhibitors, are also suitable for use in uveitis. CONCLUSIONS: Biologics have revolutionized the treatment of noninfectious uveitis and are now considered indispensable. They are used in cases of insufficient response to or intolerance of conventional immunosuppressive agents. However, they can also be indicated as a first-line therapy for certain types of uveitis (e.g., Behçet's disease). TNF-α inhibitors are the most commonly used biologics in the treatment of uveitis.

Incidence of severe rise in intraocular pressure after intravitreous injection of aflibercept with prefilled syringes.

Our aim was to analyze the intraocular pressure (IOP) changes following different intravitreous injection (IVI) procedures with or without prefilled syringes (PFS) and to elaborate their possible causes. Clinical study and laboratory assessment. 173 eyes of 141 patients. The IOP was prospectively measured pre- and postoperatively in three groups of patients receiving IVI either with ranibizumab (RP), aflibercept PFS (AP) or aflibercept vials (AV). The AP emptying volume (EV) was assessed using 40 aflibercept PFS vials: the plunger was aligned precisely (normal volume, NV) or right below the indication line (high volume, HV) and the drug was ejected with (wP) or without forced pressure (nP). Primary outcome was post-treatment IOP with type of IVI and pre-treatment IOP as fixed factors. Secondary outcome was identification of possibly confounding factors (age, sex, pathology, presence of pseudophakia, spherical error, and number of injections) and IOP > 30 mmHg post-treatment. An IOP rise above 30 mmHg was observed in 8/38 (22%), 16/51 (31%) and 35/86 (41%) cases in the RP, AV and AP groups, respectively (p = 0.129). Pre-treatment IOP was the only predictive variable for IOP rise (p < 0.001). The EV values in the NVnP, NVwP, HVnP and HVwP groups were 56.06 ± 10.32, 70.69 ± 4.56, 74.22 ± 7.41 and 81.63 ± 3.67 µl, respectively (p < 0.001). We observed a marked, although not significantly higher incidence of IOP elevations with the aflibercept PFS. One possible reason may be the error-proneness of administering the correct volume with the AP. Caution should be taken when using the aflibercept PFS in order to prevent potential optic nerve damage in cases with marked elevation in IOP.

Retinal Manifestation of an Epstein-Barr Virus-Associated Plasma Cell Neoplasm.

We report a case of an uncommon presentation of Epstein-Barr virus (EBV)-associated plasma cell neoplasm in a patient with a history of prostate cancer and hairy cell leukemia (HCL) in remission after chemotherapy. The diagnosis of an EBV-associated plasma cell neoplasm was challenging as initially the findings were also compatible with a recurrence of HCL. We highlight the value of diagnostic vitrectomy to achieve the diagnosis. Our particular case demonstrates the importance of diagnostic pars plana vitrectomy and aqueous analyses in patients with uveitis of an unknown cause to confirm the diagnosis.

Optical coherence tomography angiography (OCTA) as a new diagnostic tool in uveitis.

BACKGROUND: The broad spectrum of uveitis disorders requires a multimodal imaging approach in the daily practice of an ophthalmologist. As inflammatory conditions, they have in common an alteration in leukocyte migration. In this context, optical coherence tomography angiography (OCTA) might be of great value for diagnosing or following up patients with these disorders. To date, OCTA has rather been used as an additional tool besides the well-established diagnostic imaging tools, but its complementary diagnostic features become increasingly relevant, to follow disease activity and treatment response and for the understanding of pathomechanisms of various uveitis types. This review summarizes the possible applications of OCTA and its advantages and disadvantages as opposed to dye-based angiographies in uveitic diseases. MAIN BODY: Hitherto gold standards in the diagnostic workup of posterior or intermediate uveitis have been angiography on a dye-based method, which is fluorescein or indocyanine green. It gives information about the status of the blood-retinal barrier and the retinal and choroidal vasculature by visualizing diffuse leakage as a state of inflammation or complications as an ischemia or choroidal neovascularization. As noninvasive methods, fundus autofluorescence depicts the status of metabolic activity of the retinal pigment epithelium and OCT or enhanced depth imaging OCT, respectively, as a depth-resolving imaging method can supply additional information. OCTA as a non-invasive, depth-resolution imaging tool of retinal and choroidal vessels adds detailed qualitative and quantitative information of the status of retinal and choroidal vessels and bridges the gap between the mentioned conventional diagnostic tools used in uveitis. It is important, though, to be aware of its limitations, such as its susceptibility to motion artifacts, limited comparability among different devices, and restricted contribution of information regarding the grade of disease activity. CONCLUSION: OCTA as a non-invasive, depth-resolution imaging tool can give qualitative and quantitative information about the status of retinal and choroidal vessels, but also has certain limitations. Employing OCTA as a complementary rather than exclusive tool, it can give important additional information about the macro- and microvasculature under inflammatory circumstances. Thereby, it also contributes to the understanding of the pathophysiology of various uveitis entities.

Effects of Dietary Acute Tryptophan Depletion (ATD) on NPY Serum Levels in Healthy Adult Humans Whilst Controlling for Methionine Supply-A Pilot Study.

Central nervous serotonin (5-HT) can influence behaviour and neuropsychiatric disorders. Evidence from animal models suggest that lowered levels of neuropeptide Y (NPY) may have similar effects, although it is currently unknown whether decreased central nervous 5-HT impact NPY concentrations. Given that the production of NPY is dependent on the essential amino acid methionine (MET), it is imperative to account for the presence of MET in such investigations. Hence, this study sought to examine the effects of acute tryptophan depletion (ATD; a dietary procedure that temporarily lowers central nervous 5-HT synthesis) on serum concentrations of NPY, whilst using the potential renal acid load indicator (PRAL) to control for levels of MET. In a double-blind repeated measures design, 24 adult humans randomly received an AA-load lacking in TRP (ATD) on one occasion, and a balanced control mixture with TRP (BAL) on a second occasion, both with a PRAL of nearly 47.3 mEq of MET. Blood samples were obtained at 90, 180, and 240 min after each of the AA challenges. ATD, and therefore, diminished substrate availability for brain 5-HT synthesis did not lead to significant changes in serum NPY concentrations over time, compared to BAL, under an acute acidotic stimulus.

Studying the effects of dietary body weight-adjusted acute tryptophan depletion on punishment-related behavioral inhibition.

BACKGROUND: Alterations in serotonergic (5-HT) neurotransmission are thought to play a decisive role in affective disorders and impulse control. OBJECTIVE: This study aims to reproduce and extend previous findings on the effects of acute tryptophan depletion (ATD) and subsequently diminished central 5-HT synthesis in a reinforced categorization task using a refined body weight-adjusted depletion protocol. DESIGN: Twenty-four young healthy adults (12 females, mean age [SD]=25.3 [2.1] years) were subjected to a double-blind within-subject crossover design. Each subject was administered both an ATD challenge and a balanced amino acid load (BAL) in two separate sessions in randomized order. Punishment-related behavioral inhibition was assessed using a forced choice go/no-go task that incorporated a variable payoff schedule. RESULTS: Administration of ATD resulted in significant reductions in TRP measured in peripheral blood samples, indicating reductions of TRP influx across the blood-brain barrier and related brain 5-HT synthesis. Overall accuracy and response time performance were improved after ATD administration. The ability to adjust behavioral responses to aversive outcome magnitudes and behavioral adjustments following error contingent punishment remained intact after decreased brain 5-HT synthesis. A previously observed dissociation effect of ATD on punishment-induced inhibition was not observed. CONCLUSIONS: Our results suggest that neurodietary challenges with ATD Moja-De have no detrimental effects on task performance and punishment-related inhibition in healthy adults.