Giant Cell Arteritis. / Riesenzellarteriitis.

Giant cell arteritis (GCA) is the most common primary vasculitis and is associated with potential bilateral blindness. Neither clinical nor laboratory evidence is simple and unequivocal for this disease, which usually requires rapid and reliable diagnosis and therapy. The ophthalmologist should consider GCA with the following ocular symptoms: visual loss or visual field defects, transient visual disturbances (amaurosis fugax), diplopia, eye pain, or new onset head or jaw claudication. An immediate ophthalmological examination with slit lamp, ophthalmoscopy, and visual field, as well as color duplex ultrasound of the temporal artery should be performed. If there is sufficient clinical suspicion of GCA, corticosteroid therapy should be initiated immediately, with prompt referral to a rheumatologist/internist and, if necessary, temporal artery biopsy should be arranged. Numerous developments in modern imaging with colour duplex ultrasonography, MRI, and PET-CT have the potential to compete with the classical, well-established biopsy of a temporal artery. Early determination of ESR and CRP may support RZA diagnosis. Therapeutically, steroid-sparing immunosuppression with IL-6 blockade or methotrexate can be considered. These developments have led to a revision of both the classification criteria and the diagnostic and therapeutic recommendations of the American College of Rheumatologists and the European League against Rheumatism, which are summarised here for ophthalmology.

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.

Clinicopathological Correlation of Microbial Keratitis and Ahead: Is There a Corneal Sepsis? / Zur klinisch-pathologischen Korrelation der mikrobiellen Keratitis und darüber hinaus: Gibt es eine korneale Sepsis?

Microbial, infectious keratitis is a relevant indication for penetrating keratoplasty. The requirement for transplantation results in histopathological examination of the entire thickness of the cornea. Although the clinical diagnosis is not always possible to confirm, pathology can support diagnostic evidence of clinical presentation and pathogenesis. This is achieved with multiple methods from cytology, histochemistry, immunohistology, molecular pathology and in rare cases electron microscopy. These allow tissue-based detection of previous and parallel diseases and the responsible pathogens. The failure of satisfactory clinicopathological correlation raises the question whether a suspected pathogen was not ultimately responsible for destroyed corneal tissue. The pathogenesis of keratitis requiring transplantation is not yet completely understood, also on the experimental level. The development of such a keratitis can lead to a clinical symptomatology which can be described as "threatening organ dysfunction", a term used in sepsis research. Considering recent literature, possible correlations between sepsis and microbial keratitis and their relation to histopathology are discussed.

Open globe and penetrating eyelid injuries from fish hooks.

BACKGROUND: A few case reports have described accidental eye injuries caused by fish hooks. The severity of ocular injuries is dependent on the involved ocular structures. Severe ocular injuries due to fish hooks are rare. We describe open globe and penetrating eyelid injuries from fish hooks at the Baltic Sea. METHODS: Nine patients with traumatic ocular injuries caused by fish hooks were included. The following parameters were evaluated: severity of injury, best corrected visual acuity at admission and last follow-up, and surgical treatment. RESULTS: All nine patients were male. Age ranged between 7 and 51 years with a median of 13 years. Sixty-seven percent of the patients were children. Four of the nine patients were 9 years or younger. In 5 eyes (55%) the injury was limited to the eyelid. An open globe injury was found in 4 patients (45%). The mean follow-up was 16.7 ± 32.8 months. All patients required surgical treatment. The number of operations ranged from 1 to 3, with a mean of 1.4. At admission and last follow-up, patients with eyelid injuries showed a median best corrected visual acuity (BCVA) of logMAR 0.0. Patients with open globe injuries showed a median best corrected visual acuity of logMAR 1.5 at admission, and of logMAR 0.6 at last follow-up. CONCLUSIONS: Nearly half of the patients suffered severe penetrating injuries. Especially children misjudge the risk potential of fishing due to their lack of experience. Fishing glasses should be worn not only for UV protection, but also as injury prevention strategy.

Long-term results of glaucoma drainage device surgery.

BACKGROUND: To evaluate long-term results of eyes with glaucoma drainage device (GDD). METHODS: We retrospectively reviewed medical records of all patients who underwent GDD placement at our institution between 2001 and 2014. A total of 110 eyes of 90 patients were studied. Glaucoma outcome was assessed by postoperative intraocular pressure (IOP), number of medications, and need for further glaucoma surgery. Surgical procedures before and during the study period, and their complications were evaluated. RESULTS: The mean follow-up was 78.3 ± 44.0 months. The mean preoperative intraocular pressure was 30.8 ± 6.9 mmHg with 3.5 ± 1.1 glaucoma medications. At last postoperative follow-up, the mean IOP decreased to 14.3 ± 5.4 mmHg with 1.6 ± 1.5 glaucoma medications. GDD implantation successfully controlled glaucoma in 86, 85, 81, 78, 79, 76 and 73% of eyes at 1, 2, 3, 4, 5, 7 and 10 years, respectively. At last follow-up IOP was successfully controlled in 67% of eyes. Clinical complications occurred in 56.4% of eyes during the follow-up period. CONCLUSIONS: A glaucoma drainage device can successfully control intractable glaucoma even after a very long period of time.

Intravitreal injection of anti-Interleukin (IL)-6 antibody attenuates experimental autoimmune uveitis in mice.

PURPOSE: To evaluate the effect of an intravitreally applied anti-IL-6 antibody for the treatment of experimental autoimmune uveitis (EAU). METHODS: EAU was induced in female B10.RIII mice by Inter-Photoreceptor-Binding-Protein (IRBP) in complete Freund's adjuvant, boosted by Pertussis toxin. Single blinded intravitreal injections of anti-IL-6 antibody were applied 5-7days as well as 8-10days (3day interval) after EAU induction into the randomized treatment eye and phosphate buffered saline (PBS) into the fellow control eye. Clinical and fluorescein angiography scoring (6 EAU grades) was done at each injection day and at enucleation day 14. Enucleated eyes were either scored histologically (6 EAU grades) or examined by ELISA for levels of IL-6, IL-17 and IL-6 soluble Receptor (sIL-6R). RESULTS: Uveitis developed in all 12 mice. Clinical uveitis score was significantly reduced (p=0.035) in treated eyes (median 2.0, range 0-4.0, n=12) compared to the fellow control eyes (median 3.0, range 1.0-4.0, n=12). Angiography scores were reduced in 9/12 treated eyes and histological scores in 3/4 treated eyes compared to the fellow control eyes. Cytokine levels were determined in 8 mice, of which 4 responded to anti-IL-6 treatment and 4 did not respond. All mice responding to treatment had a significant reduction of IL-6 (p<0.01) and IL-17 (p=0.01) levels in treated eyes compared to the fellow control eyes. This difference was not seen in non-responding mice. CONCLUSIONS: Intravitreal anti-IL-6 treatment significantly attenuates experimental autoimmune uveitis in mice. EAU activity correlates with ocular IL-6 and IL-17 levels.

Reduction of GAPDH in lenses of Parkinson's disease patients: A possible new biomarker.

BACKGROUND: We previously showed that the protein pattern of lenses removed in cataract surgery differs between patients with Parkinson's disease and age-matched controls. In this study, we identified the protein reduced in abundance in the 34- to 37-kDa gel band. METHODS: During cataract surgery (phacoemulsification), we collected the rinsing fluid and lens particles from the eyes of PD patients and controls. Residual lens fragments in the supernatant of 3 PD patients and aged-matched controls were studied for protein profiles using liquid chromatography-mass spectrometry and Western blots. RESULTS: We identified glyceraldehyde-3-phosphate dehydrogenase by mass spectrometry as the protein reduced in abundance and verified this finding in Western blots. CONCLUSIONS: Glyceraldehyde-3-phosphate dehydrogenase has been implicated in PD development. The reduction of glyceraldehyde-3-phosphate dehydrogenase in the lenses of PD patients may be a new biomarker for PD and might also indicate an important role for this protein in PD development. © 2016 International Parkinson and Movement Disorder Society.

Clinical presentation and long-term outcome of 144 patients with microscopic polyangiitis in a monocentric German cohort.

OBJECTIVE: To evaluate the clinical presentation and long-term outcome of a vasculitis centre cohort of patients with microscopic polyangiitis (MPA) with respect to organ manifestations, treatment, chronic damage and mortality. METHODS: We performed a retrospective chart review at our vasculitis referral centre. MPA patients admitted between 1991 and 2013 classified by a modified European Medicines Agency algorithm were diagnosed and treated according to a standardized interdisciplinary approach. RESULTS: Comprehensive data from standardized interdisciplinary workups was available for 144 patients (median follow-up 72 months). The overall standardized mortality ratio was 1.40 (95% CI 0.91, 2.07; P = 0.13). We observed a higher mortality [hazard ratio (HR) 4.04 (95% CI 1.21, 13.45), P = 0.02] in 17 patients with MPA-associated fibrosing interstitial lung disease (ILD) and 56 patients with peripheral nervous system involvement [HR 5.26 (95% CI 1.10, 25.14), P = 0.04] at disease onset. One hundred and fifteen patients (79.9%) responded to the initial treatment. Sixty-one (42.3%) achieved complete remission and 54 (37.5%) achieved partial remission. Twenty (13.9%) showed a refractory disease course. CONCLUSION: MPA patients at our tertiary rheumatology referral centre seemed to have a less severe phenotype resulting in a less severe disease course and better outcome than reported in other cohorts. Fibrosing ILD was significantly associated with mortality in this cohort.

Visualization of Keratopathy Associated With the Antibody-Drug Conjugate Belantamab Mafodotin Using Infrared Imaging in Patients With Multiple Myeloma.

PURPOSE: The treatment of patients with relapsed/refractory multiple myeloma (RRMM) with the antibody-drug conjugate belantamab mafodotin is affected by ocular adverse effects, most frequently keratopathy with corneal microcyst-like epithelial changes (MECs). To assess ocular side effects, the "Keratopathy and Visual Acuity (KVA) scale," based on the extent of keratopathy subjectively graded on slit-lamp examination and the change in best corrected visual acuity from baseline, was created. Advanced corneal imaging techniques have been explored to further characterize MECs and identify objective imaging biomarkers. We examined whether infrared reflectance imaging of the anterior segment (AS-IR) could contribute to the assessment, monitoring, and documentation of corneal toxicity in patients treated with belantamab mafodotin. METHODS: In addition to the KVA examination, AS-IR imaging was performed. AS-IR images were evaluated for presence of visible hyporeflective lesions and their spatial and temporal distribution between visits and compared with keratopathy identified on slit-lamp examination. To standardize the assessment, a scoring system for lesions on AS-IR was implemented for additional analysis. RESULTS: Nine patients undergoing treatment with belantamab mafodotin for up to 9 months were examined. All patients exhibited hyporeflective lesions on AS-IR imaging, indicative of corneal toxicity corresponding to MECs observed on slit-lamp examination. AS-IR lesions showed early occurrence, variable quantity and size, and distinct distribution patterns, correlating with clinical findings during treatment. CONCLUSIONS: As shown for belantamab mafodotin, AS-IR imaging represents a fast, noninvasive, supplemental method for documentation, monitoring, and assessment of corneal adverse effects during treatment with antibody-drug conjugates, which may enable more standardized analyses.

A vasculitis centre based management strategy leads to improved outcome in eosinophilic granulomatosis and polyangiitis (Churg-Strauss, EGPA): monocentric experiences in 150 patients.

OBJECTIVE: To evaluate a vasculitis centre based management strategy for eosinophilic granulomatosis and polyangiitis (Churg-Strauss, EGPA). METHODS: A retrospective cohort study at a vasculitis referral centre was performed. All EGPA patients admitted from 1990 to 2009 were included. A structured interdisciplinary work-up for proof of diagnosis, Disease Extent Index and Birmingham Vasculitis Activity Score was performed. Immunosuppressive therapy was initiated and regularly adapted. Treatment targets were induction and maintenance of remission according to definitions given by the European League Against Rheumatism and the European Vasculitis Study Group. Outcomes were mortality, rate of remission, relapses, adverse events and prednisolone-dose. RESULTS: Out of 269 patients with suspected EGPA 150 fulfilled the inclusion criteria. Of those, 104 had more than one follow-up visit resulting in a mean follow up of 53±4.9 months. By using additional data sources the follow-up concerning survival was extended to 92±5 month. Severe organ manifestations occurred at heart (46%), kidney (18%) and lungs (10%). Cyclophosphamide was used in 107 patients (71%). The prednisolone-doses of all patients were within the targeted range (i.e. ≤7.5 mg) in 69% of the total follow-up time; the median dose at end of follow-up was 5mg/d. The 10-year survival rate was 89% resulting in mortality comparable to the general population (SMR 1.29). Only patients with cardiac failure associated with EGPA had an increased mortality (SMR 3.06). CONCLUSIONS: Regular re-evaluation and target-orientated adaption of therapy may lead to normalization of life expectancy and attenuation of disease progression. Continued centre based interdisciplinary treatment should be standard of care.

Orbital masses in granulomatosis with polyangiitis are associated with a refractory course and a high burden of local damage.

OBJECTIVES: To identify and characterize patients with orbital masses in a monocentric cohort of 1142 GPA patients followed up from 1990 until the end of 2010 with regard to disease stage, local orbital inflammation, course of disease and outcome and to assess the efficacy of immunosuppressive treatment. METHODS: All GPA patients fulfilling ACR criteria or Chapel Hill Consensus Conference definitions or who had localized GPA and who developed orbital masses were evaluated regarding the course and outcome of the orbital masses (assessed by MRI, ophthalmologist and ENT specialist), all other clinical manifestations, disease stages, ANCA status, immunosuppression and its side effects and surgical procedures. RESULTS: Of 1142 GPA patients 58 developed orbital masses during a median follow-up of 101.5 months (range 23-255 months). Forty patients fulfilled the inclusion criteria and had complete clinical assessments [44% females, median age 43 (20-74) years, 85% ANCA positive]. Seventy-five per cent (29/40) had systemic disease when orbital masses occurred; both orbits were affected in 30%. Seventy-two per cent had evidence of infiltration from paranasal sinuses. Under highly potent immunosuppression (mostly CYC and glucocorticoids), 41% were refractory, 24% had unchanged activity, 24% showed a response and 8.1% had complete remission. Forty-four per cent had relapses of orbital masses. Seventy-two per cent developed visual impairment, 19% suffered blindness. Blindness was associated with a longer time to remission and a relapsing and refractory course. CONCLUSION: Orbital masses are a rare manifestation of GPA and are characterized by a refractory course and by a high rate of local damage. Patients with a refractory or relapsing course are at higher risk of developing blindness.

Improved outcome in 445 patients with Wegener's granulomatosis in a German vasculitis center over four decades.

OBJECTIVE: To determine the long-term outcome in patients with Wegener's granulomatosis (WG) over 4 decades in an academic hospital unit specializing in rheumatology. METHODS: We included 290 patients, divided them into 2 cohorts, and compared them with the historical cohort of 155 patients. Comparisons were retrospective regarding disease manifestations, therapy, mortality, and incidence of malignancies. The historical cohort (cohort 1) included 155 patients diagnosed between 1966 and 1993, cohort 2 included 123 patients diagnosed between 1994 and 1998, and cohort 3 included 167 patients diagnosed between 1999 and 2002. RESULTS: Over time, the interval between first symptoms and diagnosis was reduced by half (from 8 months to 4 months). Organ manifestations were similar in the 3 cohorts, and more than 80% of patients still required cyclophosphamide (CYC); however, the median cumulative dose was reduced significantly (from 67 gm in cohort 1 to 36 gm in cohort 2 and to 24 gm in cohort 3). The standardized mortality ratios (SMRs) declined (from 2.1 in cohort 1 to 1.41 in cohort 2 and to 1.03 in cohort 3), with fewer deaths related to WG and/or therapy (86.4% in cohort 1, 76.9% in cohort 2, 50% in cohort 3), decreasing relapse rates (63.9% in cohort 1, 51.2% in cohort 2, 35.3% in cohort 3), and no increased rate of malignancies. Compared with young females, young males had a considerably higher SMR (8.87 [95% confidence interval 4.05-16.8]) and more frequent renal manifestations (54.4% versus 33.8%). CONCLUSION: Mortality of WG patients declined over the last 4 decades, probably due to improved diagnostic and therapeutic procedures and increased awareness of WG, which led to earlier diagnosis and therapy, reduction in relapse rates, and lower cumulative CYC dose with fewer deaths related to therapy.

Ten-Year Outcome of Glaucoma Drainage Device Surgery After Penetrating Keratoplasty.

PRECIS: In eyes with intractable glaucoma, drainage devices provide long-term control of intraocular pressure also after penetrating keratoplasty (PK). There is a high incidence of corneal graft failure. PURPOSE: To compare very long-term results of eyes with glaucoma drainage device (GDD) after PK. METHODS: We retrospectively reviewed medical records of all patients who underwent GDD placement after PK at our institution between 2001 and 2017. Forty eyes of 40 patients were studied. Glaucoma outcome was assessed by postoperative intraocular pressure (IOP), number of medications, and need for further glaucoma surgery. Corneal outcome was assessed by graft rejection, failure, and visual acuity. Surgical procedures before and during the study period, and their complications were evaluated. RESULTS: The mean follow-up was 125.0±52.3 (median, 116.5) months. Twenty of 40 eyes had a follow-up of at least 10 years. The mean preoperative IOP was 34.0±8.3 (median, 32.0) mm Hg with 3.2±1.3 (median, 3.5) glaucoma medications. At last postoperative follow-up, the mean IOP decreased to 12.7±4.9 (median, 14.0) mm Hg with 1.0±1.2 (median, 0.0) glaucoma medications. GDD implantation successfully controlled glaucoma in 88%, 88%, 85%, 80%, 78%, 75%, and 70% of eyes, at 1, 2, 3, 4, 5, 7, and 10 years, respectively. At last follow-up 68% showed glaucoma success. The corneal grafts remained clear in 74%, 63%, 45%, 45%, 37%, 32%, and 26% of eyes at 1, 2, 3, 4, 5, 7, and 10 years, respectively. Only 7 corneal grafts (17.5%) remained clear at last follow-up. CONCLUSIONS: A GDD can successfully control intractable glaucoma even after a very long period of time also after PK. However, the survival of the corneal grafts is low.

SARS-CoV-2: Impact on, Risk Assessment and Countermeasures in German Eye Banks.

INTRODUCTION: Since the beginning of the COVID-19 pandemic there has been some debate regarding the risk of transmission through tissue transplantation and tissue banking processes. AIM OF THE STUDY: To analyze the changes that SARS-CoV-2 has caused regarding the harvesting of corneal donor tissue and eye bank activities in Germany. METHODS: A questionnaire was provided to 26 eye banks in Germany, consisting of questions about adaptations made in the screening of potential donors and the harvesting of corneal tissue following the pandemic spread of SARS-CoV-2. RESULTS: Eighteen eye banks actively reduced recruitment of donors and two banks ceased all activity. Additional diagnostic screening was performed in eight banks, using conjunctival swabs and/or nasopharyngeal swabs. In six eye banks, additional protective measures, such as FFP2 masks and/or facial shields, were implemented. Overall, a mean reduction in the number of obtained donor tissues of 17% was observed. DISCUSSION: Conjunctival and/or nasopharyngeal swabs of donors have been implemented by a minority. Reasons for not performing additional tests may be moderate sensitivity and lack of validation for postmortem use of RT-PCR testing. Also, the hazard of SARS-CoV-2 entering the corneal donor pool with subsequent transmission might be perceived as theoretical. Face shields provide a sufficient barrier against splash and splatter contamination but may be insufficient against aerosols. Additional face masks would provide support against aerosols, but it remains debatable if corneal harvesting can be considered an aerosol-producing procedure. In the future we expect to see changes in current guidelines because of a surge in scientific activities to improve our understanding of the risks involved with cornea donation in the COVID-19 pandemic, and because current practice may reduce the availability of donor corneas due to new exclusion criteria while the demand remains unchanged.

Acute retinal necrosis: clinical features, early vitrectomy, and outcomes.

OBJECTIVE: To determine the viral diagnosis and the outcome of eyes with acute retinal necrosis (ARN) treated with intravenous acyclovir and oral prednisolone alone or combined with early vitrectomy and intravitreal acyclovir lavage. DESIGN: Nonrandomized, retrospective, interventional, comparative, consecutive series. PARTICIPANTS: A cohort of 27 human immunodeficiency virus-negative patients with ARN comprising 24 unilateral and 3 bilateral cases. INTERVENTION: Vitreous biopsy for viral diagnosis. Twenty eyes were treated with intravenous acyclovir in combination with oral prednisolone (group A). Ten eyes were treated additionally with early vitrectomy, intravitreal acyclovir lavage, laser demarcation of necrotic retinal areas when feasible-with or without scleral buckling, and gas or silicone oil tamponade (group B). Vitrectomy was performed in all cases of secondary rhegmatogenous retinal detachment (RD). MAIN OUTCOME MEASURES: Results of vitreous biopsy, rate of RD, rate of phthisis bulbi, and course of best-corrected visual acuity (BCVA). RESULTS: Varicella zoster virus (VZV) was detected in 26 eyes, followed by herpes simplex virus (5 eyes), and Epstein-Barr virus (2 eyes, in conjunction with VZV). An RD developed in more eyes in group A (18 of 20 eyes) than in group B (4 of 10 eyes; P = 0.007). In 2 of 20 eyes in group A and in 0 of 10 eyes in group B, phthisis bulbi developed without a significant difference between groups A and B. Mean BCVA (logarithm of the minimum angle of resolution) at first visit was 1.09 (standard deviation [SD], 0.83), and mean final BCVA was 1.46 (SD, 0.88) without significant difference between groups A and B. CONCLUSIONS: Varicella zoster virus is the leading cause of ARN. Visual prognosis is guarded. Early vitrectomy with intravitreal acyclovir lavage was associated with a lower incidence of secondary RD; however, it did not improve mean final visual acuity.

Implantation of retropupillar iris claw lenses with and without combined penetrating keratoplasty.

BACKGROUND: For aphakic patients without lens-supporting apparatus, secondary lens implantation can be considered. Literature on retropupillar iris claw lens implantation as a safe alternative to scleral fixated posterior chamber lenses is scarce. METHODS: The study included 22 patients. In ten cases, an iris claw lens was implanted retropupillary without penetrating keratoplasty (group 1), in 12 patients the implantation of a retropupillar iris claw lens was combined with penetrating keratoplasty (group 2). Complications observed were retrospectively evaluated. Previous operations and accompanying diseases were compiled. Reasons for aphakia in group 1/group 2 included perioperative complications (60%/75%) and primary ocular trauma (40%/25%). Unless already performed in an earlier operation, anterior or complete vitrectomy was performed in both groups. RESULTS: Perioperative complications (within 1 week postoperatively) in group 1 included ocular hypotony in 20%, choroidal detachment in 10%, vitreous haemorrhage in 10% and intraocular lens (IOL) decentration in 10% of the cases; in group 2, transient intraocular pressure elevation in 8% of the cases. Postoperative complications (after the first postoperative week) in group 1 were lens tilt in 10%, lens luxation in 10%, cellular deposits (assumed to be macrophages) on lens surface in 10%, cornea guttata in 10% and epiretinal gliosis in 10% of the cases; in group 2, secondary glaucoma in 33%, iris defect in 8% and corneal ulcer in 8% of the cases. CONCLUSIONS: Retropupillar iris claw lenses are an alternative to scleral fixated secondary lenses, which are worth considering for aphakic patients without lens supporting apparatus. This approach appears to be recommendable even in cases requiring penetrating keratoplasty, and can be performed as a combined procedure. In these patients, the most frequent complication following iris claw lens implantation seems to be secondary glaucoma.

Anti-inflammatory and immunosuppressive concepts.

BACKGROUND/PURPOSE: Patients with symptomatic dry eyes are frequently seen by every ophthalmologist. Understanding of the plethora of factors involved in sicca syndrome is essential to substantially help the patient. Besides important and frequent topical treatment options, anti-inflammatory and immunosuppressive systemic treatment concepts sometimes play an additional role. MATERIAL AND METHODS: Relevant data of publications listed in Medline between 1966 and 2006 are analyzed. RESULTS: Local treatment options are listed, immunosuppressive substances are shortly characterized with regard to action, side effects, and control parameters. An overview of new applicable biological substances is given. CONCLUSIONS: A variety of treatment options can be offered to patients with dry eyes. The spectrum ranges from lubricants to systemical immunosuppressive substances. At present no official guidelines replace individual strategies to treat the patient. An escalation of treatment options has to be performed with individual experience.

Detection of surfactant proteins A and D in human tear fluid and the human lacrimal system.

PURPOSE: To evaluate the expression and presence of surfactant protein (SP) A and SP-D in the lacrimal apparatus, at the ocular surface, and in tears in healthy and pathologic states. METHODS: Expression of mRNA for SP-A and SP-D was analyzed by RT-PCR in healthy lacrimal gland, conjunctiva, cornea, and nasolacrimal ducts as well as in a spontaneously immortalized conjunctival epithelial cell line (HCjE; IOBA-NHC) and a SV40-transfected cornea epithelial cell line (HCE). Deposition of SP-A and SP-D was determined by Western blot, dot blot, and immunohistochemistry in healthy tissues, in tears, aqueous humor, and in sections of different corneal abnormalities (keratoconus, herpetic keratitis, and Staphylococcus aureus-based ulceration). Cell lines were stimulated with different cytokines and bacterial components and were analyzed for the production of SP-A and SP-D by immunohistochemistry. RESULTS: The presence of SP-A and SP-D on mRNA and protein levels was evidenced in healthy lacrimal gland, conjunctiva, cornea, and nasolacrimal duct samples. Moreover, both proteins were present in tears but were absent in aqueous humor. Immunohistochemistry revealed the production of both peptides by acinar epithelial cells of the lacrimal gland and epithelial cells of the conjunctiva and nasolacrimal ducts, whereas goblet cells revealed no reactivity. Healthy cornea revealed weak reactivity on epithelial surface cells only. In contrast, SP-A and SP-D revealed strong reactivity in patients with herpetic keratitis and corneal ulceration surrounding lesions and in several immigrated defense cells. Reactivity in corneal epithelium and endothelium was also seen in patients with keratoconus. Cell culture experiments revealed that SP-A and SP-D are produced by both epithelial cell lines without and after stimulation with cytokines and bacterial components. CONCLUSIONS: These results show that SP-A, in addition to SP-D, is a peptide of the tear film. Based on the known direct and indirect antimicrobial effects of collectins, the surfactant-associated proteins A and D seem to be involved in several ocular surface diseases.