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Toxoplasma gondii, Treponema pallidum and Mycobacterium tuberculosis are the most important infectious causes of posterior uveitis. The epidemiology, clinical picture, diagnostic and treatment strategies of these diseases are presented.Infektionen mit Toxoplasma gondii, Treponema pallidum und Mycobacterium tuberculosis sind nach wie vor die wichtigsten infektiösen Ursachen einer posterioren Uveitis. Epidemiologie, klinisches Bild, Diagnostik und Therapie dieser Krankheitsbilder werden dargestellt.

A 60 years old woman experienced a cat scratch 34 months ago on the left eyelid. Chronic, progredient skin lesions and headache developed. Treatments with cortisone, pimecrolimus, pregabalin and metamizole were not successful. After 24 months the patient complained of severe bulbus pain in the left eye, increased eye movement pain, and high photosensitivity. There were granulomatous papules in the area of the eye.The interdisciplinary examination findings and clinical-chemical parameters were inconspicuous. A biopsy of the eyelid area revealed the detection of Delftia acidovorans by bacterial 16S-rRNA-PCR.Treatment with piperacillin/tazobactam 3 × 4.5 g/d IV for 10 days led to rapid clinical improvement, so that the patient could be discharged after 11 days. After additional 10 months, she had no relapse and was free of complaints.D. acidovorans has not yet appeared as a zoonotic pathogen but should be included in the case of injury by animals in the differential diagnostic considerations.Die 60-jährige Patientin wurde vor 34 Monaten von ihrer Katze am linken Augenlid gekratzt. Danach kam es zu chronischen, langsam progredienten Hautveränderungen mit sich verstärkenden Kopfschmerzen. Therapieversuche mit Kortison, Pimecrolimus, Pregabalin und Metamizol waren erfolglos. Nach 24 Monaten klagte sie über starken Bulbus-Schmerz am linken Auge, zunehmende Schmerzen bei Augenbewegungen und große Lichtempfindlichkeit. Es zeigten sich granulomatöse Papeln im Bereich des Auges.Die interdisziplinären Untersuchungsbefunde und klinisch-chemischen Parameter waren unauffällig. Eine Biopsie aus dem Lidbereich erbrachte den Nachweis von Delftia acidovorans mittels bakterieller 16S-rRNA-PCR.Unter der Therapie mit Piperacillin/Tazobactam 3-mal 4,5 g/d i. v. für 10 Tage kam es zu einer raschen klinischen Besserung, sodass die Patientin nach 11 Tagen entlassen werden konnte. Nach weiteren 10 Monaten war sie rezidiv- und beschwerdefrei.D. acidovorans ist bislang nicht als zoonotischer Erreger in Erscheinung getreten, sollte aber bei Verletzungen durch Tiere in die differenzialdiagnostischen Erwägungen einbezogen werden.

Infections can affect all structures of the eye. This article focuses on corneal and uveal infections, and on endophthalmitis. The typical pathogens, the signs and symptoms and the therapy are presented.HORNHAUTENTZüNDUNG (KERATITIS): Eine Keratitis kann durch viele unterschiedliche Erreger verursacht werden. INFEKTIöSE UVEITIS: Bei der infektiösen Uveitis zeigen sich vermehrt alte Infektionen wie die Syphilis oder die Tuberkulose, aber auch lokale Infektionen mit Protozoen oder Viren. ENDOPHTHALMITIS: Die Endophthalmitis als Komplikation von intraokularen Eingriffen gewinnt durch die Zunahme der Kataraktoperationen und vor allem der intravitrealen Medikamentengabe immer mehr an Bedeutung.

Presentation of 3 cases of intraocular inflammation: 1. 47-year old female patient with severe necrotising scleritis and uveitis with underlying granulomatous polyangiitis (formerly known as Wegener granulomatosis, in honour of the German pathologist Friedrich Wegener), known for 10 years. 2. 48-year old male patient with longstanding bilateral uveitis and granulomatous polyangiitis for 2 years. In the histopathological examination of the enucleation specimen, a retrolental tumour turned out to be a granuloma. 3. 57-year old male patient in status post renal transplantation with intraocular cellular infiltration suspicious for lymphoma, which surprisingly proved to be Toxoplasma gondii-associated uveitis. The clinical course and characteristic histological signs and therapeutic options are discussed.

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.

A number of "new" (emerging) infections that can also cause inflammatory eye changes are appearing and becoming increasingly important. In the past, diseases such as chikungunya, dengue fever or West Nile virus infections were endemic in tropical regions, but are now expanding worldwide and causing significant morbidity and even mortality. "Globalization" and human migration are important factors leading to the import of these infections. Climate changes are probably even more important. Increasing temperatures provide suitable conditions for new vectors, and may lead to autochthonous transmission of infectious pathogens. Diagnosis of these diseases requires not only careful assessment of medical and travel history, but also the application of specific laboratory diagnostic tests. A broad spectrum of ocular involvement has been reported, with frequent posterior segment involvement. Emerging infections should therefore be considered in the differential diagnosis of retinitis, chorioretinitis, retinal vasculitis and optic neuropathy in a patient living in or traveling back from an endemic area. Since these infections are often vector (insect) borne and effective treatments are almost uniformly lacking, prevention is at least as important as prompt diagnosis and initiation of supportive care. Here, we focus on Chikungunya, Dengue fever, Ebola fever, the West Nile virus and Rickettsioses, which frequently demonstrate ocular involvement.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare severe and often life-threatening reactions of the skin and mucous membranes. They are considered as a single disease entity with different expressions of severity and are summarized under the term epidermal necrolysis (EN). There is a high risk of ocular involvement, which can lead to long-lasting eye problems and even blindness without immediate ophthalmological treatment. The acute occurrence, the unpredictable course and extreme variation in the manifestation of complications require an interdisciplinary approach. A rapid diagnosis of eye involvement and initiation of an intensive lubricating and anti-inflammatory surface treatment is of utmost importance for the long-term outcome. This article should help ophthalmologists to have a better understanding of this condition and therefore lead to substantial improvement in visual outcome and the quality of life of patients.Das Stevens-Johnson-Syndrom (SJS) und die toxisch epidermale Nekrolyse (TEN) sind seltene, schwere und oft lebensbedrohliche Reaktionen der Haut- und der Schleimhäute. Sie werden als eine Krankheitsentität verschieden schwerer Ausprägung angesehen und unter dem Begriff epidermale Nekrolyse zusammengefasst. Es besteht ein hohes Risiko okulärer Beteiligung, die ohne eine rasche, adäquate ophthalmologische Behandlung zu langwierigen Augenproblemen bis zur Erblindung führen kann. Das akute Auftreten, der unvorhersagbare Verlauf und die stark variierende Manifestation der Komplikationen erfordern einen interdisziplinären Ansatz. Eine rasche Diagnosestellung und Einleitung einer antiinflammatorischen oberflächenwirksamen Behandlung ist von großer Bedeutung für das Langzeitergebnis. Dieser Beitrag soll dem Verständnis dieser Reaktionsformen dienen und so zu einer Verbesserung der visuellen Rehabilitation und Lebensqualität der Patienten führen.

Infectious aetiologies represent the largest entity in patients affected by posterior uveitis. As a single diagnosis, ocular toxoplasmosis ist the most frequently diagnosed infectious entity, wheres Behçet's uveitis represents the most frequently encountered immunologic aetiology. In acute posterior uveitis, an exact clinical diagnosis is sometimes prohibited by a dense vitreal infiltration. In this situation, the clinical course and progression of the disease may help in the differential diagnosis. Rapidly progressive instances such as viral retinal necrosis may be differentiated from cases of ocular toxoplasmosis and Behçet's disease, which tend to present in the office within one to two weeks of symptoms, and from other more slowly progressive diseases such as mycotic or nematode infections. The clinical picture at presentation is influenced by the duration of disease, underlying systemic conditions, and by the natural course of disease including the healing process and scare formation. Generally, visual function has to be assumed at risk, if a lesion is located close to the macula, if frequent recurrences increase the likelihood of macular involvement and, furthermore, if secondary complications affect the macula, e. g., macular oedema. In paediatric cases, the risk of amblyopia is frequently under-estimated, namely in the context of persistent dense vitreal infiltration. Therefore, a rapid interdisciplinary clinically tailored diagnostic access has to be reinforced in order to establish an early, targeted and etiologically based therapeutic strategy including steroid-sparing immunomodulating agents and possibly surgical alternatives.

Biologics are increasingly being used in the treatment of non-infectious sight-threatening uveitis. While the advantages of biologics, such as avoidance of glucocorticoid side-effects or rapid control of intraocular inflammation therapy refractive to corticosteroids, cannot be dismissed the treating ophthalmologist should be aware of the specific risks. Biologics increase the risk for severe and atypical infections, lymphomas and other malignancies. Treatment should only be initiated when profound knowledge about indications, management and monitoring of treatment with biologics is readily available. Weighing up the risks versus the benefits should be made on an individual basis and guide patient consultation.

Besides antimetabolites (5-fluorouracil [5-FU]), cytostatic agents (mitomycin C [MMC]) and topical steroids, various substances have been used for the modulation of wound healing in filtering glaucoma surgery. The anti-inflammatory effects of hyaluronic acid and its space-occupying properties may be useful in filtering as well as in non-filtering glaucoma surgery.In a non-randomised pilot study cross-linking hyaluronic acid (HealaFlow) was injected below the scleral flap and under the conjunctiva in 66 patients undergoing filtering surgery. All 66 patients (age 70.3 +/- 9.6 years; 41 - 88) had a standard trabeculectomy with MMC (0.25 % for 3 min). Glaucoma diagnoses were pseudoexfoliation glaucoma in 32 cases, primary open-angle glaucoma in 32 cases, ICE syndrome in one case and Axenfeld/Rieger in one case.Intraocular pressure (IOP) levels were reduced from preoperatively 22.3 +/- 6.0 mmHg (12 - 40) with 2.7 +/- 1.0 (1 - 4) IOP-lowering medications to 11.9 +/- 5.1 mmHg (2 - 26) after 29.8 +/- 12.4 weeks (13 - 56) follow-up. Fifty-nine of the 66 patients (89.4 %) did not need IOP lowering medications at the end of the follow-up, 52 / 66 patients (78.8 %) had an IOPor = 14 mmHg, 47 of these 52 patients (90.4 %) without medication. Argon laser suturolysis had to be performed in 28 / 66 eyes (42.4 %), 40 / 66 patients (60.6 %) required 1 - 4 subconjunctival injections of 15 mg (0.3 mL) 5-fluorouracil.Injections of HealaFlow below the scleral flap and the conjunctiva at the end of the surgery along with intraoperative application of MMC showed promising IOP-lowering effects in trabeculectomy. A prospective randomised study is required to confirm these preliminary results.

Microscopic polyangiitis (mPA) is one of the ANCA-associated primary systemic vasculitides. It is defined as necrotic vasculitis without granuloma development and without minimal immuno-depots in situ. The clinical picture is characterised by destruction of the small vessels with the main manifestations in the upper and lower respiratory tract, in the lungs and kidneys. The eye manifestations were noted yet not so often.There were 2 clinical cases, aged 5-12 years, with primary eye manifestations of the mPA. The initial oedema and the reddening of the lid area were common to all the patients. The diagnostic excisions of the inflammatory tumour of the anterior orbital area have shown histologically vasculitis of the small vessels. mPA was diagnosed by clinical and immunological parameters, including the examination of the respiratory tract and kidneys.In inflammatory orbital pseudotumour, diagnostic excision and evaluation of the immunological parameters are useful for the exclusion of a systemic vasculitis. Proper examinations must be performed to determine other possible organ manifestations. Prognosis is characterised by the severity of kidney involvement. Early immunosuppressive therapy is crucially important for survival prognosis.

Laser in situ keratomileusis (LASIK) is an effective option and currently one of the most commonly applied surgical techniques in the correction of refractive errors such as myopia, hyperopia, and astigmatism. In contrast to photorefractive keratectomy, it maintains the integrity of Bowman's membrane and the epithelium leading to faster visual rehabilitation as well as less pain and discomfort. Nevertheless, following LASIK the stroma is exposed to infectious organisms. Sight-threatening complications after LASIK are reported to be as rare as 1 in 1000 procedures. However, any infectious keratitis remains potentially devastating. Reports about infectious keratitis following LASIK have increasingly surfaced in recent years. We present a review of the literature on microbial keratitis and present our own cases and recommendations for possible prophylaxis and therapy.

We present the current concepts for the use of anti-infectives parallel to surgery of traumatic eye injuries.Data from the national and international literature were collected using the PubMed, Medline, Drugs and Pharmacology, ISI, and Cochrane databanks. In addition, the experience from our tertiary center was taken into consideration.For palpepral and globe injuries prophylactic and therapeutic anti-infectives are recommended as supporting measures to surgical repair. These include antiseptics (PVP-iodine), antibiotics (cefuroxime, vancomycin, ceftazidime), antimycotics (voriconazole) and anti-inflammatory substances (prednisolone).Several drugs are useful for the prevention and/or treatment of infection following eye injury.

The close localization of the paranasal sinuses both to the brain and the orbit can even today lead to severe and potentially lethal complications in patients with sinusitis. These incidents are rare, however, they should be duly diagnosed and treated since fatal outcome is described in 5-10% of cases. Current diagnosis and therapy for acute inflammatory complications and mucoceles of paranasal sinuses are presented in this article.

The so-called focal infections are today considered to be poly-etiologic manifestations, in which there is a summation of various aggressions. The concept of focal infection is still not exactly defined. Bacterial products, toxic or antigenic substances originating from different foci are but one of the elements susceptible of unleashing the disease. This explains why there are so many foci and so few results after their elimination. The diagnosis of chronic tonsillitis or occult sinusitis especially concerning a focal disease is sometimes difficult. The ENT-specialist is responsible for both the detection of a focus in the head and neck region and its operative treatment. The interrelationship between a focal infection and its actual secondary disease must be diagnosed by the primarily inquired doctor. The diagnosis and the treatment of focal infections of the head and neck region are an interdisciplinary problem.

Not every patient who consults his physician because of reddening, pain, burning or itching sensation in an eye suffers from a bacterial or viral infection of the anterior eye segments. The sicca-syndrome mainly occurring in the elderly leads often to chronic reddening and a disturbing sensation of a foreign body in the eye. Allergic manifestations are often a cause for swelling and reddening of the conjunctiva. If next to reddening a rapidly progressing deterioration of vision develops, eventually accompanied by nausea and vomiting acute glaucoma has to be considered. In uveitis the patient mainly complains about sensations of dazzling, reduced visual acuity and pain, reddening of the conjunctiva may be variable. If in addition to acute hyperemia also a yellow-whitish infiltrate of the cornea is observed a bacterial ulcer of the cornea may be suspected. In this case an ophthalmologist has to be consulted without delay. Viral inflammations are often a diagnostic and therapeutic challenge. If reduced sensibility of the cornea is observed, herpetic infection should be considered.

The polymerase chain reaction (PCR) is a relatively new molecular biology-based technique that allows the specific identification of small amounts of DNA or RNA. This technique offers significant advantages compared to conventional microbiological tests, such as microscopy or culture. Increasing numbers of immunosuppressed patients with intraocular infections and, improvements in antibiotic therapy for specific organisms require a more accurate diagnosis. PCR is capable of providing such requirements. This technique is evolving rapidly and in cooperation with clinicians and molecular biologists a number of applications are being developed, which contribute to the growing demands on microbiological testings. This article describes the basics, indications and the limitations of the polymerase chain reaction.

Inflammatory eye diseases in Aids patients are common. For CMV-retinitis an incidence of up to 45% is reported in the literature. Other retinal diseases such as acute retinal necrosis are less common but are difficult to treat and often follow a disastrous course. Ocular lues may present very different clinical pictures and is the great "imitator" in AIDS patients as well. In toxoplasmosis the typical chorioretinal scars next to the acute inflammatory infiltrates are commonly absent. Infections with candida occur in i.v. drug-addicts in particular. Bacterial corneal ulcers and herpetic keratitis are not more common in HIV-positive patients than in immunocompetent individuals, but the course of the disease is often more severe and prolonged. In patients with low CD4 counts Microsporus can cause painfull keratitis. Mollusca contagiosa are more common in AIDS patients and show the typical lesions, though these are greater in number (commonly more than 20) or in unusual localizations (mucous membrane).

The physiological mechanisms for the protection of the eye are only partly known. It becomes increasingly evident that the eye is supervised by and included in the immune system of the body. The physiological protection system of the eye consists of a mechanical and an immunological component. The lacrimal gland plays a key role for the immune system of the anterior segment. It is part of the MALT system, and the characterisation of the special ocular components of this system-including possible homing receptors-will give important informations. Research of the ocular immune system has disclosed various special features, like the anterior chamber associated immune deviation (ACAID). The distribution of antigen presenting cells and its localization, but also the distribution of T- and B-lymphocytes is an important factor for limiting ocular inflammation. The phenomenon of 'apoptosis' seems to have an important role in maintenance of the ACAID. The cornea is nearly free of cells, and infiltrating antigen presenting cells may prevent ACAID. Research regarding mechanisms which are used to tuned these various cells will give answers to the questions how the cornea contains its optical transparency, how corneal transplant rejection works, how the eye participates in systemic disorders and may also define the role of a possible dysfunction of antigen presenting cells of the retinal pigment epithelium in senile maculopathy.

Some ocular infections, only rarely seen in otherwise healthy individuals, are sometimes seen in patients with immunodeficiencies, i.e., with HIV infection. A typical example is the ophthalmic zoster or luetic uveitis in young individuals which should always imply the possibility of HIV infection. The so called opportunistic infections in contrast are only seen in HIV infection defining the AIDS syndrome. These infections are systemic in origin and only secondarily affecting the eye. Consequently, a therapy concept for these diseases should be developed always involving both, the ophthalmologist and the general physician. Pathogens causing ocular infections are cytomegalovirus (CMV), cryptococcus, pneumocystis carinii, mycobacteria, toxoplasma gondii, histoplasma capsulatum and candida albicans. Under these, CMV retinitis is the commonest infection affecting nearly 20% of all AIDS patients. The clinical findings and therapy of the most frequent ocular infections are discussed and a scheme for the care of these patients introduced.

The possible causes of intraocular infections after microsurgical operations on the eye are discussed. Extensive experiments were carried out to investigate infection caused by the patient himself, by the surgeon and by the surgical surroundings. To consider the different aspects involved in "perioperative prophylaxis", we examined the preoperative, intra- and postoperative periods. Conjunctival diagnostics, disinfection of the conjunctival sac, and the operating area were investigated for the preoperative period. Microbiological examinations were carried out to check the possibility of contamination of eye drops, the operating theatre equipment, and of microscopes, etc. The sterilization of microsurgical instruments using different procedures was checked in particular. During the intraoperative period surgical clothing like face masks, gloves and gowns were examined. Sterile sheets for the patient, including an analysis of the respiratory air under the sheet, were monitored. The results are evaluated with respect to their significance for perioperative prophylaxis and the practical consequences for optimal prevention of infection.

Seventy percent of patients with AIDS have AIDS-related ocular involvement. This is a special challenge for the ophthalmologist which requires specific knowledge. The nature and frequency of the ocular involvement as well as the time of manifestation during the HIV-disease are discussed. The potential therapy for such opportunistic infections is discussed. Furthermore, the HIV-specific aspects for disinfection procedures in the office (tonometry, three-mirror lens, contact lenses) are also elucidated.