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Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Recent analyses have shown that in health services research in Germany, healthcare organisations are often considered primarily as a study setting, without fully taking their complex organisational nature into account, neither theoretically nor methodologically. Therefore, an initiative was launched to analyse the state of Organisational Health Services Research (OHSR) in Germany and to develop a strategic framework and road map to guide future efforts in the field. This paper summarizes positions that have been jointly developed by consulting experts from the interdisciplinary and international scientific community., Methods: In July 2023, a scoping workshop over the course of three days was held with 32 (inter)national experts from different research fields centred around OHSR topics using interactive workshop methods. Participants discussed their perspectives on OHSR, analysed current challenges in OHSR in Germany and developed key positions for the field's development., Results: The seven agreed-upon key positions addressed conceptual and strategic aspects. There was consensus that the field required the development of a research agenda that can guide future efforts. On a conceptual level, the need to address challenges in terms of interdisciplinarity, terminology, organisation(s) as research subjects, international comparative research and utilisation of organisational theory was recognized. On a strategic level, requirements with regard to teaching, promotion of interdisciplinary and international collaboration, suitable funding opportunities and participatory research were identified., Conclusions: This position paper seeks to serve as a framework to support further development of OHSR in Germany and as a guide for researchers and funding organisations on how to move OHSR forward. Some of the challenges discussed for German OHSR are equally present in other countries. Thus, this position paper can be used to initiate fruitful discussions in other countries., Competing Interests: LA ist Vorstandsmitglied der DGMS und des DNVF. Sie ist Mitglied des Editorial Boards des Journal of Health Care Services and Implementation. JB erhält Fördermittel für mehrere OVF-Projekte in Australien und Europa. ME ist Vorsitzender der Society for Studies in Organizing Healthcare (SHOC). Die Arbeit des Instituts für Arbeitsmedizin, Sozialmedizin und Versorgungsforschung, Universitätsklinikum Tübingen, wird durch einen zweckungebundenen Zuschuss des Arbeitgeberverbands der Metall- und Elektroindustrie Baden-Württemberg (Südwestmetall) unterstützt. Die übrigen Autor*innen erklären, dass keine Interessenkonflikte bestehen., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Competing Interests: The authors declare that they have no conflict of interest./Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Background: The swinging flashlight test is a standard diagnostic procedure to detect relative afferent pupillary defects. The advantages of the test lie within its objectivity and minimal effort. However, its value depends on its correct execution and interpretation. This questionnaire-based survey investigates whether this is given among German speaking ophthalmologists., Methods: A multiple-choice questionnaire with 14 questions on the use of the swinging flashlight test was designed. It was presented to German speaking ophthalmology specialists (primary data) and orthoptists (secondary data) on specialist conferences or by telephone interviews., Results: 249 ophthalmologists and 76 orthoptists participated in the survey. Only 2% of ophthalmologists answered all 14 questions correctly. On average 66% (range 29 - 100%) of the questions were answered correctly by the ophthalmologists. The question with the lowest result had a rate of 19%, the question with the highest result was correctly answered by 95%. The orthoptists achieved similar results., Conclusion: The rate of correct answers appears disturbingly low. The swinging flashlight test being a basic tool and an obligatory test in a number of guidelines should rather be performed nearly error-free. In light of the high error rates, misdiagnoses and treatment errors must be feared. Better training seems necessary., Competing Interests: The authors declare that they have no conflict of interest./Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: It has been assumed that visual field defects in optic disc drusen slowly increase with age or occur during adolescence and do not change substantially in later years. In our study, we aimed to validate these assumptions., Material and Methods: 255 consecutive cases with optic disc drusen were identified from the patient records of the University Eye Hospital Tübingen; the diagnosis was verified and visual fields were quantified as long as available and of sufficient quality. Additionally, visual acuity was evaluated., Results: In 104 cases, quantifiable visual fields of sufficient quality for both eyes were available. In general, few patients with marked visual field defects could be detected. Only three patients showed visual field defects of ≥ 50% in both eyes. Both eyes were usually involved to approximately the same extent. Older age was correlated with more visual field defects. Only one patient remained below visual acuity of 0.3 in both eyes., Discussion: By means of our patient base, a continuous slight decline in the visual field with age can be assumed. Marked visual field defects were rare. The same was true for visual acuity, which showed some mild decline above the age of 60 years., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Meningiomas are slow growing tumours, usually becoming symptomatic with visual loss or diplopia, or they are found incidentally. Not all meningiomas need to be treated. Treatment consists of neuro-surgical removal or radiotherapy if surgery is not possible. Whether a meningioma of the anterior visual pathways needs to be treated is mainly determined by the ophthalmological state. This must also include assessment of the prognosis by evaluation of the clinical findings and OCT scanning. This contribution is intended as an overview of all relevant factors with meningiomas of the anterior visual pathways. It is mainly based on the authors' own experiences., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

With a prevalence of about 2%, drusen papillae are a very frequent papilla anomaly. The pathological mechanism of their origin is unclear. If the ophthalmoscopic image is not unambiguous, it may be helpful to examine relatives, as the heredity exhibits irregular dominance. Calcium deposits are common and can be detected by sonography. Glands can also be detected by OCT in section and by autofluorescence. Precise funduscopy and documentation of the findings and follow-up are very important. There is no therapy for drusen papillae. The internal ocular pressure must be regularly controlled, as glaucoma cannot be identified from the papilla findings. The risk is increased of anterior ischaemia of the optical nerve., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

The evaluation of pupillary function is a keystone in the neuro-ophthalmic assessment of patients. The diagnosis of an afferent or efferent pupillary disorder is crucial in the acquisition of a broad range of diseases of the brain or the peripheral nervous system. This "update" of pupillary disorders covers a major part of clinical conditions eye doctors have to expect in their daily practice. The significance of pupillary evaluation, however, extends far beyond the area of ophthalmology., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Neuro-ophthalmological history may be very complex and difficult. This article provides 14 hints about how to construct history taking efficiently and how to avoid collecting unnecessary information., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Acute diplopia can be caused by harmless disorders of the optical system, but also by dangerous intracranial or intraorbital processes that lead to movement disorders of the eyes. It may therefore be difficult to decide whether further diagnostic evaluation is necessary. This article presents a short, structural overview of the most important differential diagnoses of acute diplopia and the treatment options., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Photophobia is in many cases linked to pathologies of the anterior segment of the eye, e.g. cataract or iritis. We report an unusual case of increased light sensitivity due to a compressing lesion of the chiasm. Pituitary adenomas are among the most frequent intracranial tumours and can affect the chiasm - the site where all the visual afferences meet. A lesion of the chiasm is therefore particularly dangerous. Fortunately, in two-thirds of all cases, pituitary adenomas lead to hormonal dysfunction, so that magnetic resonance imaging of the brain is conducted. However, in the remainder of the cases, the ophthalmologist may be the first physician to see the patient because of visual problems. Usually patients report reduced vision or show typical visual field defects, such as bitemporal hemianopsia. However, the only pathological symptom may be increased light sensitivity. In rare cases of photophobia which cannot be explained by pathologies of the anterior segment, a compressing lesion of the chiasm should be considered., (Georg Thieme Verlag KG Stuttgart · New York.)

Non-arteritic ischemic optic neuropathy (NAION) is virtually unknown outside ophthalmology. It is characterised by acute unilateral visual loss, no pain on eye movements and virtually always optic disc swelling. Optic disc oedema resolves within 1 to 2 months, leaving behind optic atrophy. Vision hardly improves. NAION is the product of local abnormalities of the vascular supply to the optic nerve and general vascular risk factors. Of these, diabetes, hypertension and especially sleep apnoea syndrome are the most important. Recurrences in the involved eye are rare; contralateral recurrence occurs in approximately 15 % of patients. There is no clear scientific evidence for any specific therapy. However, there is general agreement that it is reasonable to control risk factors., (Georg Thieme Verlag KG Stuttgart · New York.)

Optic neuritis is a frequent neuro-ophthalmological disease in which the diagnosis can be based on just a few symptoms and findings. It is not only important to differentiate from other optic nerve disorders but also to recognise special types of optic neuritis, which is mostly only possible during the course of the disease. This article presents a review of the current state in diagnosis and therapy from the authors' personal point of view., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: Contrast studies can provide important knowledge for treatment decisions before surgery or for assessing the driving ability of professional drivers. Accordingly, high demands are placed on contrast panels to obtain reliable and reproducible results. The aim of the study is to find out if the contrast panels on the market meet the requirements., Methods: On the basis of measurement evaluation and schematic presentations potential sources of error can be identified. These sources of error may have a decisive influence on the assessment of contrast vision., Results: Far-reaching analyses have shown that three parameters can have a significant influence on the accuracy and reproducibility of printed contrast panels. This holds for certain properties of the printing substrate, the type of representation of display element, and the choice of the colourant. Only the correct interaction between the substrate and the print colour effects an angle-independent contrast. A matt substrate is necessary, which has a low difference to the printed contrast element in respect of glow, so that possible angle differences have no influence on the contrast assessment. The contrast elements of a contrast panel vary in brightness. Conventional methods for typographical representation of different brightnesses use the method of screening. This causes undesirable edges, which weaken in particular the lower-contrast elements unintentionally. Use of special colours can avoid this effect. In the visible wavelength range the studied contrast elements have an irregular absorption behaviour. Because of differences between the lighting surroundings, this can lead to a differentiated stimulation of cones in practice. Appropriate colourants have a constant absorption behaviour., Conclusion: To get representative results of contrast studies the production of contrast panels needs more knowledge about the interaction between paper and colour than is typically required for print products. On the basis of a prototype optimisation, approaches are presented in this article., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Lectures with many participants are considered inefficient and ophthalmology is seen as "not so important" for those studying medicine. We wondered about the students' view on this subject., Methods: During the last lesson of a two-week-series of lectures together with the written test, 337 students of two consecutive semesters received a questionnaire with specific questions concerning ophthalmology lectures., Results: 257 questionnaires (76 %) were returned. The students claimed that the lecture itself contributed most of the knowledge for their later medical practice, more than books, scripts, internet etc. Interactivity was welcome, audience response systems were appreciated. Personal contact to the lecturers was considered less important, a variation of the lecturers was considered advantageous. It would be seen as a serious loss if the ophthalmology lecture were abolished., Conclusion: These results contradict clearly the concept of the unimportance of lectures with many participants and contradict as well tendencies not to teach "small" specialties in separate lectures., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Hitherto recommendations and thresholds for contrast tests are available for mesopic but not for photopic methods. While mesopic tests are widespread in ophthalmology, in occupational medicine photopic contrast tests are often used. With regard to the attachment 6 of the German Fahrerlaubnisverordnung (FeV) which is relevant since July 2011 we tested the specificity and sensitivity as well as the test-retest reliability of available test devices and defined cut-off values., Methods: We examined patients with medium opacities, healthy volunteers and a sample of employees. Optovist EU, Binoptometer 4P and Pelli-Robson charts with standardised illumination were applied for contrast sensitivity testing. All these methods were compared to the Mesotest II as gold standard. We followed the recommendations of the German Qualitätssicherungs-Kommission der Deutschen Ophthalmologischen Gesellschaft (DOG) for contrast vision testing and definition of cut-off values., Results: 64 patients with cataract (age 42-70 years, median 62 years), 50 pilots (age 40-69 years, median 53.5 years) and 109 employees of a transportation company (age 40-59 years, median 50 years) were included in the trial. All contrast sensitivity tests showed a good sensitivity and specificity (AUC 0.86 to 0.99). For Optovist EU and Binoptometer 4P a threshold of 15 % Weber contrast is recommended for examinations according to FeV. The test-retest reliability was high in all methods with highly significant Pearson correlation coefficients of 0.77 to 0.94 and a repeatability coefficient between 0.08 und 0.4. The standard distance of 1 m common for the Pelli-Robson chart cannot be recommended for FeV examinations, while the results at 3 m distance are comparable to those of the other contrast vision tests. The preliminary cut-off for the Pelli-Robson chart at 3 m distance is 1.65., Conclusions: Cut-off values for the lawful assessment of applicants are now available. Both Binoptometer 4P and Optovist EU proved to be appropriate and - as expected due to comparable technical properties - the same cut-off can be recommended. At 1 m distance the Pelli-Robson chart is not sensitive enough. Because the new distance of 3 m for the Pelli-Robson chart was investigated in 55 cataract patients and 10 pilots in this trial, a confirmatory trial for this distance is planned., (Georg Thieme Verlag KG Stuttgart · New York.)

Aim of the Study: For the construction of true accommodating intraocular lenses and for refractive surgery a knowledge about pupil diameter in daily life is important. Sufficient data are available only in darkness., Material and Methods: 206 volunteers aged between 18 and 72 years without disorders influencing the pupil have been examined by means of pupillography at two luminance conditions (3 and 30 cd/m2) and 3 fixation distances (5 m, 1 m, 0.33 m)., Results: Pupil size decreases by 0.42 mm per decade with the darker condition and 0.25 mm per decade with brighter light. Fixation change from 5 to 1 m has hardly any influence on pupil size, changing to 0.33 m constricts the pupil by 0.43 mm at dark condition and 0.33 mm at the lighter condition., Conclusion: Luminance has the strongest influence on pupil size, near fixation has hardly any influence down to 1 m. The well-known age relation of pupil size in darkness is also valid for mesopic and photopic conditions. At 3 cd/m2 it was the same as reported in darkness, at 30 cd/m2 it was less in absolute numbers, but relative as compared to young adults it was approximately the same., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: For expert opinions on mesopic and contrast vision as stipulated in the recent version of the German driving licence regulations (2011), a standardised implementation of the relevant test method is crucial. DIN 58220, part 7, regulates the assessment of mesopic vision and the required parameters of evaluation are guaranteed by the respective test instruments. Because no standard exists for photopic contrast vision, it is recommended that it conform to that of DIN EN ISO 8596 for visual acuity. For test equipment with integrated viewing fields, the application of such tests may not be difficult. But if visual charts are used the question of standardised illumination arises. The present paper investigates this question when using the Mars Letter Contrast Sensitivity Test in the light of the recommendations by the producer to use a desk lamp for illumination., Methods: The Mars Chart was illuminated by three different commercially available desk lights from different directions at a distance of 50 cm, which is the test distance recommended by the producer. The luminance distribution was measured on the chart at twelve equally distributed test points., Results: For all conditions, the asymmetric illumination produced by a single light source leads to an extremely inhomogeneous luminance distribution over the chart. Adherence to the tolerance ranges for brightness, as well as the homogeneity of illumination from such light sources is left to chance and a subjective judgment of both parameters is not adequate., Conclusion: Illumination of the Mars Chart with a desk light only does not necessarily satisfy the requirement of reproducible test conditions that is mandatory for expert evaluations. For comparable test outcomes for contrast vision, illumination devices that produce a uniform illumination should be employed., (Georg Thieme Verlag KG Stuttgart · New York.)

Dissociated vertical divergence (DVD) is frequently associated with the infantile strabismus syndrome. There are different theories on the pathomechanism of this disorder, but none of them is generally accepted. Some authors believe that the slow upward movement of the covered eye is due to a different illumination of both retinae and consequently an unequal activity of the oculomotor nerve's nuclei. In one hypothesis a predominance of crossing pupillary tract fibres from the pretectal area to motor and parasympathetic nuclei of the oculomotor nerve was supposed. The consequence of this abnormal pathway in the midbrain would be a pronounced contraction anisocoria in patients with DVD. In contraction anisocoria the directly illuminated pupil contracts more strongly than the contralateral pupil without any efferent defect. In a small study we compared direct and indirect pupillary light reflexes in 11 DVD patients and 10 normal subjects. We found no significant differences of contraction anisocoria between the two groups. The results do not support the hypothesis of a different pupillary tract pathway in the midbrain of patients with DVD., (Georg Thieme Verlag KG Stuttgart · New York.)

We report two cases of atypical temporal arteritis. A 73-year-old woman with typical internal (diabetes, hypertony, hypercholesterinemia) and ophthomological (optic disc drusen) risk factors for N-AION reported with an acute unilateral decrease in vision. General symptoms, laboratory analysis and biopsy led to the diagnosis of temporal arteritis and iv steroids were administered. An 83-year-old male patient reported with a sudden unilateral decrease in vision, but did not complain about general symptoms. Laboratory analysis revealed no signs for temporal arteritis, therefore the patient was referred to his internal specialist for evaluation of internal risk factors for N-AION. A few days later the patient reported with a unilateral decrease in vision of the partner eye. This time blood analysis was suggestive of temporal arteritis although no general symptoms were reported. Diagnosis was supported by a biopsy of the temporal artery and steroids were administered. These two cases teach us how dangerously easy temporal arteritis can be overlooked and that we have to take even the slightest hint for temporal arteritis seriously and initiate treatment as early as possible., (Georg Thieme Verlag KG Stuttgart · New York.)

Optic neuritis and anterior ischaemic optic neuropathy (AION) present with acute visual loss. AION shows a swollen optic disc, in optic neuritis it may be swollen in one third of the patients. Optic neuritis patients complain usually about pain with eye movements. A tumour causes slowly progressive visual loss, mostly painless. In all these cases a relative afferent pupillary defect (RAPD) may be expected. If RAPD is missing, a problem of the optic media (retinoscopy, pinhole test), macular disease (micropsy, improvement with grey filters), amblyopia or non-organic visual loss can be causative. However, it has to be considered that a homonymous visual field defect may be perceived as an unilateral visual loss. Therefore visual field testing is necessary., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The aim of the study was to find out if pupillographic assessment of the visual field by means of pupil campimetry can identify glaucomatous visual field defects and as such be used for glaucoma screening purposes., Patients and Methods: 20 patients with open angle glaucoma and 30 healthy persons were examined by means of pupil campimetry. All glaucoma patients had a glaucomatous visual field defect in at least one eye. The stimulus pattern consisted of 17 white-light stimuli which were presented within the 30° visual field, particularly in the Bjerrum region. The stimulus diameter was 6°. Each stimulus was presented for 200 ms and the interval between the stimuli was 1800 ms. Three stimulus intensities (16.4 cd/m2; 27.1 cd/m2 and 40.5 cd/m2) were tested. The individual pupil light reaction (PLR) amplitudes at all examined locations in the visual field, their sums and partial sums were compared between both groups by the two-sided two-sample t test. The diagnostic performance of the method in glaucoma diagnosis was evaluated by ROC curves (receiver operating characteristics)., Results: The average PLR at all locations in the visual field was reduced in glaucoma patients compared to healthy persons. The sums of the PLR were reduced in glaucoma patients as well. Significant differences in the PLR were found especially in the central and paracentral visual fields. The best AUC values (area under the curve) were reached with the highest stimulus intensity, the highest AUC value overall was 0.769., Conclusion: Although the difference in PLR between glaucoma patients and the control group was significant, the reached AUC values fell short of being ideal for screening purposes. A surprising finding was that the most central pupil response was reduced by the same amount as that in the Bjerrum region., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Since July 2011 driving licensing in Germany requires contrast vision to be tested. Recommendations are available for testing under mesopic conditions only. This study is aimed to provide recommendations for photopic testing., Method: 169 persons were tested both under mesopic (Mesotest) and photopic (Optovist) conditions., Results: With the Mesotest the setting without glare and the requirement to recognize contrast 1:5 or with glare contrast 1:23 proved to be suitable. With the Optovist visual acuity size 0.4 without and 0.25 with glare proved to be adequate, if the requirement is to recognize the limit of 5 %., Discussion: Not unexpectedly, there is no perfect congruence between the tests. We therefore recommend that the screening methods used in industrial medicine need to be sufficiently sensitive and specific, unfortunately this is met only by some of the conditions supplied with the instruments., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The aim of this retrospective study was to estimate the frequency of relative afferent pupillary defect (RAPD) in glaucoma and whether its occurrence relates to the severity of the visual field defect and its side asymmetry as detected by standard automated perimetry., Patients and Methods: Among patients with primary open angle glaucoma examined at the glaucoma unit of our university eye hospital patients were identified in whom a swinging-flashlight test as part of their routine examination was carried out. The central 30° visual field was examined by means of static perimetry using the Tübinger Automatic Perimeter or the Octopus Perimeter. The visual field findings and their side difference were compared between patients with and without RAPD by means of the Wilcoxon rank-sum test., Results: After having taken into consideration the inclusion criteria, 100 glaucoma patients were included in the study, 34 of them had an RAPD (34 %). For the visual field analysis only the data of 85 patients, who received the same perimetric strategy, were used. 25 of them had an RAPD (29 %). The calculated visual field scores in patients with RAPD were significantly higher than those in patients without RAPD (p < 0.01), that means their visual field loss was generally more advanced. Also the side difference in visual field of both eyes was significantly greater in patients with RAPD (p < 0.01). A receiver operating characteristics (ROC) curve showed that the side difference in visual field defect is a good predictor for RAPD with an area under curve (AUC) of 0.81., Conclusion: RAPD can be diagnosed in about one third of patients with primary open angle glaucoma. It can be found especially with more advanced visual field defects and visual field defects with greater side asymmetry. Its absence does not mean that there is no visual field defect at all. We advise to include the swinging-flashlight test in glaucoma diagnostics., (© Georg Thieme Verlag KG Stuttgart · New York.)

Aim of the Study: Colour comparison tests are a subjective supplement to the swinging flashlight test. We have investigated the specificity and sensitivity, compared 3 exactly defined different colours (red, green, blue), and looked for age relationships., Method: 101 patient with various unilateral optic neuropathies were compared to 103 age-correlated healthy controls in randomised order by letting the patient evaluate red, green and blue colour charts of 5.5 cm diameter., Results: The area under the receiver operator characteristics curve was 0.804 for red, 0.821 for green and 0.789 for blue, and for any of the 3 colours 0.835 (at least one colour was seen differently). Best results were obtained when even small differences in colour perception were considered as pathological. 29 healthy controls perceived colours differently in both eyes, 24 of those being older than 50 years. The specificity decreased with age, was significant for green and red, not for blue., Discussion: There were no significant differences between the 3 colours in all age groups. Evaluation of more than one colour does not increase the sensitivity significantly. Even small differences have to be considered as pathological to obtain the highest possible sensitivity. Test specifity decreases with age., (© Georg Thieme Verlag KG Stuttgart · New York.)

Examination of the pupil offers an objective evaluation of visual function as well as the vegetative pathways to the eye. Essential information is gathered within a short time. This makes pupillary inspection a valuable part of the routine ophthalmological, neurological and general medical examinations. Due to the proximity of pupillary pathways to various anatomic structures, pupillary dysfunction can be caused by a variety of disorders, some of which may be life threatening. The ophthalmologist plays a key role in detecting pupillary disorders and in directing further investigations. Therefore, one should have a good knowledge of the diagnostic significance of pupillary function and dysfunction., (© Georg Thieme Verlag KG Stuttgart · New York.)

Classically, the pupillary pathway is considered as a simple reflex arc comprising retinal ganglion cells, midbrain interneurons, oculomotor nerve and short ciliary nerves. However, there are some specialties in the construction of the pupillary pathways that have to be kept in mind when dealing with diseases involving pupillary disorders. This may help to localise lesions. Additionally, studies in patients with lesions of the retrogeniculate pathways have shown that pupillary disorders are possible even with lesions not involving the classical reflex arc. The pupil is therefore not only controlled subcortically, some components are influenced by the visual cortex. The aim of this article is to clarify various findings and terms such as relative afferent pupillary defect and pupillary hemihypokinesia., ((c) Georg Thieme Verlag KG Stuttgart-New York.)

Purpose of the Study: While evaluating radiotherapy results in patients with primary and secondary optic nerve sheath meningiomas (ONSM) treated between 1993 and 2002, a large amount of data about early signs and symptoms has been collected which might be helpful for establishing an early diagnosis., Methods: We have reviewed the charts of the patients available at the Centre of Ophthalmology, collecting especially pretreatment data., Results: 112 patients, 4 with bilateral tumours, 83 % female were included. Mean age was 51.7 years. Visual acuity loss with relative afferent pupillary defect was the main symptom and sign in primary ONSM (38 patients). Median interval between first symptoms and diagnosis was 12 months. Optic discs were in approximately one half atrophic, the other half were swollen, and only rarely normal (3 cases only). Retinociliary shunt vessels were seen in 10 cases. Nerve fibre bundle defects were the major visual field finding (including constriction and central scotoma). Visual acuity was better than 0.5 (20 / 40) in 46 % and worse than 0.1 (20 / 200) in 30 %. In secondary ONSM, the interval to diagnosis was with a median of 6 months shorter than in primary ONSM. Approximately half of the optic discs were atrophic, only 6 % were swollen. Even here nerve fibre bundle defects were dominating, only 7 % had vertical hemianopic defect. Visual acuity was better than 0.5 (20 / 40) in 30 % and in worse than 0.1 (20 / 200) 22 %. 45 % had ocular motility disorders., Discussion: Vertical hemianopic defects were surprisingly rare. The high rate of nerve fibre bundle defects and the relatively high number of patients with good visual acuity might explain why this disorder is occasionally mistaken for glaucoma. A typical clinical appearance can be outlined: mainly mid-aged women, slowly progressing visual loss, frequently motility disorders, relative afferent pupillary defect, nerve fibre bundle defects and atrophic or--mainly in primary ONSM--swollen optic disc form the characteristic picture., ((c) Georg Thieme Verlag KG Stuttgart-New York.)

Traumatic optic neuropathy is a severe complication of a head or face trauma. Diagnosis is established by analyzing pupillary responses to light. Fundus examination and orbital CT scan help to localize the site of the lesion and may show a fracture involving the optic canal. Surgical decompression or megadose steroids are therapeutic options. No therapeutic approach has proven with sufficient evidence to be effective. Spontaneous improvement is definitely possible. Based on experiences in single cases direct compression of the optic nerve by bone fragments or optic nerve sheath haemorrhage are as a rule treated surgically. In all other cases usually high dose steroids are given without proven effectiveness.

Background: Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a chronic inflammatory disease of unknown origin that is morphologically characterized by a local fibrotic thickening of the dura mater with a sterile lymphocytic infiltrate. Patients usually present with chronic headache, ataxia and cranial nerve palsies. Because of the great diversity of symptoms and the fact that IHCP can be associated with many other disorders, there is often a long time between the occurrence of clinical features and making the diagnosis. During this time symptoms can further increase. In addition, this is the third case report describing bone involvement in this disorder., Case Report: In May 2000, a 51-year-old woman presented with reduced visual acuity on both eyes, complete palsies of the fourth and sixth cranial nerve, a partial palsy of the third cranial nerve and numbness and pain concerning the area of the fifth cranial nerve on the left side, painful eye movement on the left side, headache, and numbness and palsies on the left side of her body. Magnetic resonance imaging of the brain showed a focal gadolinium-enhanced small thickening of the dura mater close to the left hemisphere and a homogeneous bone thickening in the same area close to the thickened dura mater. Cerebrospinal fluid analysis revealed an elevated cell count (lymphocytic pleocytosis), routine blood counts and serum chemistry showed an elevated white blood count, an elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Therapy with corticosteroids resulted in a complete remission in November 2000 except for a persistent numbness of the left side of her face and body and reduced visual acuity on both sides. The following three years were characterized by repeated clinical deteriorations followed by a temporary increase of the daily steroid dose. Altogether, daily oral steroid therapy could slow down the progression of disease and improve the visual acuity when compared with the first examination., Conclusions: Chronic headache, ataxia and cranial nerve palsies in combination with inflammation and dural thickening should call to mind idiopathic hypertrophic cranial pachymeningitis. In principle, every ophthalmological or neurological symptom can be associated with IHCP.

Fulminant processes of the orbit can cause considerable diagnostic difficulties with regards to the clinical, radiological and microbiological appearance. Rhino-orbito-cerebral mucormycosis is a rare but, when untreated, fatal orbital disease capable of destructive infiltration of soft tissue and bone. It occurs preferably in the ill adjusted diabetic or in the course of an immunodeficiency. The following case report describes a leukaemia patient developing a severe rhino-orbito-cerebral mucormycosis which was initially not recognised. Since untreated mucormycosis is fatal, an aggressive surgical approach with excision of the whole necrotic area is necessary even if the diagnosis cannot be confirmed with certainty.

Direct or indirect trauma may damage the optic nerve and result in permanent visual loss. The diagnosis of traumatic optic neuropathy is not always straightforward and is complicated by unfavourable circumstances for the examination. The diagnosis should only by established if it can be based on a clear objective finding, a relative afferent pupillary defect or a pathological flash-evoked visual response. Concerning therapy, surgical decompression (even without direct injury to the nerve) or megadose steroids or both in combination have been recommended. But even spontaneous improvement may occur. A large multicentre study could not demonstrate a significant advantage for any of the measures recommended, not even against the spontaneous course. However, the study was not randomised. In animal experiments steroids have shown an unfavourable effect. Currently, therapeutic decisions have to be made on an individual basis, in the absence of any evidence-based recommendations.