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Background It is unclear whether or not an additional encircling band improves outcome in vitrectomy for pseudophakic retinal detachment (PRD). Also unclear is whether small gauge transconjunctival trocar-guided vitrectomy is as successful as conventional 20 gauge (G) vitrectomy. Methods 257 adult patients with uncomplicated PRD were enrolled in 14 vitreoretinal centres across Germany. Contingent on availability of qualified surgeons, eligible patients were randomly assigned either (i) with ratio 1:1 to 20 G vitrectomy plus encircling band (group E1) or 20 G vitrectomy without any buckle (group C) or (ii) with ratios 1:1:1 to group E1, C or 23/25 G vitrectomy without any buckle (group E2). Treatment success was defined as no indication for any retina reattaching procedure during the follow-up of 6 months. Results Success was reached in 79.0% (=79/100, group E1) versus 73.5% (=72/98, group C) (p=0.558, OR 1.32, 95% CI 0.65 to 2.65. In group E2 87.7% (=50/57) of patients reached success compared with 78.7% (=48/61) in group C, demonstrating non-inferiority of E2 to C regarding the prespecified margin of 0.8 (OR scale; p=0.05, OR 2.17, 95% CI 0.80 to 5.89). Best corrected visual acuity significantly increased after surgery independent of technique, that is, on average −0.7 (from 1.0 to 0.3) logMAR. Patients suffered from a shift in spherical refraction of −1.0 D in group E1 compared with −0.1 D in group C. Similarly, intraoperative complications (15.2% vs 8.8% of patients) and serious adverse events (30.3% vs 22.5% of patients) were more frequent in group E1. Conclusions Vitrectomy with gas is an efficient and safe treatment for uncomplicated PRD. An additional encircling band does not significantly reduce the risk for any second procedure necessary to reattach the retina in 20 G vitrectomy. Small gauge transconjunctival vitrectomy is not inferior to the conventional 20 G technique. Trial registration number DKRS 00003158, Results.

Die Effektivitat der Anti-VEGF-Therapie bei der exsudativen AMD konnte in grosen klinischen Studien sowohl unter Verwendung monatlicher Applikation als auch unter SD-OCT-orientierter PRN-Behandlung aufgezeigt werden. Hierbei zeigten die Visusverlaufe in allen Studien im Mittel bereits nach 3 Monaten einen Visusanstieg, der bei konsequenter Therapie uber 12 Monate und 24 Monate gehalten wird. Differenziert man diesen mittleren Visusgewinn aber genauer, so sieht man, dass individuell grose Unterschiede zu beobachten sind. Ziel der vorliegenden Studie war es, eine differenzierte Analyse spezifischer SD-OCT-Charakteristika initial vorzunehmen und sie mit dem Visusverlauf zu korrelieren, um initiale morphologische Faktoren zu charakterisieren, die fur einen unterschiedlichen Visusverlauf verantwortlich sein konnen. In einer prospektiven Fallserie wurden die Visusverlaufe und SD-OCT-Veranderungen von 156 Patienten uber mind. 12 Monate analysiert (mittleres Follow-up 80,1 Monate). Hierzu wurde in regelmasigen Abstanden das Sehvermogen (LogMar) registriert und mit den Veranderungen im SD-OCT-Volumenscans (Parameter: foveale Netzhautdicke, Hohe der subretinalen Flussigkeit, Nachweis einer RPE-Abhebung, Nachweis intraretinaler Zysten, Lange einer Unterbrechung der IS/OS-Linie, Aderhautdicke) korreliert Der initiale mittlere Visusanstieg konnte uber die Zeitachse gehalten werden. Er ging mit einer deutlichen und anhaltenden Reduktion der fovealen Netzhautdicke einher. Wahrend sowohl die Hohe assoziierter subretinaler Flussigkeit oder der Nachweis einer RPE-Abhebung als auch die Dicke der Aderhaut keine Korrelation mit einem besseren oder schlechteren Visusverlauf zeigten, war eine grosere initiale zentrale Netzhautdicke, der Nachweis von intraretinalen Zysten oder eine langere Unterbrechung der IS/OS-Linie signifikant mit einem schlechteren Visusverlauf korreliert. In der vorliegenden Fallserie korrelierten eine grosere zentrale Netzhautdicke, der Nachweis von intraretinalen Zysten oder einer langeren Unterbrechung der IS/OS-Linie signifikant mit einem schlechteren Visusverlauf. Dies kann als Hinweis gewertet werden, dass das Ausmas praexistierender initialer Schaden auf der Ebene der Fotorezeptoren fur die Visusprognose verantwortlich sein konnte. Eine bessere Charakterisierung dieser initialen Schaden und ihre Beeinflussung muss daher das Ziel der Weiterentwicklung der Therapie der exsudativen AMD sein.

Aktivitatsbasierte Behandlungsschemata bilden derzeit die Standardbehandlung der exsudativen AMD (nAMD) mit Anti-VEGF (Vascular Endothelial Growth Factor). Wahrend mit einem Pro-re-nata (PRN)-Behandlungsschema prospektive Studien eine Injektionshaufigkeit von etwa 7 Injektionen im ersten Jahr und 6 im zweiten Jahr erwarten lassen, messen retrospektive Beobachtungen deutlich verminderte Injektionsanzahlen. In dieser Arbeit wurden die Grunde fur abnehmende Kontrollvisiten gesucht. Ferner wurde untersucht, ob eine telemedizinische Befundubermittlung mit Untersuchungen vor Ort die Motivation der Patienten und Einhaltung der notwendigen regelmasigen Kontroll- und Behandlungstermine positiv beeinflussen kann. Im ersten Untersuchungskollektiv wurden retrospektiv Kontroll- und Therapieintervalle von 210 Augen (191 Pat.) mit einer nAMD in den Jahren 2010 und 2011 unter aktivitatsbasierter Anti-VEGF-Therapie bei einem mittleren Follow-up von 2 Jahren analysiert. In einem anderen Kollektiv von 100 Augen (100 Pat.) wurden 2 Gruppen beobachtet: eine Gruppe mit Durchfuhrung der Kontrolluntersuchung vor Ort und telemedizinischer Befundubermittlung zum Behandlungszentrum und eine Gruppe, in welcher die Patienten auch zur Kontrolluntersuchung zum Behandlungszentrum anreisen mussen. Im ersten Untersuchungskollektiv waren nach 140 Wochen noch 50 % der Beobachteten in regelmasigen Kontrollen, nach 1 Jahr waren es noch 79 %. Nach 2 Jahren ist die Wahrscheinlichkeit einer kontinuierlichen Betreuung nur noch bei 62 % der Patienten gegeben, wahrend bei 38 % ein Abbruch der Betreuung erfolgte. Wahrend bei 8 % dieser Abbruch basierend auf Abbruchkriterien vorlag, fand der Abbruch der Kontrollen in 30 % unbeabsichtigt statt. Der Hauptgrund fur eine unbeabsichtigte Beendigung der Kontrollen und Behandlungen war mit 38 % die haufige und weite Anreise. Im zweiten Kollektiv zeigte sich eine Verbesserung der Compliance der Patienten hinsichtlich der Kontrollen (p

To document the long-term outcome in cases of retinal pigment epithelial (RPE) tears after treatment of vascularized pigment epithelial detachments with anti-vascular endothelial growth factor therapy.A retrospective analysis of the long-term outcome of a consecutive series of eyes with RPE tear developed during anti-vascular endothelial growth factor therapy for pigment epithelial detachment associated with choroidal neovascularization or retinal angiomatous proliferation (vascularized pigment epithelial detachment) was performed. Best-corrected visual acuity (BCVA), spectral domain optical coherence tomography, and autofluorescence images and also fluorescein angiograms were analyzed to determine the functional and morphologic development over time.The long-term outcome of 22 eyes (21 patients, 13 women and 8 men; 65-85 years; mean: 76 years) with RPE tear was performed with minimal follow-up of 3 years (range: 3-5 years, mean: 44 months) and re-treatment with different therapeutic strategies. The eyes were differentiated in 2 groups according to the course of BCVA after the first 2 years of follow-up: Group 1 (11 eyes) demonstrated a stabilized or improved BCVA after 2 years and Group 2 (11 eyes) demonstrated a decrease in BCVA after 2 years. The initial BCVA between both groups was comparable. Also the mean initial size of the RPE tear was the same between the 2 groups, the area of the RPE tear decreased continuously during follow-up in Group 1, whereas this was the case in Group 2 only at the beginning of treatment with a further increase of the size of the RPE tear with longer follow-up. This corresponded with a different morphologic development between the two groups. In Group 1, increasing recovery of autofluorescence at the RPE-free area was visible beginning from the outer border, whereas in Group 2, further growth of the neovascular complex in the area of the RPE tear was observed resulting in larger fibrovascular scars. In addition, in both groups, the development of hyperreflective tissue was seen on spectral domain optical coherence tomography in the RPE-free area. The major therapeutic difference between the 2 groups was a significantly larger number of injections especially during the first year in Group 1.The development of RPE tear after anti-vascular endothelial growth factor therapy for vascularized pigment epithelial detachment in exudative age-related macular degeneration does not necessarily result in large disciform scars and functional loss, but multiple injections seem to be beneficial especially in the first year. With this strategy, RPE tears seem to be covered by autofluorescent and hyperreflective tissue and a regrowth of the neovascular complex can be prohibited. As a result, photoreceptor cells regain their metabolic support with functional recovery.

Purpose Macular telangiectasia is associated with neurodegenerative changes including focal outer retinal atrophy and a loss of macular pigment (MP). We aimed to investigate whether an association between spectral domain optical coherence tomography neurodegenerative signs and MP abnormalities can be detected. Methods Forty-seven eyes of 27 macular telangiectasia Type 2 patients (mean age 66.7 years, range 50-82 years, 12 male) were investigated. An MP pattern was recorded using a dual-wavelength autofluorescence method and classified according to severity (I-III). Outer plexiform, inner nuclear, and photoreceptor layer thickness values were measured in Spectralis spectral domain optical coherence tomography scans. Thickness values were compared with those of a control group of 14 healthy age-matched eyes. Results Macular pigment redistribution was found to be Class I in 11 eyes, Class II in 28 eyes, and Class III in 8 eyes. More advanced stages of MP loss were associated with a greater, statistically significant thinning of the outer plexiform and inner nuclear layer complex and photoreceptor layers (P ≤ 0.001). Lower absolute levels of MP were also associated with a thinning of the photoreceptor layer. Thinning was restricted to within the parafovea, more severe at temporal eccentricities. Conclusion Our findings support the hypothesis that in macular telangiectasia Type 2 cellular degenerative processes leading to a thinning of these layers also result in reduction and redistribution of MP.

BackgroundThe aim of this study was to ascertain whether there are relevant differences between the vascular morphology of macular neovascularizations (MNV) in 3×3mm and 6×6mm images, produced by optical coherence tomography angiography (OCTA).MethodsMNV of 49 patients were automated quantitative analysed, measuring area, flow, the fractal dimension, average vessel length, vascular density, and average vessel caliber. These parameters were compared between the 3×3mm and the 6×6mm images.ResultsA strong linear association was found between the 3×3mm and the 6×6mm images. While area, flow, and FD of the MNV were very similar, the 3×3mm images showed significantly lower average total vessel length, greater vascular density, and lower average vessel caliber.ConclusionIn quantitative analysis of the morphologic parameters of MNV in 3×3mm and 6×6mm images, the structures are not directly equivalent in the two sizes of scan. The images must be evaluated on an individual basis.

Vital dyes have become a clinical standard during chromovitrectomy but toxicity remains an issue. We compared the clinical outcome of one supposedly toxic vital dye (AV 17 with 5% mannitol) with a standard vital dye (MBB Dual) and performed a power analysis for future comparative studies.Retrospective analysis of 270 eyes after chromovitrectomy with internal limiting membrane peeling because of macular holes. Primary endpoint was loss in BCVA2 lines and photoreceptor atrophy as seen on optical coherence tomography examination.In 173 eyes, staining of the epiretinal membrane and extracellular matrix was performed using MBB (Group A), and in 97 using AV 17-M (Group B). The mean BCVA was not significantly different after more than 3 months and also not in the early postoperative period after surgery between Group A and Group B. The number of patients suffering from a decline in BCVA of two lines and more was not significantly higher in patients of Group B. There was not a significantly higher percentage of patients with an inner segment/outer segment defect.Our rather homogeneous study showed no significant difference between both dyes. Thousand five hundred patients would need to be examined to find a significant difference in future studies.

Das Goodpasture-Syndrom (GS) ist eine seltene organspezifische Autoimmunerkrankung, die aus einer Glomerulonephritis und einer pulmonalen Blutung bestehen kann. Nur wenige Fallberichte mit einer okularen Beteiligung wurden im Zusammenhang mit dem GS veroffentlicht. Dies ist ein Fallbericht eines 22-jahrigen Mannes mit GS. Er wurde aufgrund von Sehstorungen in unserer Praxis vorgestellt. Seine Anamnese ergab eine pulmonale Blutung, ein akutes Nierenversagen und ein nephrotisches Syndrom, das durch immunsuppressive Therapie mit zusatzlicher Plasmapherese behandelt wurde. Ophthalmoskopisch zeigten sich bilaterale Cotton-Wool-Herde entlang der Gefase und bilaterale Netzhautblutungen vorwiegend am hinteren Pol. Durch eine Forcierung der bestehenden antihypertensiven Therapie verbesserte sich der Augenbefund deutlich. Obwohl es im Rahmen eines Goodpasture-Syndroms selten okulare Manifestationen gibt, ist es wichtig, an dieses Krankheitsbild zu denken, da die Augensymptome auch die initialen Zeichen eines GS sein konnen.

Selbst unter konsequenter Anti-VEGF („vascular endothelial growth factor“)-Therapie zeigen sich bei neovaskularer altersabhangiger Makuladegeneration (AMD) oft Reaktivierungen der Lasion. Die vorliegende Fallserie untersucht, ob ein Wechsel des Praparates von Ranibizumab zu Aflibercept sicher ist und Unterschiede hinsichtlich der Wirksamkeit beobachtet werden konnen. Bei 56 konsekutiven Patienten mit erneuter Aktivitat der AMD, gemas morphologischen Kriterien der Spectral-Domain-optischen Koharenztomographie (SD-OCT)-Untersuchung, wurde nach 6 bis maximal 41 Injektionen (im Mittel 18,9, SD 6,3) ein Wechsel von Ranibizumab zu Aflibercept vorgenommen. Bei allen Kontrollen und vor jeder Injektion wurde neben der klinischen Untersuchung der Visus (LogMAR) erhoben und eine SD-OCT (Volumenscan) durchgefuhrt. Der mittlere Visusverlauf war unter beiden Therapien stabil. Morphologisch zeigte sich eine starkere Reduktion der Netzhautdicke nach dem Therapiewechsel (innerhalb von 1000 μm und foveolar) gegenuber der initialen Behandlung. Sowohl die Anderung der subretinalen Flussigkeit als auch die Hohe einer assoziierten Pigmentblattanhebung (PED) wiesen keinen signifikanten Unterschied auf. Die Analyse der morphologischen Veranderungen auf der Ebene der Photorezeptoren zeigte eine Abnahme der Diskontinuitat sowohl in der ellipsoiden Bande als auch im Bereich der Membrana limitans externa (ELM). Bei Patienten mit erneuter und/oder hoher Lasionsaktivitat kann durch einen Wechsel des Praparates eine erneute funktionelle Stabilisierung trotz mehrfacher Vorbehandlung erreicht werden. Morphologisch fanden sich zudem Hinweise auf eine Regression des intraretinalen Odems und Verbesserungen auf der Ebene der Photorezeptoren. Im Rahmen einer klar definierten Behandlungsstrategie ist der Wechsel von einem Anti-VEGF-Praparat auf einen ahnlichen Wirkstoff sicher. Vor einer definitiven Bewertung sind prospektiv kontrollierte Studienbedingungen erforderlich, bevor der klinische Nutzen eines Wechsels verifiziert werden kann.

Background: Retinal pigment epithelial (RPE) cells undergo functional changes upon complement stimulation, which play a role in the pathogenesis of age-related macular degeneration (AMD). These effects are in part enhanced by pretreating ARPE-19 cells with UV-irradiated photoreceptor outer segments (UV-POS) in vitro. The aim of this study was to investigate the effects of human complement serum (HCS) treatment on p44/42 mitogen-activated protein kinase (extracellular signal-regulated kinase 1/2 [ERK1/2]) activation in ARPE-19 cells pretreated with UV-POS. Methods: UV-POS-pretreated ARPE-19 cells were stimulated with 5% HCS or heat-inactivated HCS (HI-HCS) as a control. Pro tein expression of phosphorylated (activated) ERK1/2, total ERK1/2, Bax, and Bcl-2 was analyzed by Western blotting. Cell culture supernatants were analyzed for IL-6, IL-8, MCP-1, and VEGF by enzyme-linked immunosorbent assay (ELISA). Furthermore, extra- and intracellular reactive oxygen species (ROS) were determined. Results: The amount of phosphorylated ERK1/2 was increased in UV-POS-pretreated ARPE-19 cells, especially in combination with HCS stimulation, compared to non-pretreated ARPE-19 cells incubated with HCS alone or HI-HCS. The same observation was made for Bax and Bcl-2 expression. Furthermore, an increase in extra- and intracellular ROS was detected in UV-POS-pretreated ARPE-19 cells. The ELISA data showed that the production of IL-6, IL-8, and MCP-1 tended to increase in response to HCS in both UV-POS-pretreated and non-pretreated ARPE-19 cells. Conclusions: Our data imply that ERK1/2 activation in ARPE-19 cells may represent a response mechanism to cellular and oxidative stress, associated with apoptosis-regulating factors such as Bax and Bcl-2, which might play a role in AMD, while ERK1/2 seems not to represent the crucial signaling pathway mediating the functional changes in RPE cells in response to complement stimulation.

Age-related macular degeneration (AMD) is the most common cause of blindness defined by law, in the western world, its late stages having a reported frequency of 12% [1]. It is a complex disease of the central retina with a prevalence of 30% in the population aged over 80 years.

Zusammenfassung Hintergrund Ziel der vorliegenden erweiterten Fallbeschreibung ist die Darstellung choroidaler Neovaskularisationen (CNV) bei vaskularisierten Pigmentepithelabhebungen (PE-Abhebung) initial und unter Anti-VEGF-Therapie mittels OCT-Angiografie (OCT-A) im Vergleich zur konventionellen Diagnostik. CNV-Größe und Flow-Areal wurden in der OCT-A quantifiziert und diese Befunde mit anderen SD-OCT-Charakteristika der Läsion verglichen. Patienten und Methode Bei 8 Patienten mit vaskularisierter PE-Abhebung wurde zusätzlich zur konventionellen Bildgebung eine OCT-A (Avanti, Optovue) durchgeführt. Auf diesen Aufnahmen wurde mit einer zum retinalen Pigmentepithel parallelen (RPE-parallel) Segmentierung das CNV-Areal manuell umgrenzt und die Größe sowie der Gefäßanteil (Flow-Areal) initial und nach der durchgeführten Anti-VEGF-Therapie ausgemessen. Gleichzeitig wurden der Visus (logMAR) und im SD-OCT die Höhe der PE-Abhebung und die NH-Dicke im Verlauf bestimmt und statistisch verglichen. Ergebnisse Initial zeigte die Größe der CNV in der OCT-A eine große phänotypische Variationsbreite (0,33 – 1,35 mm2; Mittel 0,71 mm2) mit signifikanter Abnahme unter Therapie (0,44 – 0,84 mm2; Mittel 0,57 mm2; p = 0,02). Das Flow-Areal variierte ebenso initial (0,21 – 0,88 mm2; Mittel 0,45 mm2) und reduzierte sich unter Therapie (nach Therapie 0,08 – 0,44 mm2; Mittel 0,27 mm2; p = 0,07). Die Höhe der PE-Abhebung im SD-OCT war initial unterschiedlich (initial 274 – 1459 µm; Mittel 607 µm), zeigte unter Therapie aber nur eine geringe Veränderung (132 – 1317 µm; Mittel 524 µm; p = 0,09). Dies galt ebenso für die mittlere Netzhautdicke (vor der Therapie 315 µm, nach der Therapie 294 µm; p = 0,5). Der Visus verbesserte sich nach der Therapie im Mittel von initial 0,51 auf 0,45 logMAR ebenfalls nur gering (p = 0,7). Schlussfolgerungen Die Kombination aus SD-OCT und OCT-A ermöglicht eine verbesserte Darstellung und Quantifizierung von CNV-Arealen bei vaskularisierten PE-Abhebungen. Hierdurch können Veränderungen in der Perfusion und Größe der CNV quantifiziert werden. Dies könnte neben den retinalen Aktivitätszeichen eine 2. Aktivitätsbeurteilung des CNV-Anteils unter einer Anti-VEGF-Therapie ergeben. Aufgrund der dreidimensionalen Grundstruktur können insbesondere bei diesem Subtyp der exsudativen AMD zukünftige dreidimensionale Darstellungsmöglichkeiten sowohl des strukturellen SD-OCT als auch der OCT-A von großer Bedeutung sein.

ZusammenfassungDie OCT-Angiografie bietet eine Kombination aus vaskulärer und struktureller Information und kann im Gegensatz zur konventionellen Fluoresceinangiografie nichtinvasiv und ohne Farbstoff choroidale Neovaskularisationen darstellen. Derzeit existiert noch keine gültige OCT-angiografische Klassifikation der AMD, obwohl verschiedene Muster und Aktivitätskriterien von Neovaskularisationen beobachtet werden konnten. Die OCT-Angiografie könnte so in Zukunft zu einem besseren Verständnis pathophysiologischer Mechanismen und therapeutischer Strategien beitragen.

Gibt es morphologische Parameter bei Pigmentepithelabhebungen (PED) bei altersbedingter Makuladegeneration (AMD), die vor Beginn einer Anti-VEGF-Therapie auf eine Entwicklung eines Risses (RIP) im retinalem Pigmentepithel (RPE) hindeuten? Retrospektiv wurden OCT (optischer Koharenztomographie)-, Fluoreszenzangiographie(FLA) - und Nahinfrarotaufnahmen (NIR)-Aufnahmen von 98 Augen mit PED bei exsudativer AMD vor Beginn der Therapie (Ranibizumab, Bevacizumab) ausgewertet. Die Augen, in denen unter Therapie ein RIP zu beobachten war (RIP-Gruppe), wurden mit denen ohne RIP-Entwicklung (PED-Gruppe) auf folgende morphologische Parameter verglichen: Hohe der PED, Anzahl der Gipfel im Pigmentepithel, Vorhandensein eines hyporeflexiven Spaltes an der PED-Basis, Vorhandensein von „schwimmender“ maximaler Hyperreflexivitat in der PED, Menge und Lokalisation der Hyperreflexivitat in der PED, Struktur des RPE, Hyperreflexivitat in der NIR-Aufnahme. Die 80 Augen der PED-Gruppe waren mit einer mittleren Hohe der PED von 373,7 µm (± 197) niedriger als die 18 Augen der RIP-Gruppe [PED-Hohe: 694,2 µm (± 284,3); p 350 µm Hohe und 1 Gipfel zeigte haufiger einen RIP (43 %) als der PED-Typ 350 µm ein Trend uber einen geringeren Visusanstieg (rm ANOVA p = 0,18; ɛ HH = 0,88) gesehen werden als in PED-Typen 350 µm mit mehreren Gipfeln ein vermehrter Injektionsbedarf (p = 0,032) zu beobachten als bei den anderen PED-Typen. Morphologische Parameter wie die PED-Hohe, die Anzahl der Gipfel pro PED und das Vorhandensein einer Hyperreflexivitat im Bereich der PED in der NIR-Aufnahme sind prognostisch relevante Faktoren fur eine spatere RIP-Entwicklung unter Therapie. PED-Hohe und Gipfelanzahl konnen fur eine PED-Klassifikation in der taglichen Routine verwendet werden.

Seit dem 17. Januar 2013 ist das Medikament Ocriplasmin (JETREA®) zur intravitrealen Behandlung der vitreomakularen Traktion bei Erwachsenen auch in Zusammenhang mit einem Makulaloch kleiner oder gleich 400 µm Durchmesser von der European Medicines Agency zugelassen. Im Folgenden werden die zwischen der Retinologischen Gesellschaft, der Deutschen Ophthalmologischen Gesellschaft und dem Berufsverband fur Augenarzte konsentierten Behandlungsempfehlungen und das Anwendungsspektrum dargelegt.

A 71-year-old female patient with a status following multiple conjunctival excisions, histopathologically confirmed conjunctival melanoma (CMM) and also multiple therapy with mitomycin C presented with progressive conjunctival pigmentation. Treatment was carried out with local interferon α2b administration four or five times daily for several months. The lesion showed regression and lost pigmentation without any side effects.

Background The pathophysiology of pigment epithelial detachment (PED) secondary to age-related macular degeneration (AMD) is as yet incompletely understood and treatment remains challenging. Spectral domain optical coherence tomography (SD-OCT) allows for improved morphological characterisation of the space underneath the retinal pigment epithelium (RPE). Objective To investigate eyes with PED for structures underneath the detached RPE cell layer. Methods In a retrospective observational case study, SD-OCT scans of AMD-related PEDs were assessed for the presence of distinctive morphological features in the space between the detached RPE and inner Bruch9s membrane. Results Structures present in the space between the detached RPE and Bruch9s membrane were found in 14 of 90 eyes with AMD-related PED. Each of these eyes shows hyper-reflective material underneath the PED, presenting as highly reflective, multilayered, laminar structures, usually orientated parallel to Bruch9s membrane. Conclusions The findings indicate that SD-OCT may be useful for a more refined phenotypic stratification of AMD-associated PED. Further studies are warranted to explore the correlates on other imaging modalities, to investigate the composition of this material and to assess the potential prognostic relevance of this new finding.

In phase III trials, the therapeutic efficacy of anti-VEGF therapy with ranibizumab (Lucentis) in patients with choroidal neovascularization due to AMD was demonstrated in a 24-month period with monthly injections. Other studies and models suggested that flexible reinjection regimens can provide similar visual results. The aim of the present study was to evaluate the flexible, predominantly visual acuity-driven ranibizumab retreatment regimen in clinical practice in Germany. Best-corrected visual acuity (VA, logMAR) and central retinal thickness (CRT) were recorded initially and every 4–6 weeks during follow-up (mean follow-up 75.5 weeks) from 152 eyes. All eyes were treated initially 3 times with ranibizumab at 4-weekly intervals, and retreated with another three injections if visual acuity decreased and/or CRT increased (>100 μm), and/or if new angiographic leakage and/or new retinal hemorrhages developed. Visual acuity development was analyzed in the whole group. A quartile analysis was also performed, and visual course was correlated with CRT. In all groups, numbers and times of reinjections within the first year were registered and analyzed. An increase in mean VA of 0.14 (SD 0.22) logMAR could be observed after 3 months, but during follow-up from months 3 to 12 the mean visual acuity decreased again by 0.14 (SD 0.24) logMAR, and was similar to the initial VA despite several reinjections (mean five injections). Stratification of patients according to the visual effect after 3 months (quartile analysis) demonstrated a differentiation of the visual course. Quartile 1, with the largest increase in VA after 3 months and reduction of the retinal edema, lost this positive effect during follow-up (100% of eyes received further injections). In contrast, quartile 2, with a minor increase, and quartile 3 demonstrated a stabilized response during follow-up (80% reinjections), while quartile 4 demonstrated a further loss in VA despite reinjections initially and during follow-up (60% reinjections). The flexible, predominantly visual acuity-driven ranibizumab retreatment regimen employed in clinical practice in Germany generally resulted in a loss of initially gained VA during 12 months of follow-up. Subgroup analysis showed that this negative effect was especially present in patients with relatively bad VA at treatment entry as well as the highest visual gain. Because this result demonstratse that a visual acuity-related retreatment regimen can not preserve the initial positive treatment effects with ranibizumab in exudative AMD, a revision of this schematic retreatment regimen used in Germany and adaptation to more sensitive retreatment parameters is recommended.

Introduction Based on data from multicentric studies the treatment of exudative age-related macular degeneration (AMD) with VEGF inhibitors has recently become a more and more standard procedure. Nevertheless, the proper end point of the treatment and also the adequate interval between single injections have not been defined yet. In subtypes of AMD associated with pigment epithelium detachment. (PED) the natural course as well as laser coagulation treatment and photodynamic therapy (PDT) showed unsatisfactory results. The main cause of decreased visual acuity has proven to be recurrence of choroidal neovascularisation and ruptures of the pigment epithelium (RIP). This retrospective study presents the clinical results following a change of the injected VEGF inhibitor after ineffective initial therapy. Method 15 patients with serous PED, 7 patients with PED associated with retinal angiomatous proliferation (RAP) exhibited insufficient stabilisation after initial treatment with pegaptanib (Macugen). Therefore we continued treatment with ranibizumab (Lucentis). The mean age was 74.67 years. Best corrected visual acuity was evaluated with logMAR. Additional morphological parameters were fovea full thickness (OCT), measurement of the height of pigment epithelium detachment and finally fluorescein and indocyaningreen angiography. In cases of functional and morphological deterioration, we changed the treatment from 1.25 mg pegaptanib (Macugen) to 0.5 mg ranbizumab (Lucentis). Results During the mean follow-up of 46.5 weeks (95 % CI 35.9 - 57.1) no RIP occurred. After changing the drug, visual acuity showed a stabilisation or improvement in 11 cases. Also the height of PED decreased after beginning with ranbizumab. Regarding the therapeutic outcome, no difference between eyes with serous PED caused by occult CNV or RAP could be observed. Conclusion Treatment using VEGF inhibitors in patients suffering from AMD with exudative serious PED has proven to be effective regarding both the morphological damage and functional injuries. In cases of therapeutic failure after pegaptanib functional and/or morphological stabilisation of the course of this disease can be achieved by changing to ranbizumab. Nevertheless, prospective clinical studies with a larger number of patients are necessary for confirmation of these findings.

Autofluorescence (AF) of the retinal pigment epithelium (RPE) are thought to reflect metabolic activity of the RPE cells, which in turn is largely driven by photoreceptor outer segment renewal. In exudative AMD, choroidal new vessels (CNV) may be confined to Bruch's membrane, or transgress the RPE, with consequence loss of photoreceptor cells. It has been suggested that they may be distinguished with autofluorescence imaging. The aim of our study was to analyze the prognostic value of RPE autofluorescence in relationship to the therapeutic outcome of anti-VEGF (vascular endothelial growth factor) therapy in exudative AMD.AF images (Heidelberg Retina Angiograph) were obtained from 95 eyes (95 patients, mean age 77.64 years, 39 male and 56 female) with exudative macular lesions and associated drusen before therapy with intravitreal Bevacizumab (Avastin). Increased, normal, or decreased AF of a central area with diameters of 500 and 1,000 microm around the foveola were distinguished, and compared with the outcome of central vision. As a measure of data reproducibility (inter- and intraobserver variability), the kappa statistics (K0.6 "good", K0.8 "excellent") and exact agreement in % were calculated.Analysis of AF showed a significant difference in outcome of visual acuity in eyes with changes in AF of the central 500 and 1000 microm (Mann-Whitney test, p500 mum0.001, p1,000 microm = 0.02). Comparison of eyes with increased AF to the other eyes also resulted a significant difference in visual acuity at follow-up (p (incr)0.001); those with decreased AF had no significant difference to the eyes with normal or increased AF (p (decr) = 0.1733).The RPE-AF of exudative AMD lesions varies greatly. The AF differences probably represent different kinds of metabolism disorders in the RPE. Furthermore, they apparently have a great influence on the chances of anti- vascular endothelial growth factor (VEGF) therapy success; in particular the development of visual acuity is less favorable in eyes with initially increased central AF.

Basal laminar and linear deposits (BLD) are associated with the development of choroidal neovascularization (CNV). Therefore, analysis of BLD composition may provide further information concerning the pathogenesis of BLD and CNV in age-related macular degeneration (AMD). BLD in 25 specimens of surgically removed CNV were examined, using histochemical and immunohistochemical methods, for extracellular matrix proteins and their modulating enzymes, and for cell markers and proteins involved in inflammatory processes. In addition, ultrastructural electron microscopic analysis (EM) was performed. The chemical and structural composition of all the BLD was similar. Only the inner aspect of the BLD contained laminin and collagen IV, which corresponded to a new RPE basal lamina upon EM analysis. The extracellular matrix protein predominantly found in all layers of BLD was vitronectin, which was seen as a homogeneous material within the BLD upon EM analysis. The metalloproteinases MMP-2 and MMP-9 could only be detected in the inner aspect, while MMP-7 and TIMP-3 were observed predominantly in the outer aspect of BLD. In this area, staining for phospholipids and less intensely for neutral lipids was also visible. The labelling of complement complexes C3 and C5b-9 was intensely positive, and vascular endothelial growth factor (VEGF) was detected in all BLDs. Diffuse deposits such as BLD appear consistently with the development of CNV in AMD. They consist of extracellular matrix components and predominantly vitronectin. However, activated complement and VEGF could also be detected. The results of the current study may support the hypothesis that inflammatory processes are involved in the pathogenesis of BLD and CNV in AMD.

Ziel Besonders bei epiretinalen pathologischen Veranderungen der Makula bietet die nahtlose Technik bei der chirurgischen Intervention gute Moglichkeiten eines schonenden Verfahrens. Kritisiert wurden zunachst eine unzureichende Dichtigkeit mit einem erhohten Endophthalmitisrisiko und eine zu hohe Flexibilitat der Instrumente. Diese retrospektive Analyse soll das Verfahren der 25-Gauge-Technik der Pars-plana-Vitrektomie bewerten.

INTRODUCTION: Occlusion of the central retinal vein (CRVO) is the second most frequent cause for blindness in the course of pathological changes of the vascular system. Vitreous haemorrhages and neovascular glaucoma are known as serious complications. Clinically accepted guidelines for treating CRVO do not exist up to now. In this report our results after radial optic neurotomy (RON) of patients suffering from CRVO associated with visual deterioration are summarised. PATIENTS AND METHOD: 78 patients (mean age 68 year, gender: 41 male, 37 female) with visual acuity of 0.2 or worse were treated with RON. Mean follow-up was 13 months. 35 patients underwent previously haemodilution treatment without success. Visual acuity tests, fluorescein angiographic appearance, OCT and postoperative complications were analysed, in 47 % additionally VEP, ERG and the visual field were evaluated. RON was carried out by conventional pars plana vitrectomy. Neurotomy was performed at the nasal side of the optic disc in all cases. Neither ILM peeling nor gas tamponade was used. Follow-up examinations were carried out after 2 and 4 weeks, after 3 and 6 months and after 3 years. RESULTS: Improvement of morpholocial parameters could be registered in 95 % of our patients by means of fluorescein angiography or OCT. Visual acuity improved in 81 % and worsened in 10 %. After 6 months patients with non-ischaemic CRVO had a significantly better visual acuity compared to patients with ischaemic CRVO. A retino-choriodal anastomosis could be observed in 38 (48 %) eyes, all these patients experienced visual improvement. The results of VEP and ERG showed partial recovery in all cases. A temporal visual field defect occurred postoperatively in 95 % of our patients. CONCLUSION: Visual acuitiy of patients suffering from non-ischaemic CRVO with low preoperative visual acuity and short history may improve after RON. Frequent complications were temporal field defects and vitreous haemorrhage. Further randomised studies are necessary to compare these results after RON with other alternative therapeutic procedures, for example, intravitreal injection of VEGF inhibitors.

„Angioid streaks“ sind die ophthalmologische Manifestation bei Pseudoxanthoma elasticum, einer erblichen Systemerkrankung. Sternformig von der Papille ausgehende gefasahnliche streifige Lasionen auf der Ebene des retinalen Pigmentepithels und der Bruch-Membran kennzeichnen das typische klinische Bild. Fur oft erhebliche Sehminderungen sind sekundare chorioidale Neovaskularisationen verantwortlich. Eine erfolgreiche Behandlung dieser Neovaskularisationen ist bisher nicht bekannt. Die Argonlasertherapie extrafoveolarer Membranen zeigte eine hohe Rezidivrate mit zentropedaler Ausrichtung. Auch die PDT mit Verteporfin brachte allein und in Kombination mit intravitrealer Applikation von Triamcinolon nicht die erhoffte Wirksamkeit wie sie bei der altersabhangigen Makuladegeneration (AMD) erwartet werden kann. Nach dem Einzug der Angiogenesehemmer (Bevacizumab, Ranibizumab, Pegaptanib) in die Therapie von chorioidalen Neovaskularisationen bei der AMD stellte sich fur uns die Frage, ob diese Substanzen ahnliche Wirkungen bei sekundaren chorioidalen Neovaskularisationen erzielen konnten. In dem hier vorgestellten Fall konnte nach erfolgloser Behandlung mit Verteporfin mit fortschreitender Visusminderung und persistierender Leckage der CNV durch die intravitreale Applikation von Bevacizumab ein morphologisch und funktionell gutes Ergebnis erzielt werden. Zu Evaluierung dieser Therapie sind weitere Ergebnisse dringend notwendig.

We investigate the association between morphologic findings in optical coherence tomography angiography (OCTA) as a new method offering the visualization of deeper layers of retinal vasculature and fluorescein angiography (FA) and macular pigment imaging and in Type 2 macular telangiectasia.Fourty-two eyes of 21 patients with macular telangiectasia (38-68 years, 14 female) were examined by FA and OCTA and 24 eyes additionally with dual-wavelength autofluorescence. Early and late FA, macular pigment density images, and (after segmentation of retinal vasculature into superficial and deep capillary network and outer) OCTA images were graded into standardized categories. Agreement between the methods was evaluated statistically.In OCTA, a reduction of density of superficial capillaries, dilated vessels in the deep capillary network, anastomoses toward the superficial capillary network, and "new" vessels in the outer retina layers can be detected. The described anatomical features, especially in the deep capillary plexus and outer retina corresponded well with changes in FA. Classes of macular pigment distribution correlated most with classes of changes in OCTA superficial capillary plexus.Progressive changes in macular telangiectasia apparent in FA and macular pigment imaging are most obvious in the deep capillary network and outer retina in OCTA. Optical coherence tomography angiography offers a noninvasive technology to analyze vascular changes in the retina and choroid of patients with macular telangiectasia.

Background/Aims: We examined the effect of human complement sera (HCS) on retinal pigment epithelial (RPE) cells with respect to pro-inflammatory mediators relevant in early age-related macular degeneration (AMD). Methods: RPE cells were treated with complement-containing HCS or with heat-inactivated (HI) HCS or C7-deficient HCS as controls. Cells were analysed for C5b-9 using immunocytochemistry and flow cytometry. Interleukin (IL)-6, IL-8, and monocyte chemoattractant protein-1 (MCP-1) were quantified by ELISA and RT-PCR. Tumour necrosis factor-a (TNF-a), intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1), were analysed by Western blotting. The intracellular distribution of nuclear factor (NF)-κB was investigated by immunofluorescence. Results: A concentration-dependent increased staining for C5b-9 but no influence on cell viability was observed after HCS treatment. ELISA and RT-PCR analysis revealed elevated secretion and expression of IL-6, IL-8, and MCP-1. Western blot analysis showed a concentration-dependent increase in ICAM-1, VCAM-1, and TNF-a in response to HCS, and immunofluorescence staining revealed nuclear translocation of NF-κB. Conclusion: This study suggests that complement stimulates NF-κB activation in RPE cells that might further create a pro-inflammatory environment. All these factors together may support early AMD development.

Macular pigment (MP) reduces oxidative damage in the central retina and can be quantified by flicker-photometric analysis (HFP) of MP optical density. These analyses demonstrate a very good correlation with central absorption by MP on autofluorescence (AF) images. With these techniques different types of MP-distribution have been described. In the present study a quantification analysis of MP in AF images was developed to verify these MP types and to compare MP distribution patterns between healthy individuals and those with age-related macular degeneration (AMD). AF images (HRA) were analysed with respect to the area of central and paracentral absorption in 400 eyes with a computerised analysis program of MP optical density. The patients were between 41 and 90 years old (mean 67.2 years); 168 were male and 232 female, and 253 had early AMD and 147 showed no AMD characteristics. The central MP concentrations (peak) were measured, the amount of MP values within the first 8-pixel radius (“C”), the total amount of MP within a 120-pixel radius (“T”) were calculated as the volume of the MP values over the regarded radius and the C/T ratio was registered. Four types of MP distribution (type 1, intense central and paracentral MP; type 2, less intense central and paracentral MP; type 3, only central MP; type 4, only paracentral MP) were identified. The differences in MP distribution were confirmed and clearly characterised by quantitative analyses of peak, total MP (“T”), central MP (“C”) and C/T ratio: mean peak in type 1, 0.65; type 2, 0.42; type 3, 0.42; type 4, 0.29; mean total amount of MP in 120-pixel radius (“T”) in type 1, 5829.0; type 2, 4412.5; type 3, 2709; type 4, 4302.8. MP types with lower levels of MP were significantly more often observed in the AMD group (AMD: type 1, 120=47.4%; types 2–4, 133=52.6%; healthy eyes: type 1, 112=76.2%; types 2–4, 35=23.8%) (P

Hintergrund. Die Fluoreszenzangiographie (FAG) erlaubt die Unterscheidung verschiedener Formen der exsudativen altersabhangigen Makuladegeneration (AMD). Ziel der vorliegenden Studie war es, den histologischen Aufbau der Lasionen zu vergleichen und mit der mittels Fluoreszenzangiographie vorgenommenen Klassifizierung zu korrelieren. Methode. Der histologische Aufbau von 36 subretinalen Lasionen, die operativ im Zuge von Makulatranslokationen entfernt wurden, wurde lichtmikroskopisch untersucht und mit den angiographischen Befunden korreliert. Ergebnisse. Die fluoreszenzangiographische Klassifizierung stimmte mit der Histologie uberein. Histologisches Hauptmerkmal der klassischen chorioidalen Neovaskularisation ist das Auftreten einer subretinalen fibrovaskularen Membran. Uber 50% der in dieser Studie untersuchten klassischen chorioidalen Neovaskularisationen (CNV) weisen zusatzlich subpigmentepitheliale Membranen auf.Okkulte chorioidale Neovaskularisationen weisen als histologisches Hauptmerkmal eine subpigmentepitheliale fibrovaskulare Membran auf.Auffallendes gemeinsames histologisches Merkmal der exsudativen altersabhangigen Makuladegeneration ist das Auftreten von diffusen Ablagerungen. Schlussfolgerung. Die unterschiedlichen fluoreszenzangiographischen Merkmale bei Formen der exudativen AMD konnten in der histologischen Analyse mit einer unterschiedlichen Lokalisation der CNV im Verhaltnis zum RPE korreliert werden.

BACKGROUND A pigment epithelial detachment (PED) is an exudative manifestation of late age-related macular degeneration (AMD). Its long-term unfavourable prognosis is influenced by the association of a neovascular membrane. Seemingly identical PEDs in ophthalmoscopy can be further differentiated by fluorescein and indocyanine green angiography. The purpose of this prospective follow-up study was to determine the most reliable angiographic classification to distinguish PEDs in AMD and to evaluate their outcome. MATERIAL AND METHODS 73 eyes of 68 patients with a PED in AMD were examined with simultaneous angiography with fluorescein and indocyanine green. 34 eyes were additionally scanned by retinatomography. Fluorescein angiographic classification comprises 4 types: 1. early hyperfluorescent type, 2. late hyperfluorescent type, 3. drusen type, 4. irregular fluorescent type. Indocyanine green angiographic classification consists of the following three groups: 1. angiographically no vascularisation, 2. associated choroidal neovascularisation, 3. associated polypoidal choroidal vasculopathy. RESULTS Both classifications show statistically significant correlation with visual acuity (fluorescein classification: P = 0.0112, ICG-classification: P = 0.0004) and area of the PEDs (fluorescein classification: P = 0.0002, ICG-classification: P < 0.0001). ICG-classification additionally is significantly associated with the volume (P = 0.0008). Both classifications correlate (P = 0.0001). Factors influencing visual acuity are: age (P = 0.0044), associated neovascular membrane (P = 0.0004), area (P < 0.0001), volume (P = 0.0077) and height (P < 0.0001). CONCLUSIONS PEDs in AMD can best be classified by indocyanine green angiography on the basis of an associated prognostically important neovascular membrane, which can only be further distinguished into choroidal neovascularisation or polypoidal choroidal vasculopathy by indocyanine green angiography. Statistical analysis shows qualitatively and quantitatively more significant results for the indocyanine green angiographic classification.

A prospective analysis was performed to characterize the angiographic appearance, natural course and prognosis of serous pigment epithelial detachments (PEDs) in elderly patients. The aim was to differentiate PEDs according to their angiographic characteristics and to analyze the specific clinical, visual and morphologic course of the different PEDs.Fluorescein and indocyanine green angiography were performed in 101 consecutive patients (53-87 years; 63 female, 38 male) with clinical signs of serous PED and drusen.Different types of serous PED were identified: polypoidal choroidal vasculopathy (PCV)-associated PED in 14 patients (13.9%), vascular PED in 72 (71.2%), and avascular PED in 15 (14.9%). All PEDs resulted initially in similar visual loss. Avascular PEDs were smaller than vascular PEDs, and the latter were smaller than PCV-PEDs. During follow-up these differences were always present, but all PEDs enlarged initially followed by regression. This course was associated in all PEDs with progressive visual loss, accompanied by the development of RPE atrophy in avascular PEDs or disciform scars or RPE tears in the two other types.Despite different associations, all PEDs have a similar clinical course with respect to visual loss and enlargement or regression. This is compatible with the proposed common pathogenetic background with a hydrophobic barrier in Bruch's membrane causing fluid resulting from RPE pumping activity to accumulate between the pigment epithelium and Bruch's membrane.

Zielsetzung. In einer prospektiven Analyse wurden die angiographischen Befunde von Pigmentepithelabhebungen bei AMD differenziert. Es sollte festgestellt werden, ob Charakteristika einer “polypoidal choroidal vasculopathy” als Ursache fur eine PE-Abhebung auch bei alteren Patienten mit mitteleuropaischem Hintergrund zu beobachten sind. Patienten und Methoden. Bei 101 konsekutiven Patienten mit einer PE-Abhebung und Drusen wurde eine Fluoreszein- und Indozyaningrunangiographie vorgenommen. Ergebnisse. Die PE-Abhebungen konnten wie folgt klassifiziert werden: PCV-assoziierte bei 14, vaskularisierte bei 72, nicht-vaskularisierte PE-Abhebungen bei 15 Patienten. Schlussfolgerungen. Die klinische Diagnose einer PE-Abhebung bei AMD kann angiographisch in PCV-assoziierte, vaskularisierte und nicht-vaskularisierte Formen unterteilt werden. Diese Unterteilung ist wichtig, da die PCV-assoziierte PE-Abhebung pathogenetisch von den anderen Subtypen abzugrenzen ist. Da zudem der naturliche Verlauf dieses Subtypes weniger vorhersagbar ist und die koagulative Beeinflussbarkeit gunstiger erscheint, ist auch aus klinisch-therapeutischer Sicht eine Differenzierung fur die Patienten von Bedeutung.

Hintergrund: Die Einfuhrung und Zulassung von Ocriplasmin als intravitreal zu applizierendes Medikament in der pharmakologischen Behandlung von vitreomakularen Traktionen (VMT) stellt einen vollig neuen Therapieansatz dar, durch den vitreoretinale chirurgische Eingriffe moglicherweise vermieden werden konnen. Es wird in dieser retrospektiven Analyse uber die ersten Erfahrungen beim Einsatz von Ocriplasmin im klinischen Alltag berichtet. Methoden: Seit Marz 2013 wurde bei einem Kollektiv von 20 Patienten die Indikation zur pharmakologischen Vitreolyse einer VMT oder eines Makulaforamens mit VMT mittels Ocriplasmin gestellt, von denen 14 behandelt wurden. Nach einem mittleren Kontrollintervall von 3 Monaten wurde bei noch bestehender Symptomatik die Therapie geplant. Am Tag der intravitrealen Injektion (IVI) wurde nochmals ein SD-OCT durchgefuhrt. Bei den 14 behandelten Patienten wurde der bestkorrigierte Dezimalvisus (BCVA) praoperativ, am Tag 7 und 28 und dann monatlich ausgewertet. Es wurden zur Analyse die SD-OCT Aufnahmen am Indikationstag, am Tag der Behandlung, und bei allen Kontrolluntersuchungen und das Nebenwirkungsprofil ausgewertet. Ergebnisse: Bei 10 Pat. war eine symptomatische VMT und bei 4 Pat. ein durchgreifendes Makulaforamen Stadium 2 mit VMT die Indikation fur die Therapie. Am Tag der Injektion war bei 3 Pat. vor der IVI die VMT bereits spontan gelost und der mittlere BCVA von 0,3 auf 0,5 angestiegen. In 2 Fallen war das Makulaforamen schon am 7. Tag deutlich vergrosert. Die mittlere Sehscharfe verbesserte sich von 0,3 vor der IVI bis zum 90. Tag auf 0,6. Als schwerwiegende Nebenwirkung trat bei einem Patienten ein massives zystoides Makulaodem auf. Weitere haufige Nebenwirkungen waren bis zum Tag 28 nach IVI Photopsien und storende Glaskorpertrubungen. Schlussfolgerung: Erste klinische Erfahrungen im Einsatz von Ocriplasmin bestatigen den therapeutischen Effekt bei der pharmakologischen Behandlung einer VMT. Kleine Makulalocher mit VMT zeigen haufiger einen Verschluss. Das Spektrum der Nebenwirkungen ist breit und muss bei der Patientenaufklarung berucksichtigt werden, da sich diese von den bekannten Nebenwirkungen anderer IVI-Medikamente unterscheiden. Um den Behandlungserfolg besser vorhersagen zu konnen, sind weitere prospektive Studien notig.

Hintergrund. Es wurde untersucht, ob bei der zentralserosen Chorioretinopathie (CSCR) eine Korrelation zwischen angiographischem und elektrophysiologischem Befund besteht und ob dies Aussagen uber Krankheitsverlauf und Pathogenese zulasst. Material/Methoden. Mit Hilfe der Fluoreszein- und Indozyaningrun-Angiographie und multifokalem ERG wurden 49 Patienten mit einseitiger akuter CSCR untersucht. Die Untersuchungen wurden nach 6 und 12 Wochen wiederholt. Ergebnisse. Angiographisch zeigten sich bei 47 Patienten im fruhen ICG-Bild hypofluoreszente Areale, die sich bei 39 Patienten im spaten ICG-Bild hyperfluoreszent anfarbten; 31 der asymptomatischen Partneraugen zeigten Auffalligkeiten im ICG-Bild. Die ERG-Amplituden waren initial vermindert und zeigten eine nur langsame Erholung im Verlauf. Wahrend der Nachbeobachtungszeit erfolgt eine angiographische Abheilung bei 44 Patienten. Die Reduktion der ERG-Amplituden ist deutlich langsamer und erreicht wahrend des Untersuchungszeitraums nicht die Normalwerte. Schlussfolgerung. Angiographisch kommt es bei der CSCR zunachst zu einer lokalen Hypofluoreszenz mit anschliesender Hyperfluoreszenz aufgrund ausgepragter Schrankenstorungen. Die funktionelle Erholung hinkt der morphologischen deutlich hinterher. Das mERG erscheint als ein geeigneter Verlaufsparameter.

Hintergrund: Es wurde untersucht, ob die Laser-scanning-Tomographie zu einer 3-dimensionalen Darstellung, Vermessung und Verlaufsbeobachtung von Pigmentepithel-Abhebungen (PE-Abhebungen) bei AMD geeignet ist. Fluoreszenzangiographische und klinische Befunde wurden mit tomographischen Befunden korreliert. Patienten und Methode: Mit dem Heidelberg-Retina-Tomographen (HRT) wurden 60 Augen von 55 konsekutiven Patienten (19 Manner; 36 Frauen) im Alter von 54 bis 87 Jahren (Mittel: 72,2 J) mit einer PE-Abhebung bei AMD untersucht. In Korrelation zu angiographischen Befunden wurden Flache, maximale Hohe, Volumen und raumliche Konfiguration analysiert. Verlaufskontrollen erfolgten nach 3 und 6 Monaten. Ergebnisse: Die maximale Hohe betrug zwischen 0,113 und 0,831 mm (Mittel: 0,425±0,19), die Flache betrug 0,93 bis 19,733 mm2 (Mittel: 10,594±5,51) in Ubereinstimmung (Korrelationskoeffizient: 0,873) mit angiographischen Messwerten. Das Volumen lag zwischen 0,073 und 6,628 mm3 (Mittel: 2,55±1,9). Es zeigte sich eine tendenzielle Volumenzunahme nicht therapierter PE-Abhebungen in Abhangigkeit vom Ausgangsvolumen. Ein Pigmentepitheleinris trat bei 3 besonders voluminosen (Mittel: 0,504 mm3±1,3) und hochblasigen (Max. Hohe im Mittel 0,63±0,14) Abhebungen auf. An Neovaskularisationsstellen (39 Augen) zeigte sich in der 3-D-Darstellung in der Mehrzahl (24Augen) eine korrespondierende Konturunregelmasigkeit. Angiographisch differenzierbare Typen der PE Abhebung zeigten Unterschiede auch in der HRT-Darstellung. Schlusfolgerung: Die Laser-scanning-Tomographie erlaubt eine 3-dimensionale Darstellung und Vermessung von PE-Abhebungen und scheint als Verfahren fur eine besonders differenzierte Verlaufsbeobachtung geeignet. Eine Analyse der raumlichen Konfiguration kann Hinweise auf vorhandene Neovaskularisationen oder Risiko eines PE-Einrises liefern.

Objective This study aimed to evaluate the efficacy and safety of ruthenium-106 brachytherapy of large peripheral retinal capillary hemangiomas. Design A retrospective case series. Participants In 25 eyes of 24 patients, peripheral capillary retinal hemangiomas were treated. Intervention Brachytherapy using 106-ruthenium/106-rhodium plaques was performed. Main outcome measures Eyes were reviewed for hemangioma regression after brachytherapy, occurrence of retinal detachment, requirement of additional vitreoretinal surgery, final visual outcome, and final retinal status. Results Preoperative mean visual acuity of all eyes treated was 20/60, mean hemangioma diameter was 3.8 mm, corresponding to approximately 2 disc diameters. In 14 eyes, the retina was attached before surgery, 8 eyes showed an exudative detachment, and 3 eyes showed a traction detachment. Fifteen patients had definite von Hippel-Lindau syndrome. Twenty-three of 25 hemangiomas could be destroyed by single brachytherapy. In 16 eyes, a favorable outcome could be achieved. In nine eyes, outcome was unfavorable, characterized by a severe drop in visual acuity, a persisting exudative retinal detachment, or a recurrent traction detachment. In one eye requiring repeated brachytherapy, irradiation retinopathy occurred. Hemangiomas up to a size of approximately 5.0 mm without preoperative exudative detachment could be treated safely by brachytherapy, whereas a larger hemangioma size or a pre-existing exudative retinal detachment predisposed to an unfavorable outcome. Conclusion Solitary peripheral retinal hemangioma can be ablated effectively by ruthenium-106 brachytherapy. A favorable outcome can be expected if the hemangioma diameter is 5.0 mm or smaller and if there is no preoperative exudative retinal detachment.

Background Lipofuscin is the main fluorophore of the human fundus. Because lipofuscin is the result of the accumulation of metabolic debris in pigmentepithelial cells (RPE), the autofluorescence can be interpreted as a clinical sign for the metabolic activity of the RPE. In order to get informations of RPE-function in different types of late AMD, the autofluorescence patterns in patients with late AMD were analyzed. Material and method A prospective examination of the fundus-autofluorescence of 64 eyes of 52 patients with different types of late AMD was performed using a confocal scanning-laser-opthalmopscope. The autofluorescence images were categorized in respect to the type of late AMD according to the opthalmoscopic and fluoresceine-angiographic findings. Results Reduced autofluorescence was found in the centre of occult (78,6% ) and classic (100% ) choroidal neovascularisations (NV) as well as in the occult NV of RPE detachments. A loss of autofluorescence was related to the RPE free area of RPE-tears (100% ) and to RPE-atrophy (88.9% ) with sometimes increased autofluorescence at the rim. Increased autofluorescence could be seen at the surface of RPE-detachments (71.4% ), in the area of the shrink age of RPE in RPE-tears (100% ) as well as at RPE-proliferations in small occult NV (100%). Disciforme scars showed variable patterns of autofluorescence. Conclusion The autofluorescence of the RPE can be analyzed clinically with the described method. Different patterns of autofluorescence could be revealed in different types of late AMD. Increased autofluorescence was found in lesions with proliferative or phagocytotic metabolic activity of the RPE like RPE-detachments, shrinked RPE in RPE-tears or occult NV with RPE-proliferations. The reduced autofluorescence in occult or classical choroidal NV can be interpreted as a sign of decompensation of the RPE and was also seen in areas with RPE-loss.

Aim/background—The most common choice of treatment for choroidal haemangiomas (CH) in the past has been the employment of scatter photocoagulation of the surface. This management often requires repetitive treatment or additional invasive management due to massive exudative detachment of the retina. The aim of this retrospective study was to investigate the outcome of the alternative application of low dose external beam irradiation with high energetic photons on these tumours. Methods—A total absorbed dose of 20 Gy was applied to a total of 51 symptomatic eyes: 36 with a circumscribed CH of the posterior pole and 15 with diVuse CH as part of the Sturge‐Weber syndrome. The indication for treatment was an exudative retinal detachment including or threatening the fovea. The mean follow up times in each group were 4.5 and 5.3 years, respectively. Out of a group of 33 patients from whom reliable data could be derived, 17 had symptoms lasting longer than 6 months. Results—In 23 cases (63.8%) with circumscribed CH complete resolution of the subretinalfluid was achieved; the remaining 13 cases (36.2%) showed residual serous detachment distant to the fovea. The visual acuity improved by two or more lines in 14 cases (38.9%), remained stable in 14 cases (38.9%), and decreased in eight cases (22.2%). The functional success was dependent on the lag duration between onset of first subjective symptoms and treatment. The morphological results with diVuse CH were similar to those of the group of circumscribed CH. The visual acuity (VA) at last examination was improved in seven cases (46.6%);in the remaining eight cases, VA was unchanged or had deteriorated. The poor functional outcome in the latter was mainly attributable to secondary glaucoma. Conclusion—External beam irradiation is a useful and a low invasive therapeutic option for CH. A successful functional outcome is dependent on the time delay between first onset of symptoms and the beginning of therapy, the formation of subretinal fibrosis, and also on secondary glaucoma in the case of Sturge‐Weber syndrome. (Br J Ophthalmol 1997;81:267‐273) Haemangiomas of the choroid are rare vascular hamartomas that can occur in two forms: circumscribed choroidal haemangiomas (CH), which are solitary and predominantly located at the posterior pole, and diVuse CH, which are usually part of the Sturge‐Weber syndrome. Histological examination of these tumours shows a vascular pattern, dominated by cavernous portions, but capillary tumours and mixed patterns are also observed. 12

Purpose To quantitatively analyze the distribution of macular pigment (MP) over a period of 5 years and for monitoring progression of macular telangiectasia. Methods Macular pigment concentration (autofluorescence, excitation wavelengths: 488 and 514 nm) was determined at baseline and after 5 years in 43 eyes of 22 subjects (46-80 years; mean, 65.6 years; 10 men) participating in the macular telangiectasia project. Results Mean MP density at 0.5° declined in the segment (one eighth of a circle) with the highest MP optical density (-0.04 density units; P= 0.015), where density units (DU), and also averaged in the 2 segments that divided segments with detectable MP from those in which MP was no longer detectable (-0.04 density units; P = 0.0005). In the first segment mentioned, 2° values decreased to a lesser extent and not significantly. The diameter of MP loss expanded horizontally from 2.64 mm to 2.74 mm (P = 0.0001) but not vertically. Macular pigment density in the "halo" of peripheral MP at a mean of 5.44° (4.53-6.21°) increased (+0.01 DU; P= 0.01). Conclusion Five years of follow-up resulted in central (0.5°) reduction and peripheral (4.53-6.21°) accumulation of MP. Longer period of follow-up may disclose significant changes in paracentral locations. The area of central MP loss expands in particular in a horizontal direction and less vertically. Centrifugal movement of MP during disease may explain our findings.

Genetic factors contribute to the development and progression of age-related macular degeneration (AMD). We aimed to assess the association of drusen as phenotypic characteristics of early AMD and their progression with polymorphisms in the CFH, ABCA1, and ARMS2 genes.In the Münster Aging and Retina Study (MARS), drusen were detected in 406 patients with early AMD and 170 healthy controls according to the International Classification using fundus photographs, with a follow-up examination after 2.6 years (median). Six drusen features were assessed: drusen number (/≥20); confluence of drusen (/≥50 %), largest drusen size (/≥175 μm); area occupied by drusen (/≥10 %); most frequent drusen size (/≥175 μm), and presence of soft, indistinct drusen (no/yes). Based on these features, an unweighted summary drusen severity score (DSS; categorized in "low", "intermediate" and "high") was calculated. The relationship of each drusen feature and the DSS with CFH rs1061170, ABCA1 rs1883025, and ARMS2 rs10490924 at baseline and after 2.6 years was analyzed using multivariate logistic regression models.Cross-sectionally, each drusen feature was associated with a higher frequency of the CFH and ARMS2 risk variants. Compared to healthy eyes, the CFH risk variant was more common in eyes with early as well as advanced drusen features, while the ARMS2 variant was only associated with advanced drusen. After 2.6 years, 43 % of the eyes showed a progression of at least 1 unit in the DSS. The progression from low to higher DSS was inversely associated with ABCA1 (OR = 0.54), and the progression from intermediate to high DSS was positively related to CFH rs1061170 (OR = 2.3; p 0.05 for each).Variants in CFH, ABCA1, and ARMS2 genes are related to the presence and progression of drusen in early AMD. CFH and, inversely, ABCA1 seem to be involved in early drusen development, while the role of ARMS2 is more pronounced in advanced stages of early AMD.

Bei 15 Patienten mit Makulaforamen im Stadium III nach Gass wurde eine Pars-plana-Vitrektomie mit Membranentfernung vorgenommen. Am Ende der Operation erfolgte eine Auffullung des Glaskorperraums mit einem 20%-SF-6-Gas-Luft-Gemisch, und die Patienten musten fur mehrere Tage eine Bauchlage einnehmen. Methode: Praoperativ und 4 – 7 Monate postoperativ wurde ein Fundusfoto von der Lochregion und der abgehobenen Netzhautregion mit einer Zeiss-Funduskamera angefertigt. Auf den in digitaler Form vorliegenden Bildern wurden die Flache des Lochs und die Flache der abgehobenen Netzhautregion mit einem speziellen, fur Meszwecke ausgelegten Bildverarbeitungsprogramm ausgemessen. Ergebnisse: Bei 7 Patienten kam es zu einer Visusverbesserung, in den restlichen Fallen blieb der Visus gleich oder nahm um 1 Visusstufe ab. In 5 Fallen, also in 33%, konnte eine vollstandige Wiederanlegung der Netzhaut am Lochbereich erreicht werden. In 8 Fallen verkleinerte sich die Flache des abgehobenen Netzhautareals um 22% im Mittel. In 2 Fallen vergroserte sich die Ablatio. In 2 Fallen war der Rand des Lochs nicht mehr abgrenzbar. In den restlichen Fallen anderte sich der Durchmesser des Lochs um weniger als 10%. Schlusfolgerung: Die Ergebnisse zeigen, das auch in den Fallen, wo eine komplette Wiederanlegung nicht erreicht werden konnte, mit einer Reduzierung des abgehobenen Netzhautbereichs zu rechnen ist. Dementsprechend beobachtet man eine Abnahme der Metamorphopsien. Der Anstieg der zentralen Sehscharfe ist allerdings weniger deutlich ausgepragt, so das wir bezuglich der Operationsindikation im Stadium III zunehmend zuruckhaltender geworden sind.

Die Interpretation subretinaler choroidaler Neovaskularisationen (CNV) in der Indozyaningrunangiographie (ICG-A) ist nicht einheitlich. Zur Klarung der Frage, wie exakt eine umschriebene Hyperfluoreszenz in der ICG-A die tatsachliche Morphologie wiedergibt, wurden die Befunde von okkulten und klassisch-demarkierten CNV der konventionellen Fluoresceinangiographie (FLA) mit denen der ICG-A verglichen. Von 168 retrospektiv analysierten ICG-A mit CNV lag in 153 Fallen eine altersabhangige Makuladegeneration (AMD) mit 114 okkult wachsenden und 39 klassischen Membranen vor. Die Angiographien wurden mit beiden Farbstoffen an einer modifizierten Zeiss-Funduskamera kombiniert mit digitaler Bildverarbeitung durchgefuhrt. In 42 Fallen (36,8%) der AMD-Patienten mit okkulter CNV zeigte die ICG-A eine demarkierte Membran. Die Morphologie und die zeitliche Darstellung waren extrem variabel. In der Gruppe der AMD-Patienten mit abgrenzbarer, klassischer Membran zeigte sich keine Anfarbung in 3 (7%), eine Demarkierung in Fruh- und Spatphase in 14 (36%), ausschlieslich in der Fruhphase in 5 (13%) und nur in der Spatphase in 17 (44%) der 39 Falle. Von diesen 17 Fallen war die Membran in 8 Befunden groser und in 9 kleiner als in der FLA. Die in der Fruh- bzw. Fruh- und Spatphase gesehenen, demarkierten Membranen waren in beiden Angiographien stets grosengleich. Das Muster der Darstellung einer CNV in der ICG-A ist komplex. Ein alleiniger Befund in der Spatphase der ICG-A sollte v. a. im Hinblick auf die Planung einer Laserkoagulation mit groser Zuruckhaltung interpretiert werden.

Background A tamponade of the vitreous space with silicone oil will obligatory lead to cataract after 6 to 12 months. Today it is easily possible, to implant an artificial lense in silicone oil filled eyes. However the combination of an artificial lense and silicone oil will lead to a strong inflammation in the anterior segment of the eye. Patients and methods 22 pseudophacic patients with silicone oil tamponade were examined 2 to 6 months after the operation. In 12 patients simple artificial lenses were implanted, in 10 patients heparin modified lenses were implanted. In 10 cases the lens was implanted followed by the insufflation of silicone oil in the vitreous cavity, in 2 cases a lens was implanted in a silicone oil filled eye and the silicon oil was not removed. In 8 cases the implantation of the artificial lens has been performed some months to years before the insufflation of the silicone oil. The indication for the silicon oil tamponade was a PVR retinal detachment in all cases. The following parameters were examined: Reaction of the pupil to light, pupil round or oval in miosis, examination of the fundus peripherie possible after mydriasis, fixation of the iris with parts of the capsula or with the anterior surface of the lens? In addition in 12 cases the postoperative refraction was compared with the results of the biometry, which was performed before the operation. Results In the cases with a simple lens in about 50% an incomplete miosis or an oval pupil because of fixation of the iris with parts of the capsula or with the anterior surface of the lense could be observed. In the cases with heparin modified lenses these complications could be observed in 20%. In all cases a strong opacification of the capsula was seen. In 8 of 12 cases with combined procedure a small hyperopia was measured, in 4 cases a large deviation was measured. Conclusions The implantation of an artificial lens in silicone oil filled eyes is an alternative to the aphacic status with an Ando Iridectomy. Obviously heparin modified lenses have advantages in these cases. Because of the strong cataract formation we suggest to remove the anterior and the posterior capsula in the first operative session and to implant the haptics of the lens into the sulcus. Because of the high rate of complications generally first a stable retina condition should be reached before the implanation of an artificial lens is performed.

Purpose This retrospective study was designed to investigate the re-injection interval, efficacy and safety of OZURDEX® in routine clinical practice. Methods This analysis contains data from 87 patients from 10 sites in Germany who had received at least 2 OZURDEX® injections. Data was collected from the time of the patients’ first injection until 3 – 6 months following their latest OZURDEX® injection. Results The mean time to OZURDEX® re-injection between 1st and 2nd treatments was 141 days (5.03 months) in the overall population. Mean time intervals for the BRVO and CRVO sub-populations were 153 days (5.46 months) and 127 days (4.52 months) respectively. In the overall population, a mean LogMAR BCVA improvement from 0.68 to 0.51 was recorded following the last OZURDEX® injection (mean time of 11.0 weeks post-injection). For BRVO, mean improvement was from 0.54 to 0.43 (mean time of 10.5 weeks post injection) and for CRVO, 0.83 to 0.58 (mean time of 11.5 weeks post injection). Reductions in central retinal thickness were also observed. Intraocular pressure measurements over 25mmHg were reported in 19.5% of patients. No glaucoma surgeries were reported. 5 patients underwent cataract surgery during the course of the study (4 had known lens opacity at baseline and opacity status data from the 5th was missing). Conclusion In this real life study, OZURDEX® was found to be safe and effective with repeat treatments. The mean re-injection interval for RVO patients was 5.0 months.

PURPOSE: There is evidence for complement dysfunction in age-related macular degeneration (AMD). Complement activation leads to formation of the membrane attack complex (MAC), known to assemble on retinal pigment epithelial (RPE) cells. Therefore, the effect of sub-lytic MAC on RPE cells was examined with regard to pro-inflammatory or pro-angiogenic mediators relevant in AMD. METHODS: For sub-lytic MAC induction, RPE cells were incubated with an antiserum to complement regulatory protein CD59, followed by normal human serum (NHS) to induce 5% cell death, measured by a viability assay. MAC formation was evaluated by immunofluorescence and FACS analysis. Interleukin (IL)-6, -8, monocytic chemoattractant protein-1 (MCP-1), and vascular endothelial growth factor (VEGF) were quantified by enzyme-linked immunosorbent assay (ELISA). Intracellular MCP-1 was analysed by immunofluorescence, vitronectin by western blotting, and gelatinolytic matrix metalloproteinases (MMPs) by zymography. RESULTS: Incubation of RPE cells with the CD59 antiserum followed by 5% NHS induced sub-lytic amounts of MAC, verified by FACS and immunofluorescence. This treatment stimulated the cells to release IL-6, -8, MCP-1, and VEGF. MCP-1 staining, production of vitronectin, and gelatinolytic MMPs were also elevated in response to sub-lytic MAC. CONCLUSIONS: MAC assembly on RPE cells increases the IL-6, -8, and MCP-1 production. Therefore, sub-lytic MAC might have a significant role in generating a pro-inflammatory microenvironment, contributing to the development of AMD. Enhanced vitronectin might be a protective mechanism against MAC deposition. In addition, the increased expression of gelatinolytic MMPs and pro-angiogenic VEGF may be associated with neovascular processes and late AMD.