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Zusammenfassung Hintergrund Die hochauflösende optische Kohärenztomografie (OCT) ermöglicht eine kontrastreiche Bildgebung von Mikrostrukturen, die mit konventioneller Bildgebung nicht so detailliert darstellbar waren. Wir berichten über unsere Erfahrungen beim Einsatz der intraoperativen OCT (iOCT) in der vitreoretinalen Chirurgie. Methoden 110 Patienten mit vitreoretinalen Erkrankungen (Makulaforamen, epiretinale Membranen, vitreomakulärem Traktionssyndrom, Ablatio und Glaskörperblutung) wurden unter Visualisierung mit dem im Mikroskop integrierten iOCT-Gerät operiert. Ergebnisse Das iOCT liefert durch die Integration von Mikroskop und SD-OCT eine sofortige Visualisierung der „Region of Interest“ (ROI). Der Operateur erhält neben dem Mikroskopbild die intraoperative Darstellung aller Netzhautschichten, des Glaskörpers sowie der Instrument-Gewebe-Interaktion in Echtzeit und kann diese intraoperativ sofort verfügbare Information für die chirurgische Strategie nutzen. Schlussfolgerung Bisher ist das iOCT nur als Standmikroskop erhältlich, es besitzt keine Messfunktion, keine Tracking-Funktion, und die Metallinstrumente verdecken den Scan. Künftig könnten transparente Instrumente, Tracking-Funktionen, ein Autofokus sowie eine noch bessere Auflösung eine optimierte, lückenlose, hochauflösende intraoperative OCT-Diagnostik in Echtzeit erlauben.

We aimed to evaluate the neuroprotective efficacy of rasagiline in pseudophakic patients who had surgery for macula-off rhegmatogenous retinal detachment (RRD). This was a 6-month, prospective, randomized, double-blind, placebo-controlled pilot study. Patients presenting with acute macula-off RRD were recruited and randomized 1:1 to receive rasagiline 1 mg/day or placebo for 7 days. Best-corrected visual acuity (BCVA) and optical coherence tomography were acquired 1 day before as well as 2 days, 3 weeks, 3 months and 6 months after surgery. We screened 26 patients with RRD whereof 23 were eventually included and randomized. The primary outcome was final BCVA. Secondary outcomes included central retinal thickness (CRT) and adverse events (AE). We evaluated photoreceptor cells (prc) recovery through morphological measurements. The baseline characteristics were comparable between groups. BCVA significantly improved in both groups (letters gained: rasagiline 61.5 ± 18.1 vs placebo 55.3 ± 29.2, p = 0.56), but no significant inter-group difference was found at any visit. CRT was stable 3 weeks after surgery onwards, with no inter-group difference. No treatment-emergent AE occurred. Significant prc restoration was observed from 3 weeks to 6 months after surgery, without inter-group difference at either visit. Ellipsoid zone integrity (β = 0.517, p = 0.008) and foveal bulge (β = 0.387, p = 0.038) were significant predictors of good final BCVA. In conclusion, perioperative oral treatment with rasagiline 1 mg/day for 7 days did not show significant benefits on visual or anatomical outcomes in macula-off RRD patients.

Human amniotic membrane (hAM) has been employed as scaffolding material in a wide range of tissue engineering applications, especially as a skin dressing and as a graft for corneal treatment, due to the structure of the extracellular matrix and excellent biological properties that enhance both wound healing and tissue regeneration. This review highlights recent work and current knowledge on the application of native hAM, and/or production of hAM-based tissue-engineered products to create scaffolds mimicking the structure of the native membrane to enhance the hAM performance. Moreover, an overview is presented on the available (cryo) preservation techniques for storage of native hAM and tissue-engineered products that are necessary to maintain biological functions such as angiogenesis, anti-inflammation, antifibrotic and antibacterial activity.

Patients suffering from type 2 diabetes are at an increased risk of developing classical microvascular complications such as retinopathy, neuropathy, and nephropathy, which represent a significant health burden. Tight control of blood glucose, blood pressure, and serum cholesterol reduce the risk of microvascular complications but effective pharmacologically targeted treatment options for the treatment and prevention of diabetic microangiopathy are still lacking. Pharmacological inhibition of sodium glucose cotransporter 2 (SGLT2) might have the potential to directly protect against microvascular complications and could represent a potential treatment option. Randomized controlled clinical proof of concept trials are needed to investigate a potential central role of SGLT2 inhibitors in the prevention of diabetic microangiopathy and its classical clinical complications of retinopathy, neuropathy, and nephropathy.

Background Intravitreal injections are a mandatory treatment for macular edema due to nAMD, DME and RVO. These chronic diseases usually need chronic treatment using intravitreal injections with anti-VEGF agents. Thus, many trials were performed to define the best treatment interval using pro re nata regimes (PRN), fixed regimes or treat-and-extend regimes (TE). However, real-world studies reveal a high rate of losing patients within a 2-year interval of treatment observation causing worse results. In this study we analyzed retrospectively 2 years of real-world experience with an individualized treat-and-extend injection scheme. Methods Since 2015 our treatment scheme for intravitreal injections has been switched from PRN to TE. Out of 102 patients 59 completed a follow up time of 2 years. Every patient received visual acuity testing, SD-OCT and slit lamp examination prior to every injection. At each visit an injection was performed and the treatment interval was adjusted mainly on SD-OCT based morphologic changes by increasing or reducing in 2-week steps. Individual changes of the treatment protocol by face-to-face communication between physician and patient were possible. Results After 1 year of treatment visual acuity gain in nAMD was 7.4 ± 2.2 ETDRS letters (n = 34; injection frequency: 7.4 ± 0.4) respectively 6.1 ± 4.7 in DME (n = 9; injection frequency: 8.4 ± 1.1) and 9.7 ± 4.5 in RVO (n = 16; injection frequency: 7.6 ± 0.5). After 2 years of treatment results were as following: nAMD: visual acuity gain 6.9 ± 2.1 (injection frequency: 12.6 ± 0.7); DME: 11.1 ± 5.1 (injection frequency: 14.0 ± 1.0); RVO: 7.5 ± 5.0 (injection frequency: 11.2 ± 0.9). Planned treatment exit after 2 year was achieved in 29.4% of patients in nAMD (0% after 1 year); 0% in DME (0% after 1 year); and 31.3% in RVO (0% after 1 year). Patients’ persistence was 94.1% during the follow-up. Conclusion Using a consequent and individualized TE regime in daily practice may lead to a high patients’ persistence and visual acuity gains nearly comparable to those of large prospective clinical trials. Crucial factors are face-to-face communication with the patient as well as a stringent management regime. At this time TE may be the only instrument for proactive therapy which should therefore be regarded as a first-line tool in daily practice.

ZusammenfassungDas Ziel dieses Artikels ist es, einen Überblick zu geben über verschiedene Strategien zur Verwendung von PRN- und T&E-Therapieschemata (PRN: pro re nata; T&E: treat and extend) mit intravitrealen Anti-VEGF-Medikamenten (Bevacizumab, Ranibizumab oder Aflibercept) bei Patienten mit Netzhauterkrankungen wie neovaskulärer AMD, diabetischem Makulaödem und Makulaödem aufgrund von retinalen Venenverschlüssen. Der Schwerpunkt liegt dabei darauf, die Wirksamkeit und die Visusergebnisse des PRN- und des T&E-Regimes in Korrelation mit den wichtigsten Zulassungsstudien und Studien basierend auf den derzeit verfügbaren Daten vorzulegen. Wir diskutieren auch die Vor- und Nachteile der beiden Therapieregimes sowie die Überwachung und Behandlung der Krankheitsaktivität einschließlich der Behandlungsintervalle und Injektionsfrequenz. Derzeit gibt es ein zunehmendes Interesse, ein Regime zu etablieren, das die besten Visusergebnisse bei reduzierter Injektionsfrequenz und konsekutiv geringerer Belastung der Patienten durch individualisierte Behandlungsintervalle mit Minimierung der Anzahl der Klinikbesuche und der entstehenden Kosten bietet. Studien haben gezeigt, dass das PRN-Regime im realen Klinikalltag keine optimalen Visusergebnisse liefert. PRN erfordert häufige Arztbesuche, um den Krankheitsstatus zu kontrollieren und intravitreale Behandlung bei Bedarf reaktiv zu indizieren. Individualisierte T&E-Regimes können das Visusergebnis mit signifikant weniger Kontrolluntersuchungen verbessern im Gegensatz zu Therapieschemata mit einer monatlichen Applikation oder einem PRN-Regime.

Vorgestellt wird eine Methode zur Messung und Visualisierung des Patientenflows komplex strukturierter Augenambulanzen. Zugrunde liegt eine hierfur programmierte netzwerkbasierte Software mit den Zielen der Prozessoptimierung und der zeitlich strukturellen Abstimmung der Prozesse aufeinander. Jede Untersuchungseinheit erhielt eine separate Warteliste, in der zu jedem Patienten der Patientenflow auf einer Timeline aufgezeichnet wurde. Von der Warteliste ausgehend, wurden Zeitraume und Zeitpunkte per Mausklick aufgezeichnet und Auftrage zur Diagnostik erteilt. Auserdem wurde uber ein Signal mitgeteilt, wann eine Oberarztabnahme gewunscht war. Hierbei wurden Feedbackschleifen verwendet, die zu jeder Zeit fur alle involvierten Instanzen innerhalb der Ambulanz den aktuellen Progress der Patienten sichtbar machten. Die praktische Anwendbarkeit wird bereits seit wenigen Monaten erfolgreich getestet. So konnte z. B. bei Aufzeichnungen des Patientenflows von 250 Vorstellungen zu intravitrealen Injektionen eine durchschnittliche Anwesenheitszeit von 169,71 min gezeigt werden, wobei auch automatisch eine zeitliche Erfassung von Teilschritten erfolgte. Langfristig bilden die Aufzeichnungen der Daten zum Patientenflow eine Basis, um Patienten zeitgerecht durch die vielschichtigen Untersuchungen einer Universitats-Augenpoliklinik zu fuhren und Wartezeiten zu reduzieren sowie den Einfluss einzelner Umstrukturierungen innerhalb einer Ambulanz zu untersuchen. Da die Einfuhrung der Software selbst mit einem Strukturwandel einhergeht, ist auch ein Fragebogen fur die involvierten Mitarbeiter geplant.

Hintergrund Wahrend die intraoperative optische Koharenztomographie (iOCT) im Bereich der Makulachirurgie oder der lamellierenden Keratoplastiken einen sichtbaren Vorteil bringen kann, ist ihr Einsatz bei der Ablatiochirurgie bisher mit unklarem Nutzen verknupft.

Spectral domain optical coherence tomography (SD-OCT) has become a standard diagnostic tool in the surgical management of vitreomacular interface disorders. The high-resolution cross-sectional information obtained from SD-OCT is a perfect complement to vitreoretinal surgery. It provides detailed intraoperative anatomical views that are not possible with a microscope.To investigate the value of intraoperative real-time OCT with respect to improvement of surgical techniques in the management of vitreomacular disorders.A review of the current literature was conducted and an analysis of own systematically evaluated data was included to provide a comprehensive overview of potential applications for the clinical use of intraoperative real-time OCT in macular surgery.Intraoperative real-time OCT can provide detailed visualization of epiretinal membranes and help to identify whether complete membrane removal has been achieved following surgery. In addition, it can provide qualitative and quantitative information that has previously not been available and assist in surgical decision-making. Intraoperative real-time OCT allows membrane peeling to be performed in selected cases without using retinal dyes, whereas it is not ideal for accurately guiding the surgeon while performing maneuvers.Intraoperative real-time OCT provides high-resolution visualization of the effects of surgical maneuvers on the microarchitecture of the retina and surrounding tissues and will fill a gap in the understanding of the pathophysiology and prognostic factors of vitreomacular disorders; however, with currently available systems, accurate intraoperative real-time guidance of surgical maneuvers is hindered by several limiting factors.

Bacterial orbital cellulitis is a life-threatening infection of the postseptal orbital tissue. It can occur in the context of sinusitis, particularly in children and adolescents. Ocular complications include exposure keratopathy, increased intraocular pressure, occlusion of the central retinal artery or vein and optic neuropathy. Rarely, a subperiosteal abscess can occur, and osteomyelitis can lead to spread of the infection to the cerebrum. A rapid diagnosis and targeted therapy are essential for saving the eye as well as the life of the patient.

Purpose To investigate 12-month outcomes of conversion to aflibercept in patients with neovascular age-related macular degeneration resistant to ranibizumab. Methods Twenty-two eyes of 19 consecutive patients received 3 monthly aflibercept injections followed by a pro re nata protocol. Spectral-domain optical coherence tomography (OCT) images were obtained before each injection. All 49 cross-sectional OCT B-scans obtained in each examination were investigated and the largest choroidal neovascularization (CNV) size was chosen. The same cross-sectional B-scan sections containing the maximum CNV size were used during the follow-up. Results After 12 months, best-corrected visual acuity increased from 45.68 ± 20.25 to 59.09 ± 17.50 Early Treatment Diabetic Retinopathy Study letters (p2 (p = 0.003), and macular volume improved from 9.64 ± 1.75 to 8.45 ± 0.98 mm3 (pConclusions Visual and anatomic improvement were obtained after conversion to aflibercept.

Background and Objectives To evaluate the changes in the size of choroidal neovascularization (CNV) lesion using spectral domain-optical coherence tomography (SD-OCT) in patients with treatment-resistant neovascular age-related macular degeneration (AMD) who were switched from ranibizumab to aflibercept. Materials and Methods In this prospective case-series, 33 eyes of 30 patients with treatment-resistant neovascular AMD were included. Treatment-resistant neovascular AMD was defined as choriodal neovascularization secondary to AMD determined by subretinal fluid and/or intraretinal fluid/cysts after more than 6 months of monthly ranibizumab therapy. Enrolled eyes were received intravitreal aflibercept injections at weeks 0, 4, and 8. Maximum area of CNV lesion in the cross-sectional area in the B-scan was measured using Heidelberg Eye Explorer software. The same cross-sectional sections containing maximum area of CNV lesion were used during the follow-up. CNV subtypes were determined based on fluorescein angiography images prior to ranibizumab therapy. Main outcome measures were changes in best-corrected visual acuity (BCVA), central subfield thickness (CST), and area of CNV lesion. Results There were five classic (15%), seven minimally classic (21%), and 21 occult subtypes of CNV (64%). Four weeks after the third injection, BCVA improvement and reduction of the retinal thickness in nine standard ETDRS subfields were significant (both P

The transforming growth factor-beta (TGFB) plays an essential role in the pathogenesis of some ophthalmologic diseases, including neovascular age-related macular degeneration (nAMD) and proliferative vitreoretinopathy (PVR). TGFB activates the transcription factors SMAD2 and SMAD3 via the TGFB receptor, which together activate several genes, including VEGFA. TGFB treated ARPE-19 cells show an increased proliferation rate and undergo epithelial to mesenchymal transition (EMT). Since microRNAs (miRNAs) are capable of inhibiting the translation of multiple genes, we screened for miRNAs that regulate the TGFB signalling pathways at multiple levels. In this study, we focused on two miRNAs, miR-302d and miR-93, which inhibit TGFB signalling pathway and therefore TGFB-induced EMT transition as well as VEGFA secretion from ARPE-19 cells. Furthermore, we could show that both miRNAs can retransform TGFB-stimulated mesenchymal ARPE-19 cells towards the morphological epithelial-like state. Taken together, transient overexpression of these miRNAs in RPE cells might be a promising approach for further translational strategies.

Selective retina therapy (SRT) targets the retinal pigment epithelium (RPE) with pulsed laser irradiation by inducing microbubble formation (MBF) at the intracellular melanin granula, which leads to selective cell disruption. The following wound healing process rejuvenates the chorio-retinal junction. Pulse energy thresholds for selective RPE effects vary intra- and interindividually. We present the evaluation of an algorithm that processes backscattered treatment light to detect MBF as an indicator of RPE cell damage since these RPE lesions are invisible during treatment. Eleven patients with central serous chorioretinopathy and four with diabetic macula edema were treated with a SRT system, which uses a wavelength of 527 nm, a repetition rate of 100 Hz, and a pulse duration of 1.7 μs. Fifteen laser pulses with stepwise increasing pulse energy were applied per treatment spot. Overall, 4626 pulses were used for algorithm parameter optimization and testing. Sensitivity and specificity were the metrics maximized through an automatic optimization process. Data were verified by fluorescein angiography. A sensitivity of 1 and a specificity of 0.93 were achieved. The method introduced in this paper can be used for guidance or automatization of microbubble-related treatments like SRT or selective laser trabeculoplasty.

Purpose Selective retina therapy (SRT) has shown great promise compared to conventional retinal laser photocoagulation as it avoids collateral damage and selectively targets the retinal pigment epithelium (RPE). Its use however is challenging in terms of therapy monitoring and dosage because an immediate tissue reaction is not biomicroscopically discernibel. To overcome these limitations real time optical coherence tomography (OCT) might be useful to monitor retinal tissue during laser application. We have thus evaluated a proprietary OCT system for its capability of mapping optical changes introduced by SRT in retinal tissue. Methods Freshly enucleated porcine eyes covered in DMEM upon collection were utilized and a total of 175 scans from ex vivo porcine eyes were analyzed. The porcine eyes were used as an ex vivo model and results compared to two time resolved OCT scans recorded from a patient undergoing SRT treatment (SRT Vario Medical Laser Center Lübeck). In addition to OCT fluorescin angiography and fundus photography were performed on the patient and OCT scans were subsequently investigated for optical tissue changes linked to laser application. Results Biomicroscopically invisible SRT lesions were detectable in OCT by changes in the RPE / Bruch's complex both in vivo and the porcine ex vivo model. Laser application produced clearly visible optical effects such as hyper reflectivity and tissue distortion in the treated retina. Tissue effects were even discernible in time resolved OCT imaging when no hyper reflectivity persisted after treatment. Data from ex vivo porcine eyes showed similar to identical optical changes while effects visible in OCT appeared to correlate with applied pulse energy leading to an additional reflective layer when lesions became visible in indirect ophthalmoscopy. Conclusions Our results support the hypothesis that real time high resolution OCT may be a promising modality to obtain additional information about the extent of tissue damage caused by SRT treatment. Data shows that our ex vivo porcine model adequately reproduces the effects occurring in vivo and thus can be used to further investigate this promising imaging technique.

Bernd Junker,1 Jens F Jordan,2 Carsten Framme,1 Amelie Pielen1 1University Eye Hospital, Medical School Hannover, Hannover, 2Eye Center, Medical Center, University of Freiburg, Freiburg, Germany Importance: This study is the first description of the use of the intraoperative optical coherence tomography (iOCT) for trabecular meshwork surgery with the Trabectome in a regular clinical setting.Background: The aim of this study is to evaluate intraoperatively the immediate success of ab interno trabeculotomy with the Trabectome defined as a removal of the trabecular meshwork.Design: This is a retrospective clinical study performed in the University Eye Hospital, Medical School Hannover.Participants: A total of nine consecutive Caucasian patients suffering from primary open angle glaucoma, pigment dispersion glaucoma, or pseudoexfoliation glaucoma took part in the study.Methods: All patients underwent ab interno trabeculotomy surgery with the Trabectome using a commercially available iOCT to visualize the anterior chamber angle (ACA) before and after the procedure. The visualization was done using a modified Swan-Jacobs lens (all nine patients) or without lens (view from above, five patients).Main outcome measures: The main outcome of this study is the success of visualization of the ACA on iOCT, especially the postprocedural visualization of the wound gap after removal of the trabecular meshwork.Results: Using the view from above, the ACA could be visualized before and after the procedure in only two of the five cases. Using the modified Swan-Jacobs lens, the ACA could be visualized before the procedure and the trabecular meshwork opening after the procedure in all nine patients.Conclusion: The iOCT can be used to objectify the immediate success of the surgical procedure, ie, the removal of the trabecular meshwork, of ab interno trabeculotomy with the Trabectome. The procedure itself cannot be captured sufficiently via iOCT. Keywords: glaucoma, imaging, iOCT, trabecular meshwork surgery

PURPOSE Modifications in ocular blood flow may play a significant role in glaucoma development. Optical coherence tomography angiography (OCT-A) is based on the detection and analysis of the reflection behaviour of motion in a static environment and therefore is able to quantify the retinal flow density. We used this new technology to examine the density of the active flow vasculature in the macular area in glaucoma patients compared to healthy patients. METHODS Thirty patients with primary open-angle glaucoma (mean age: 72.6 ± 7.1 years) and 21 healthy patients (mean age: 70.3 ± 8.6 years) were recruited. Patients received perimetry and OCT measurements of the peripapillary retinal nerve fibre layer thickness (RNFLT) and macular retinal thickness and OCT-A of the macular area in the superficial and deep retinal (DR) plexus. Flow density of the OCT-A scan was calculated by binarisation and quantification of the pixel density. RESULTS Macular flow density was globally and nasally reduced in glaucoma patients in the superficial (globally: p = 0.0203; nasally: p = 0.0003) and DR plexus (globally: p = 0.0113, nasally: p

High resolution optical coherence tomography (OCT) enables better visualization of ophthalmic microstructures than conventional imaging. When using an ophthalmic microscope, integrated optical coherence tomography (iOCT) high resolution real time visualization is possible.We report on the first 110 patients operated on using a microscope integrated OCT (iOCT) during surgical procedures for the treatment of various posterior segment pathologies.Microstructural changes that appeared during surgery were depicted precisely by iOCT, and the morphology visualized before and after each surgical step was used to help deciding how to adapt the surgical flow. The iOCT data and real-time imaging of retinal anatomy gives the surgeon the possibility of deploying patient- and operation-specific interventional procedures.To date, iOCT is only available in standing microscopes with no measurement or tracking features. Moreover, metal instruments currently obscure the scanned images. In the future, non-metal, transparent instruments (OCT-friendly surgical tools), tracking features, an autofocus and higher resolution could enable full and immediate intraoperative SD-OCT diagnostics in real time.Die hochauflösende optische Kohärenztomografie (OCT) ermöglicht eine kontrastreiche Bildgebung von Mikrostrukturen, die mit konventioneller Bildgebung nicht so detailliert darstellbar waren. Wir berichten über unsere Erfahrungen beim Einsatz der intraoperativen OCT (iOCT) in der vitreoretinalen Chirurgie.110 Patienten mit vitreoretinalen Erkrankungen (Makulaforamen, epiretinale Membranen, vitreomakulärem Traktionssyndrom, Ablatio und Glaskörperblutung) wurden unter Visualisierung mit dem im Mikroskop integrierten iOCT-Gerät operiert.Das iOCT liefert durch die Integration von Mikroskop und SD-OCT eine sofortige Visualisierung der „Region of Interest“ (ROI). Der Operateur erhält neben dem Mikroskopbild die intraoperative Darstellung aller Netzhautschichten, des Glaskörpers sowie der Instrument-Gewebe-Interaktion in Echtzeit und kann diese intraoperativ sofort verfügbare Information für die chirurgische Strategie nutzen.Bisher ist das iOCT nur als Standmikroskop erhältlich, es besitzt keine Messfunktion, keine Tracking-Funktion, und die Metallinstrumente verdecken den Scan. Künftig könnten transparente Instrumente, Tracking-Funktionen, ein Autofokus sowie eine noch bessere Auflösung eine optimierte, lückenlose, hochauflösende intraoperative OCT-Diagnostik in Echtzeit erlauben.

To explore real-world effectiveness of intravitreal aflibercept injection (IAI) for neovascular age-related macular degeneration (nAMD) in Germany.A 24-month, prospective, noninterventional, noncontrolled, multicenter observational cohort study.Patients (n = 848) with nAMD treated with IAI.Patients (n = 988) were screened at 67 study sites. Therapeutic decisions were made by the treating physician. Primary end point analysis was performed after 12 months for the entire study cohort and for predetermined subgroups of treatment-naïve and previously treated patients. Additionally, outcomes with regular injection intervals (bimonthly after 3 monthly injections) were compared with those of patients with irregularities in their treatment regimen.The primary end point was the mean change in visual acuity (VA) from baseline after 12 months. Other key end points included the proportions of patients gaining 15 letters or more and patients with reading vision (≥70 letters). Furthermore, the number of injections, anatomic measurements, and safety data were recorded.Mean ± standard deviation VA improvement was 5.3±17.4 letters in treatment-naïve patients and -0.1±15.6 letters in previously treated patients (P ≤ 0.0001), and that of the total study group was 2.9±16.8 letters. Baseline VA was 53.4±17.9 letters for treatment-naïve patients, 52.9±18.4 letters for previously treated patients, and 53.2±18.1 letters for the total patient population. Treatment pattern was associated with VA outcome: best outcomes-an average VA gain of 8.0±17.7 letters-were seen in treatment-naïve patients in the regularly treated population, whereas irregularly treated, treatment-naïve patients achieved a mean VA gain of only 4.0±17.1 letters. Among previously treated patients, regular treatment also was associated with better outcomes (+3.1±10.7 vs. -1.1±16.8 letters). For the total study group, the mean VA gain was the following: regularly treated population, 6.1±15.6 letters; irregularly treated population, 1.5±17.1 letters (P = 0.008). No cases of endophthalmitis were observed during the first 12 months of the study. Adverse events were in line with the known safety profile of IAI.After 12 months of treatment with IAI, treatment-naïve patients showed substantial functional benefit, whereas previously treated patients maintained their VA. With regular IAI treatment, it seems that similar results as those in pivotal IAI studies can be achieved in routine clinical practice.

Presentation of a patient with two foreign bodies each 21 cm long in left nasal orbit and penetrating as far as the sinciput. The patient had been knitting at the time of the accident and had probably autonomously thrust the two knitting needles into the left orbit, as assessed by questioning of other parties. The patient had a known history of paranoid schizophrenia and dementia. Central imaging revealed the position of the knitting needles with respect to the intracranial vessels to be threatening. The surgical removal of the knitting needles was carried out without any serious complications, such as intracranial hemorrhage.

With about 50-60 million cases in the US alone, dry eye disease represents a severe health care problem. Cyclosporin A (CsA) would be a potent candidate for a causal therapy. However, CsA is not sufficiently water soluble to be administrated via simple eye drops. We developed an in situ nanosuspension (INS) as a novel approach towards the administration of CsA to the cornea. It precipitates upon contact with the tear fluid and creates CsA nanoparticles that enter the cornea and release the drug by dissolution. We selected two liquid poly(ethylene glycols) (PEG) that dissolve CsA and create nanoparticles by precipitation of CsA upon water contact. Aqueous solutions of PEG and Solutol, a non-ionic surfactant, were well tolerated by primary human epithelial cells in vitro. To determine the critical water content needed for a precipitation, the solubility of CsA was investigated in quaternary systems of drug, solvent, surfactant and water. The best INS formulation showed a particle size of 505 ± 5 nm, a polydispersity index (PdI) of 0.23 ± 0.03 and a neutral zeta potential of -0.07 ± 0.05 mV. After single administration to porcine eyes in vitro, 3165 ± 597 ng(CsA)/g(cornea) were detected in corneal tissue, while the levels of Restasis a commercial formulation were, with 545 ± 137 ng(CsA)/g(cornea), significantly lower (P0.01). These results demonstrate that an INS is a promising, novel approach towards the causal treatment of inflammatory diseases at the anterior eye.

To evaluate the changes in the size of choroidal neovascularization (CNV) lesion using spectral domain-optical coherence tomography (SD-OCT) in patients with treatment-resistant neovascular age-related macular degeneration (AMD) who were switched from ranibizumab to aflibercept.In this prospective case-series, 33 eyes of 30 patients with treatment-resistant neovascular AMD were included. Treatment-resistant neovascular AMD was defined as choriodal neovascularization secondary to AMD determined by subretinal fluid and/or intraretinal fluid/cysts after more than 6 months of monthly ranibizumab therapy. Enrolled eyes were received intravitreal aflibercept injections at weeks 0, 4, and 8. Maximum area of CNV lesion in the cross-sectional area in the B-scan was measured using Heidelberg Eye Explorer software. The same cross-sectional sections containing maximum area of CNV lesion were used during the follow-up. CNV subtypes were determined based on fluorescein angiography images prior to ranibizumab therapy. Main outcome measures were changes in best-corrected visual acuity (BCVA), central subfield thickness (CST), and area of CNV lesion.There were five classic (15%), seven minimally classic (21%), and 21 occult subtypes of CNV (64%). Four weeks after the third injection, BCVA improvement and reduction of the retinal thickness in nine standard ETDRS subfields were significant (both P 0.001). Regarding and regardless of CNV subtypes, mean area of CNV lesion decreased significantly at final visit. Overall, a dry macula was achieved in 21 eyes (64%) and 12 eyes (36%) showed decreased or unchanged edema.Switching to aflibercept seems to result in reduction of CNV lesion area in short-term follow-up of patients with treatment-resistant neovascular AMD. Lasers Surg. Med. 48:668-677, 2016. © 2016 Wiley Periodicals, Inc.

PURPOSE To evaluate 3-year follow-up treatment outcomes with ranibizumab (Lucentis(®)) 0.5 mg administered either monthly or quarterly on a pro re nata (PRN) basis according to a disease activity-guided monitoring and treatment algorithm. METHODS A total of 316 treatment-naive eyes of 316 patients with exudative age-related macular degeneration met the criteria for inclusion in this retrospective, interventional case series. Patients were treated with ranibizumab 0.5 mg according to a disease activity-guided algorithm with monthly monitoring. Optical coherence tomography and fluorescein angiography were routinely used to assess disease activity: active lesions were treated with a series of three monthly injections, whereas inactive lesions were treated with quarterly injections. RESULTS Mean Early Treatment Diabetic Retinopathy Study best-corrected visual acuity improved from 52 letters at baseline to 59 letters at 12 months, achieved with a mean of 7.1 injections, 61 letters at 24 months with a mean of 5.0 injections administered in the second year and 60 letters at 36 months with a mean number of 5.2 injections. CONCLUSIONS Monthly visits and a morphology-driven PRN regimen with 3 injections in case of recurrence plus quarterly injections in case of inactive CNV resulted in an average VA gain of 7-9 letters that could be maintained over 3 years.

Visual results in treating neovascular age-related macular degeneration (AMD) using intravitreal injected anti-VEGF (IVT) clearly depend on injection frequency. Regarding to the European approval Ranibizumab has to be used only in cases of recurrent visual loss after the loading phase. In contrast monthly treatment--as also provided in the ANCHOR and MARINA studies--is generally allowed in Switzerland. However, it is commonly tried to reduce the injection frequency because of the particular cost situation in all health systems and of cause also due to the necessary strict monitoring and reinjection regimes, which raise management problems with increasing patient numbers. In this article the special treatment regimes of our University Eye Hospital is presented, in which a reduced injection frequency basically leads to the same increased and stable visual results as in ANCHOR and MARINA; however, needing significantly more injections as generally provided in other countries of Europe. The main focus for achieving this in a large number of patients is placed on re-structuring our outpatient flow for IVT patients with particular emphasis on patient separation and standardisation of treatment steps leading to significantly reduced time consumption per patient. Measurements of timing and patient satisfaction before and after restructuring underline its importance in order to be able to treat more patients at a high quality even in the future. The exceptional importance of spectral domain OCT measurements as the most important criterium for indicating re-treatment is illustrated.

To observe the excursions of short-term intraocular pressure (IOP) after 20-G pars-plana vitrectomy (ppV).In a prospective study, 851 patients (age: mean 63 ± 15 years) underwent unilateral ppV for various vitreoretinal diseases using different endotamponades [Balanced Salt Solution (BSS) 33.1%, Air 7.2%, SF(6) 33.6%, silicon oil 5000 cst 26.1%]. Intraocular pressure was measured in all patients before and at 3, 6, 24 and 48 hr after surgery. Survival analysis was performed to determine the cumulative hazard of IOP changes depending on endotamponade and time point after ppV (Log-Rang - Mantel Cox; p0.0001). At baseline, IOP ranged from 0 to 50 mmHg (mean IOP: 15.3 ± 5.3 mmHg). Mean IOP after surgery revealed a slight elevation (3 hr: 16.5 ± 11.0 mmHg; 6 hr 16.9 ± 9.8 mmHg; 24 hr 19.7 ± 8.0 mmHg; 48 hr 17.3 ± 6.2 mmHg; range: 0-64 mmHg). Silicon oil filling revealed highest mean values at already 3 hr after surgery (21.8 mmHg). Also, BSS filling showed a peak after 3 hr; however, mean values were lower. Equivalent high IOP values as for silicon oil tamponade were found for gas filling; however, maximal peak was reached after 24 hr but not after 3 hr post-treatment. The cumulative hazard in all patients to reach IOP ≥ 30 mmHg after 24 hr was 23.9%; (IOP ≥ 40 mmHg = 8.2%). Herein, oil filling revealed highest risk at all time points after surgery. The risk of suffering from IOP5 mmHg lasting longer than 6 hr was only 1.2% after 20 G vitrectomy.Intraocular pressure measurements after ppV are important to prevent unintentional high IOP, especially within the early phase (3 hr post-treatment) in eyes with silicon oil filling. Gas filling leads to prolonged IOP increase (24 hr post-treatment). Long-lasting hypotony (≥ 6 hr) is very rare after 20G vitrectomy.

To identify differences in extracellular matrix contents between idiopathic epiretinal membranes (IEM) of cellophane macular reflex (CMRM) or preretinal macular fibrosis (PMFM) type.

To judge the possibilities of detection of orbital foreign bodies in multidetector CT (MDCT) with a focus on glass slivers.

Purpose: To assess the interobserver variability (IOV) in indicating retreatment for neovascular Age-related macular degeneration 4 weeks after three Ranibizumab loading doses using spectral domain OCT (SD-OCT) as the primary objective diagnostic tool. Material and methods: Four observers decided for or against 4th Ranibizumab injection in 108 patients by six different rating rounds (RR) based on the SD-OCT findings after the loading doses. Postoperative OCT images were supplemented consecutively with information from a chart review as the ‘patients subjective estimation of vision (SE)’, the course of best-corrected visual acuity (BCVA) and the preoperative OCT as well as all information collectively. Agreement rates (AR) and Kappa statistics were calculated. Results: Based on post-treatment OCT findings only (RR1), mean reinjection rate of all observers was 37.5%. Adding supplementary information, mean reinjection rate decreased to 20% when all information was available reflecting the ‘real’ situation (RR 6). Interobserver agreement rates varied from 66.7% to 90.7% depending on rating rounds and interobserver pairs. Mean AR and Kappa values (KV) were as following: AR 81.6%, KV 0.61 (RR1: ‘only post-OP OCT’); AR 76.7%, KV 0.33 (RR2: post-OP OCT + SE); AR 80.3%, KV 0.45 (RR3: post-OP OCT + BCVA); AR 80.7%, KV 0.46 (RR4: pre- and post-OP OCT); AR 82.2%, KV 0.49 (RR5: post-OP OCT + SE + BCVA); and finally AR 83.6%, KV 0.47 (RR6: pre- and post-OP OCT + SE + BCVA). The overall mean agreement rate was 80.9% with a Kappa of 0.47. Conclusion: IOV for indicating retreatment after three Ranibizumab loading doses reveals only moderate agreement in Kappa statistics, which seems to be too low considering the high costs for retreatments. More concise guidelines based on the post-treatment OCT scans as the presumably most sensitive and noninvasive objective tool to follow choroidal neovascularization activity by judging the course of sub- and intraretinal fluid are necessary.

Detailed evaluation and cost analysis of a cranial contrast-enhanced MRI (c-ceMRI) in outpatients, inpatients, patients in an intensive care unit and children under anesthesia.

BACKGROUND: Heavier than water tamponades offer the possibility to support the inferior part of the fundus after retinal detachment. The aim of this study was to evaluate the anatomic and functional outcome of complicated retinal detachment treated with vitreous surgery and heavy silicone oil (HSO) tamponade. Surgery was performed in eyes with rhegmatogenous retinal detachment (RD) predominantly in the lower hemisphere or with penetrating injury (either as primary intervention or after development of proliferative vitreoretinopathy [PVR]). MATERIALS AND METHODS: Sixty-one eyes of 61 patients with RD - mostly complicated by PVR - and a minimum follow-up of 12 months were included in this study. Vitreoretinal surgery with HSO (Oxane HD) tamponade was performed in all patients. In 52 patients, heavy silicone oil was used in the management of complicated RD. 9 patients had surgery for complicated RD after penetrating eye injury.The mean follow-up period was 30.3 +/- 10.2 months. RESULTS: The overall final anatomic success rate was 79 %. In 39 % of the cases the retina remained attached during the entire follow-up period. CONCLUSIONS: The anatomic success rate after surgery with HSO (Oxane HD) was relatively low; however, only complex cases bearing a higher risk of retinal re-detachment received HSO in this study. Oxane HD does not appear to have major advantages compared to conventional silicone oil or other new-generation heavy silicone oils in these cases.

At the 111th German Medical Assembly in May 2008 in Ulm, Germany, a public debate on rationing of health care performances was started. Since the money in the German health care system is not enough to provide every diagnostic or therapy for every patient as a coverage of the compulsory medical insurances, a lot of specific health care performances have been rationed during the last years not to be covered by the regular medical insurance any more, such as, e. g., PSA measurements in urology or IOP measurements in ophthalmology. In contrast to the health care system in Scandinavia, where rationing of health care performances is publicly documented by the government, no similar public statements exist in Germany. Due to this, it is left to physicians to explain to their patients the "hidden" rationing of public health care performances, which also leads to an increase in individual health care performances (IGeL in Germany) to be paid for privately by the patient. It is undoubtedly true that not all medically possible performances need to be paid for by the health insurance; however, an official determination of these "out of pocket" health care performances is necessary. Therefore, it was the aim herein to work out possible "stop" criteria--according to the Scandinavian system--for common eye diseases and consecutive therapies, which need not be paid for or only be paid after a delay by the health insurances.

Spectral domain optical coherence tomography (SD-OCT) in patients can deliver retinal cross-sectional images with high resolution. This may allow the evaluation of the extent of damage to the retinal pigment epithelium (RPE) and the neurosensory retina after laser treatment. This article aims to investigate the value of SD-OCT in comparing laser lesions produced by conventional laser photocoagulation and selective retina treatment (SRT).In a retrospective study, conventional retinal laser (CRL) lesions and SRT laser lesions were evaluated with SD-OCT. One hundred seventy-five CRL lesions were investigated in 10 patients with diabetic maculopathy at timepoints between 1 hr and 4 years after treatment. Ninety-one SRT lesions were examined in 9 patients with central serous retinopathy, geographic atrophy, and diabetic maculopathy at timepoints between 1 hr and 2 years. CRL lesions were applied with an ophthalmoscopically slightly grayish-white appearance (Nd:YAG laser at 532-nm wavelength; power 100-200 mW; retinal spot diameter 100 microm; pulse duration 100 ms). SRT lesions were applied with a Nd:YLF (527 nm; pulse duration 200 ns [30 pulses at 100 Hz]; energy 100-200 microJ/pulse; retinal spot diameter 200 microm) and were visible only angiographically.All CRL lesions were characterized by high reflectivity in OCT images throughout the full thickness of the neurosensory tissue 1 hr after irradiation, suggesting complete neurosensory coagulation. Strong contraction through the full thickness of the neurosensory layers was observed within 7 days after treatment. In contrast, the neural retina appeared unaffected after SRT. For both lesion types, the RPE layer appeared to be regular or thinner immediately after treatment, whereas within a period of 4 weeks, a RPE thickening indicating RPE proliferation was observable. One year and later after treatment, CRL lesions were characterized by RPE atrophy combined with significant damage of the neurosensory tissue. SRT lesions aged one year and older revealed unaffected neurosensory structures and an intact RPE layer.Spectral domain OCT can be used clinically to follow the development of laser-induced lesions over time. Postoperative RPE proliferation was observed in both CRL and SRT laser lesions. RPE atrophy appeared subsequently only in CRL lesions, whereas the neurosensory retina appeared unaffected following SRT. These results suggest the selective effect of SRT in humans without causing adverse effects to the neurosensory retina.

Background Selective retina therapy (SRT) solely affecting the RPE while sparing of the photoreceptors is usually performed with a train of repetitive laser pulses of 1.7 microseconds in duration. It was our purpose to evaluate the principle feasibility of SRT with shorter 200 nanoseconds laser pulses in patients. Methods Nineteen patients with macular disorders [diabetic maculopathy (DMP), geographic atrophy (GA), drusen maculopathy and central serous chorioretinopathy (CSR)] were treated with a prototype of a SRT laser (Nd:YLF laser; 527 nm; 1.7 microseconds and 200 nanoseconds pulse duration; 30 pulses at 100 Hz; spot size: 200 µm). Test lesions (n = 175) with increasing energy were applied at the lower arcade to determine the individual angiographic and ophthalmoscopic threshold radiant exposures (therapeutic window) before applying the central treatment lesions within these ranges additionally guided by online optoacoustic measurements. Postoperatively RPE damage was visualized and confirmed by fluorescein angiographic leakage and correlated with optoacoustic results. Additionally ED50 damage thresholds were calculated by probit analysis. Results None of the short repetitive 200 nanoseconds laser pulses led to retinal hemorrhages or retinal ruptures. Nearly all of the test- and treatment lesions could be visualized by angiography indicating desired RPE damage but were ophthalmoscopically invisible suggesting intact neurosensory retinal structures. ED50 cell damage threshold energies were significantly lower using 200 nanoseconds (99.6 µJ; n = 122) instead of 1.7 microseconds (196.3 µJ; n = 53) laser pulses. Optoacoustic and angiographic visibility correlated in 83.7% (200 nanoseconds) and 87.5% (1.7 microseconds). Conclusions Selective RPE effects can safely be achieved using shorter 200 nanoseconds laser pulses in patients without adverse effects to the neurosensory retina. The required pulse energy compared to the standard 1.7 microseconds regime was reduced by about a factor of 2 suggesting a reduced heat generation and flow into adjacent tissues during the shorter laser impact and thus possibly enhancing selectivity. Optoacoustics also seem to be a viable alternative in 200 nanoseconds treatment for a non-invasive online dosimetry control system. Lesers Surg. Med. 40:616–624, 2008. © 2008 Wiley-Liss, Inc.

Hospital quality management (QM) is a legal obligation in Germany. This article reviews the regulations of quality control, the basic principles of QM, specific quality techniques, the process of QM implementation in the hospital and the possibilities of external QM certifications. Due to the increasing and effective privatisation of hospitals in Germany, careful attention to specially designed QM systems for private hospitals seems to be reasonable.

The scientific background of laser photocoagulation of the ocular fundus was studied extensively by several investigators in the 1970 s and 1980 s. The basic principles were successfully resolved during that time and clinical consequences for proper application of the laser photocoagulation for various diseases were deduced. The present paper gives an overview about the physical basics of laser-tissue interactions during and after retinal laser treatment and the particular laser strategies in the treatment of different retinal diseases. Thus, it addresses the issue of the impact on tissue of laser parameters as wavelength, spot size, pulse duration and laser power. Additionally, the different biological tissue reactions after laser treatment are presented, such as, e. g., for retinopexia or macular treatments as well as for diabetic retinopathies. Specific laser strategies such as the selective laser treatment of the RPE (SRT) or the transpupillary thermotherapy (TTT) are presented and discussed.

The purpose of this study was to characterise an ex-vivo adult porcine retina-retinal pigment epithelium (RPE) perfusion organ culture model. Fresh porcine full-thickness retina-RPE-choroid tissue samples were clamped into tissue carriers and mounted in two-compartment containers. The retinal and choroidal sides were continuously perfused with culture medium. pO(2), [Na(+)], [K(+)], [Cl(-)], [glucose], [lactate], and pH were measured in the medium. Tissue samples were examined after 24h, 4, 7, and 10 days in culture. The morphology of the retina and the RPE was examined by light and electron microscopy (LM, EM). The retinal cellular integrity was further examined by immunohistochemistry (Ki 67, GFAP, rhodopsin, synaptophysin, syntaxin, NF 200, TUNEL-test). Fresh porcine full-thickness retina-RPE-choroid tissue samples and tissue samples in static organ culture served as controls. LM, EM, and immunohistochemistry showed intact retinal and RPE cytoarchitecture kept in perfusion culture. Photoreceptor outer segments showed first signs of degeneration after 24h, significant signs of apoptosis and necrosis appeared in the retina after 4 days in perfusion culture. Control tissue samples kept in static culture showed disintegration of the retinal cytoarchitecture after 4 days in culture. The data show that adult porcine retina-RPE tissue can be maintained morphologically intact in perfusion organ culture for at least 10 days. Although first signs of degeneration set in after 24h the structural preservation of the tissue in perfusion organ culture is superior to that in static culture. The perfusion culture model of the retina refines organotypic in vitro test systems and may help to reduce the number of necessary animal experiments in retina and RPE research. It offers new perspectives for the safety testing of substances designed for intraocular application.

Seit 2004 wird die Krankenhausbehandlung offener Augenverletzungen in der DRG C01Z als Fallpauschale abgerechnet. Da das Ausmas der Behandlungsmasnahmen allerdings signifikant vom sehr heterogenen Verletzungsmuster abhangt, werden in dieser DRG okonomisch sehr unterschiedliche Falle zusammengefasst. Ziel dieser Arbeit war daher die Uberprufung der Kostendeckung fur die operative Behandlung von offenen Augenverletzungen an einer Universitats-Augenklinik. Die Leistungsdaten fur die DRG C01Z wurden fur die Jahre 2005 und 2006 uber die E1-Bogen nach §21 KHEntG zusammengefasst. Die Behandlungskosten wurden uber die Berechnung der OP-Fixkosten, der variablen OP-Kosten inklusive Personal und Material und der stationaren Kosten auf eine durchschnittliche OP heruntergebrochen. Im Untersuchungszeitraum wurden 180 offene Augenverletzungen von insgesamt 4721 stationaren Operationen behandelt. In 80 Fallen wurde eine Hornhaut-/Skleranaht (+Phako/IOL; n=10); (mittlere OP-Zeit: 67,81 min) durchgefuhrt. In 100 Fallen wurde eine Pars-plana-Vitrektomie (ppV) mit entsprechenden adjuvanten Masnahmen (mittlere OP-Zeit: 124,69 min) benotigt. Der OP-Fixkostenanteil pro OP belief sich auf 130,60 EUR; die variablen Kosten inklusive Personal und Material variierten zwischen durchschnittlich 570 EUR (Hornhaut-/Skleranaht ± 250 EUR fur Phako und IOL; n=10) und 1230 EUR fur die ppV. Kostentrachtige Adjuvanzien wie die Benutzung von Cerclage, Perfluorocarbonen, Gas und Silikonol sowie die kombinierte Phako ± IOL verursachten zusatzliche Kosten zwischen 51 und 250 EUR pro Zusatz (durchschnittlich 182 EUR) wobei mindestens zwei dieser Zusatze bei 50% und mindestens ein Zusatz bei 90% der ppVs benutzt wurde. Die stationaren Kosten beliefen sich bei einer mittleren Verweildauer von ca. 8 Tagen pro Fall auf 2184 EUR (Tagessatz 273 EUR). Die durchschnittlichen Gesamtkosten eines Falles differierten masgeblich fur die reine Naht-OP (2662 EUR, mittlere Verweildauer: 7,06 Tage) und ppVs (3712 EUR; mittlere Verweildauer: 8,62 Tage). Zusatzliche nicht gedeckte Kosten entstanden bei 20 Fallzusammenfuhrungen (11,1%) fur Reoperationen wahrend des stationaren Aufenthaltes. Die C01Z wurde im Erhebungszeitraum mit durchschnittlich 3205,96 EUR bei einem Relativgewicht von 1,177 und einer Baserate von 2723,79 EUR in Bayern vergutet. Damit sind die ppVs deutlich unterbezahlt und die reine Versorgung durch Naht ist deutlich uberbezahlt. Aufgrund der Inhomogenitat befurworten wir einen Split der C01Z fur penetrierende Augenverletzungen.

Purpose: Up to date several approaches have been undertaken to achieve an ‘easy-to-handle’ animal model of choroidal neovascularizations (CNVs) in rabbits; however, so far in none of the studies could healthy retinal tissue be maintained, which is mandatory to further investigate the effects of photodynamic therapy (PDT) or anti-vascular-endothelial-growth-factor treatments. It was our aim to reevaluate and verify the method of inducing experimental CNVs in rabbits using subretinally injected linoleic acid hydroperoxide (LHP) as proposed by Tamai et al. and to use it for experimental PDT. Material and Methods: In 33 eyes of Chinchilla breed rabbits LHP of two different concentrations (25 and 100 µg/50 µl) was injected into the subretinal space via a transvitreal approach under guidance of an operation microscope. Ophthalmoscopic and angiographic examinations were performed on days 3, 7, 14 and 28 after surgery. Preliminary PDT with different experimental parameter sets was performed in 3 eyes using the new photosensitizer Tookad. Results: Using LHP in the higher concentration, an angiographically determined CNV induction was observed in 27% of all injection sites (n = 34) on days 14 and 28 revealing early well-demarcated and progressive leakage. No CNV was detected at the lower LHP concentration (60 injection sites). Subretinal CNV was verified histologically revealing vessel formation above the retinal pigment epithelium level. Herein, a significant damage to the outer retinal layers was always observed; however, the general structure of the choriocapillary layer was maintained. Tookad PDT was clinically able to completely stop leakage in 1 case and reduce leakage in 2 cases. Histologically the choriocapillary layer was occluded. Conclusion: Subretinal injection of LHP induces angiographically well-demarcated classic CNVs in rabbits; however, the CNV rate was low, and histology revealed severe damage of the outer retinal layers but not of the choriocapillary layer, which is important for studying PDT interactions. Preliminary experimental PDT could clinically stop or reduce leakage from angiographic CNV. Due to the small CNV rate and the significant collateral retinal tissue damage, this model seems to be only of partial suitability for investigating new treatment modalities in CNV.

Hintergrund Seit 2004 werden stationare Behandlungen uber Fallpauschalen nach DRGs abgerechnet. Die Entgelthohe richtet sich nach den Kostenkalkulationen der Kalkulationskrankenhauser, zu denen nur wenige Universitatskliniken gehoren. Ziel dieser Arbeit war die Uberprufung der Kostendeckung fur die operative Behandlung von netzhaut-/glaskorperchirurgischen Eingriffen (DRG C03Z und C17Z) mittels Pars-plana-Vitrektomie (ppV) an einer Universitatsaugenklinik.

Background Post-translational protein modification by lipid peroxidationproducts orglycation is a feature of aging as well as pathologic processes in postmitotic cells at the ocular fundus exposed to an oxidative environment. The accumulationofmodifiedproteinssuchasthose found inlipofuscinand advanced glycation end products (AGEs) contribute greatly to the fundus auto-fluorescence. The distinct fluorescence spectra of lipofuscin and AGE enable their differentiation in multispectral fundus fluorescence imaging. Method A dual-centre consecutive case series of 78 pseudophacic patients is reported. Digital colour fundus photographs as well as auto-fluorescence images were taken from 33 patients with age related macular degeneration (AMD), 13 patients with diabetic retinopathy (RD), or from 32 cases without pathologic findings (controls). Fluorescence was excited at 475–515 nm or 476–604 nm and recorded in the emission bands 530–675 nm or 675–715 nm, respectively. Fluorescence images excited at 475–515 nm were taken by a colour CCD-camera (colour-fluorescence imaging) enabling the separaterecording of green and red fluorescence. The ratio of green versus red fluorescence was calculated within a representative region of each image. Results The 530–675 nm auto-fluorescence in AMD patients was dominated by the red emission (green vs. red ratio, g/r=0.861). In comparison, the fluorescence of the diabetics was green-shifted (g/r=0.946; controls: g/r= 0.869). Atrophic areas (geographic atrophy, laser scars) showed massive hypo-fluorescence in both emission bands. Hyper-fluorescent drusen and exudates, unobtrusive in the colour fundus images as well as in the fluorescence images with emission >667 nm, showed an impressive green-shift in the colour-fluorescence image. Conclusions Lipofuscin is the dominant fluorophore at long wavelengths (>675 nm or red channel of the colour fluorescence image). In the green spectral region, we found an additional emission of collagen and elastin (optic disc, sclera) as well as deposits in drusen and exudates. The green shift of the auto-fluorescence in RD may be a hint of increased AGE concentrations.

PURPOSE A review of treat-and-extend regimens (TERs) with intravitreal anti-vascular endothelial growth factor agents in retinal diseases. METHODS There is a lack of consensus on the definition and optimal application of TER in clinical practice. This article describes the supporting evidence and subsequent development of a generic algorithm for TER dosing with anti-vascular endothelial growth factor agents, considering factors such as criteria for extension. RESULTS A TER algorithm was developed; TER is defined as an individualized proactive dosing regimen usually initiated by monthly injections until a maximal clinical response is observed (frequently determined by optical coherence tomography), followed by increasing intervals between injections (and evaluations) depending on disease activity. The TER regimen has emerged as an effective approach to tailoring the dosing regimen and for reducing treatment burden (visits and injections) compared with fixed monthly dosing or monthly visits with optical coherence tomography-guided regimens (as-needed or pro re nata). It is also considered a suitable approach in many retinal diseases managed with intravitreal anti-vascular endothelial growth factor therapy, given that all eyes differ in the need for repeat injections. CONCLUSION It is hoped that this practical review and TER algorithm will be of benefit to health care professionals interested in the management of retinal diseases.

Die selektive Retinatherapie (SRT) wird zurzeit als neue, schonende Laserbehandlungsmethode fur verschiedene Erkrankungen des Augenhintergrunds evaluiert, die mit einer reduzierten Funktion des retinalen Pigmentepithels (RPE) assoziiert werden. Mit der SRT wird im bestrahlten Areal lediglich das RPE behandelt, ohne die angrenzende neurosensorische Netzhaut mit den Photorezeptoren und die unter dem RPE liegende Aderhaut zu schadigen. Die Therapie fuhrt idealerweise zu einer Regeneration des RPE und einem gesteigerten Metabolismus am chorioretinalen Ubergang. Im Gegensatz zur etablierten Laserphotokoagulation, bei der die bestrahlten und umgebenden Areale der Netzhaut komplett verodet werden, bleiben bei der SRT Skotome vollstandig aus. Der Artikel gibt eine Ubersicht uber die Methodik und die Mechanismen zu selektiven RPE-Effekten und resumiert In-vitro- und vorklinische Ergebnisse zur Bandbreite der Selektivitat fur verschiedene Bestrahlungsparameter. Die Beschreibung einer optoakustischen Methode zur Online-Visualisierung der optisch nicht sichtbaren Effekte und damit zur Dosimetrie ohne angiographische Kontrolle runden die Ubersicht ab.

To carry out a prospective investigation of the functional and morphological outcome of idiopathic epiretinal membrane (IEM) surgery with or without the assistance of indocyanine green (ICG) in a randomised controlled clinical trial. Sixty patients who underwent vitrectomy with removal of IEM combined with cataract surgery were randomly allocated to two groups: 27 patients were operated on with ICG 0.1% in glucose 5%, 33 patients without ICG. Functional outcome was assessed 3-4 months postoperatively with improvement of best-corrected visual acuity (BCVA), Amsler grid test, and automated and kinetic perimetry. Postoperative residual or recurrent IEM was assessed with bio-microscopy, and macular oedema with optical coherence tomography (OCT). Improvement in BCVA was the main outcome measure. BCVA improved in 49 patients, remained unchanged in five and decreased in five. Improvement in BCVA and reduction of macular oedema were statistically significant within both groups (P

Hintergrund Selektive RPE-Lasertherapie ist durch repetitive Laserbestrahlung mit Mikrosekundenpulsen unter Schonung der Photorezeptorschicht moglich. Damit konnen zentrale Netzhautpathologien wie diabetische Makulopathie, weiche konfluierende Drusen im Rahmen der altersbedingten Makuladegeneration oder die Chorioretinopathia centralis serosa ohne konsekutive Laserskotome behandelt werden. Es war Ziel dieser Studie zu zeigen, ob ein selektiver RPE-Schaden auch mit einem konventionellen grunen cw-Laserstrahl erreicht werden kann, wenn dieser zur Bestrahlung uber die Netzhaut gescannt wird.

Purpose: Central serous chorioretinopathy (CSC) affects mostly young and middle-aged adults. Typically, a serous retinal detachment occurs with a focal leakage point in fluorescein angiography. Fundus autofluorescence (AF) is related to the lipofuscin within the retinal pigment epithelium (RPE). As CSC is thought to be associated with RPE disorders, AF measurements might be able to detect distinct changes within the RPE level. The purpose of this study was to compare AF patterns in acute and chronic-recurrent CSC and to evaluate the potential value of AF as a non-invasive monitoring tool. Methods: From 85 patients diagnosed with CSC (mean age 43 years), AF images were retrospectively evaluated and compared with angiographic and ophthalmoscopic findings. Fluorescein angiography and AF measurements were performed using a Heidelberg retina angiograph. Autofluorescence was excited at a wavelength of 488 nm and detected above 500 nm. Results: Acute CSC as determined by an acute decrease in visual acuity (VA) within the last 6 weeks, focal point leakage and neurosensory retinal detachment was diagnosed in 39 patients. In 36 of those patients (92%), a significantly decreased AF at the leakage point (72%) and/or decreased AF in the area of neurosensory detachment (77%) were observed. Regarding chronic-recurrent CSC as determined by a decrease in VA for longer than 6 weeks and mottled hyperfluorescent appearance in angiography, abnormalities in AF were observed in 44/46 patients (96%). In those patients, decreased or mottled AF was observed at the leakage point itself (76%), whereas significantly increased AF was seen in the area of residual neurosensory retinal detachment (85%). Conclusions: In acute CSC, decreased AF is presumably due to a blockage caused by oedema, whereas in chronic-recurrent forms, irregular and increased AF is observed, possibly reflecting reactive RPE changes secondary to RPE defects and neurosensory detachment. If these findings could be systematically underlined by prospective clinical studies, AF might be an interesting non-invasive tool for monitoring RPE changes in CSC and for performing differential diagnosis.

Non-invasive imaging of the retinal pigment epithelium (RPE) using autofluorescence became recently available with the introduction of confocal laser scanning ophthalmoscopes. Fundus autofluorescence is usually excited at a wavelength of 488nm and the emitted light is detected above 500nm. This intrinsic autofluorescence was shown to derive from the lipofuscin accumulating within the RPE either with age or also due to different hereditary or degenerative diseases of the macula as e.g. age-related macular degeneration. Since a variety of macular diseases correlate with distinct RPE changes, specific patterns of autofluoresce nce could be evaluated within the recent years for diagnostic and prognostic reasons in those RPE-related diseases. Moreover autofluorescence can also be regarded as a monitoring tool after therapeutic applications as macular surgery or laser treatment. Other new applications try to determine macular pigment density using autofluorescence or use it to evaluate oxygen-dependent cell metabolism. This review summarizes the recent findings of autofluoresce nt patterns in specific diseases and therapeutic approaches and emphasizes on the tremendous potential of this novel imaging method.