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Abstract: Elevated permeability of retinal endothelial cells (REC), as observed in diabetic retinopathy (DR), is induced by extended exposure to ≥25 ng/ml vascular endothelial growth factor A165 (VEGF165) for up to 3 d and this effect is more pronounced when equimolar amounts of basic fibroblast growth factor (bFGF) and insulin-like growth factor (IGF-1) are present. Down-regulation of the tight-junction protein claudin-1 and its loss from the plasma membrane is associated with induced higher permeability, whereas other tight-junction proteins (e.g. claudin-3, claudin-5, ZO-1) show only subtle changes in our experimental setting. Using immortalized bovine REC (iBREC) as a well-established model, we investigated effects of other members of the VEGF family, i.e. VEGF121, placental growth factor (PlGF-1 and PlGF-2) and viral VEGF-E which activate different sets of VEGF receptors, on barrier function after extended treatment: iBREC were incubated with 1–100 ng/ml of the growth factors for up to 2 days before barrier function was assessed by measuring transendothelial resistance (TER). Presence of TJ-proteins was determined by western blot analyses and immunofluorescence staining. Similar experiments were performed to evaluate whether the primary actions of PlGF-1, PlGF-2 or VEGF121 are modulated by bFGF or IGF-1 when all growth factors (each at 25 ng/ml, but 10 ng/ml IGF-1) act simultaneously at equimolar concentrations. We also studied the potential normalization of the barrier disturbed with combinations of growth factors by addition of the VEGF-specific Fab fragment ranibizumab or the recombinant protein aflibercept which binds VEGF and PlGF. Whereas 1 ng/ml VEGF-E were sufficient to impair the iBREC barrier, a higher concentration of 100 ng/ml VEGF121 was needed to reduce TER and expression of claudin-1 over 2 days. By PlGF-1 or PlGF-2, the barrier was not affected even at the highest concentration tested (100 ng/ml) and these factors also did not modulate the effect of VEGF165. The weak barrier derangement caused by VEGF121 was slightly enhanced by bFGF and IGF-1. After induction of the barrier breakdown with various combinations of all growth factors included in the study, normal TER and claudin-1 expression was re-established by ranibizumab. Both VEGF inhibitors ranibizumab and aflibercept similarly reinstated lost claudin-1, even when applied at a small fraction of the clinically relevant concentrations. These results show that VEGF-A, but not PlGF impairs the barrier function of iBREC and that the longer isoform VEGF165 is more potent than VEGF121. To induce barrier dysfunction in iBREC, activation of VEGF receptor 2 – probably in concert with neuropilin-1 – seems to be sufficient because VEGF-E and VEGF165, but not PlGF-1/-2 reduced TER or claudin-1 expression. [Copyright &y& Elsevier]

Objective: To demonstrate superiority of ranibizumab 0.5 mg monotherapy or combined with laser over laser alone based on mean average change in best-corrected visual acuity (BCVA) over 12 months in diabetic macular edema (DME). Design: A 12-month, randomized, double-masked, multicenter, laser-controlled phase III study. Participants: We included 345 patients aged ≥18 years, with type 1 or 2 diabetes mellitus and visual impairment due to DME. Methods: Patients were randomized to ranibizumab + sham laser (n = 116), ranibizumab + laser (n = 118), or sham injections + laser (n = 111). Ranibizumab/sham was given for 3 months then pro re nata (PRN); laser/sham laser was given at baseline then PRN (patients had scheduled monthly visits). Main Outcome Measures: Mean average change in BCVA from baseline to month 1 through 12 and safety. Results: Ranibizumab alone and combined with laser were superior to laser monotherapy in improving mean average change in BCVA letter score from baseline to month 1 through 12 (+6.1 and +5.9 vs +0.8; both P<0.0001). At month 12, a significantly greater proportion of patients had a BCVA letter score ≥15 and BCVA letter score level >73 (20/40 Snellen equivalent) with ranibizumab (22.6% and 53%, respectively) and ranibizumab + laser (22.9% and 44.9%) versus laser (8.2% and 23.6%). The mean central retinal thickness was significantly reduced from baseline with ranibizumab (−118.7 μm) and ranibizumab + laser (−128.3 μm) versus laser (−61.3 μm; both P<0.001). Health-related quality of life, assessed through National Eye Institute Visual Function Questionnaire (NEI VFQ-25), improved significantly from baseline with ranibizumab alone and combined with laser (P<0.05 for composite score and vision-related subscales) versus laser. Patients received ∼7 (mean) ranibizumab/sham injections over 12 months. No endophthalmitis cases occurred. Increased intraocular pressure was reported for 1 patient each in the ranibizumab arms. Ranibizumab monotherapy or combined with laser was not associated with an increased risk of cardiovascular or cerebrovascular events in this study. Conclusions: Ranibizumab monotherapy and combined with laser provided superior visual acuity gain over standard laser in patients with visual impairment due to DME. Visual acuity gains were associated with significant gains in VFQ-25 scores. At 1 year, no differences were detected between the ranibizumab and ranibizumab + laser arms. Ranibizumab monotherapy and combined with laser had a safety profile in DME similar to that in age-related macular degeneration. Financial Disclosure(s): Proprietary or commercial disclosure may be found after the references. [Copyright &y& Elsevier]

Retinal vessels are at least in part involved in clearing of Fc terminus-containing proteins from the vitreous. In vitro, the Fc fusion protein aflibercept is transported through a monolayer of unchallenged immortalized bovine retinal endothelial cells (iBREC), mediated by the neonatal Fc receptor (FcRn), but part of the Fc fusion protein is also degraded. Aflibercept's target VEGF-A not only enhances the permeability of REC by destabilization of tight junctions (TJs) thereby allowing for paracellular flow, it may also lower the intracellular stability of the Fc fusion protein by changing its binding properties to the FcRn. Therefore, we investigated the transport and fate of aflibercept in VEGF-A 165 -challenged iBREC. All cell culture media were supplemented with 5% fetal bovine serum (FBS) as its absence results in accumulation of aflibercept in iBREC due to deregulated expression of transport proteins. Early after exposure of a confluent iBREC monolayer cultivated on gold electrodes to 5% FBS, the cell index (CI) - assessed as a measure of barrier function, cell viability and cell adhesion - transiently declined but recovered again within a few hours to high values. These values remained stable for several days associated with a strong expression of the TJ-protein claudin-1, indicative of a functional barrier formed by the iBREC monolayer. Transient changes of the plasma membrane localizations of claudin-5 and vascular endothelial cadherin - both important for regulation of paracellular flow - accompanied the transient reduction of the CI not prevented by VEGF-binding proteins. Treatment of iBREC with 50 ng/ml VEGF-A 165 for one day resulted in a strong and persistent decline of the CI associated with a low expression level of the TJ-protein claudin-1; reversion to normal values was complete one day after aflibercept's addition at a final concentration of 250 μg/ml. Expressions of other proteins involved in regulation of paracellular flow or transcellular transport were not significantly changed. More aflibercept passed through the monolayer of iBREC cultivated on permeable membrane inserts pretreated with VEGF-A for one day, but this was not affected by a FcRn-inhibiting antibody. Subcellular localization of aflibercept was hardly changed in VEGF-A-exposed iBREC 3 h after its addition to the cells; inhibition of (non)-lysosomal or proteasomal proteases then only weakly affected the amount of internalized aflibercept. iBREC also internalized VEGF-A which was barely detectable as early as 2 h after addition of aflibercept. In contrast, blocking the tyrosine kinase activity of VEGF receptor(s) did not prevent VEGF-A's uptake. Inhibition of cellular proteases strongly increased the amount of internalized VEGF-A in the absence and presence of the Fc fusion protein. We therefore conclude that a FcRn-mediated transport plays a minor role in aflibercept's passage through a leaky barrier of REC. Even early after addition of aflibercept to VEGF-A-exposed iBREC, the levels of free intracellular VEGF-A are low, as aflibercept likely prevents binding of VEGF-A to its receptor. Interestingly, the growth factor's detrimental effects still persist for nearly one day. • VEGF-A enhances aflibercept's passage through a monolayer of retinal endothelial cells. • Passage of aflibercept is not dependent on the FcRn under these conditions. • Exogenously added VEGF-A is internalized and degraded by retinal endothelial cells. • Aflibercept prevents uptake of VEGF-A by retinal endothelial cells early after addition. • VEGF-A-induced disturbances persist for nearly one day after addition of aflibercept. [ABSTRACT FROM AUTHOR]

Various severe ocular diseases are associated with an elevated intravitreal expression of VEGF-A which increases the permeability of retinal endothelial cells (REC) or retinal pigment epithelial (RPE) cells in vivo and in vitro. Inhibition of VEGF receptor 2 (VEGFR2) is sufficient to completely prevent VEGF-A 165 -induced dysfunctions of barriers formed by long-term cultivated, immortal human ARPE-19 cells or immortalized bovine retinal endothelial cells (iBREC). Extended exposure to VEGF-A could result in additional activation of other growth factor receptors, potentially promoting synergistic effects of corresponding factors on various cellular processes including angiogenesis. Based on these observations, we investigated whether blocking of VEGFR2 is also sufficient to revert VEGF-A-induced changes of the barriers consisting of iBREC (i.e. inner blood-retina barrier) or ARPE-19 cells (i.e. outer blood-retina barrier) in vitro. Alterations of confluent monolayers' properties induced by treatment with VEGF-A 165 for one day followed by addition of small molecule inhibitors of the VEGFR2 were determined by continuous cell index (CI) measurements using the microelectronic biosensor system for cell-based assays xCELLigence. VEGF-A 165 induced a long-lasting drop of the otherwise high CI of iBREC accompanied by reduced expression of the tight junction (TJ) protein claudin-1 and subtle changes of the plasma membrane localizations of TJ-protein claudin-5 and of vascular endothelial cadherin. Blocking mainly VEGFR2 with 10 nM nintedanib, 10 nM tivozanib or 500 nM ZM323881 efficiently reverted these changes within one day; higher concentrations of nintedanib or additional inhibition of neuropilin-1 were not superior. Interestingly, the CI of short-term cultivated, confluent ARPE-19 cells slightly increased in the presence of VEGF-A 165 , but was not changed by nintedanib. In contrast, VEGF-A 165 markedly reduced the transepithelial electrical resistance of ARPE-19 cells cultivated on porous membrane inserts for three weeks, which was also accompanied by a significant loss of the then strongly plasma membrane-expressed TJ-protein ZO-1. These alterations were completely reverted within one day by 10 nM nintedanib of which higher concentrations were not superior. None of the inhibitors tested diminished the strong barrier properties of iBREC or long-term cultivated ARPE-19 cells. Taken together, inhibition of VEGFR2 efficiently reverts VEGF-A 165 -induced barrier disturbances of both cell types forming and regulating the inner and outer blood-retina barrier. As synergistic actions of growth factors seem to play only a minor role in inducing a barrier dysfunction, specific inhibition of VEGFR2 could be an interesting option to treat VEGF-A-induced macular edema without obvious effects on vitality and functions of REC and RPE cells. • Blocking VEGFR2 efficiently reverts VEGF-induced dysfunction of cells of the BRB. • Additional blocking of other (non)-tyrosine kinase receptors is not superior. • Inhibiting VEGFR2 does not alter vitality of REC or RPE cells. • Long-term cultivated ARPE-19 cells respond differently to VEGF-A than short-term cultivated ones. [ABSTRACT FROM AUTHOR]

Purpose: Ranibizumab monotherapy showed stronger effects on area of retinal neovascularization (NV) reduction while offering better visual acuity (VA) results than panretinal laser photocoagulation (PRP) monotherapy during the first 12 months of the PRIDE study. The second year of PRIDE was an observational, non-interventional follow-up, performed to evaluate long-term anatomical and functional outcomes in proliferative diabetic retinopathy (PDR) patients under real-life conditions, prior to the approval of ranibizumab for PDR., Methods: Seventy-three PDR patients (28 from the ranibizumab group; 20 from the PRP group; 25 from the combination group) were included in the observational follow-up phase and treated at the investigators discretion. Visual acuity (VA) measurements and retinal imaging were performed at Months 12, 18 and 24., Results: Mean (± SD) NV area in the ranibizumab monotherapy and combination follow-up groups increased from 3.16 ± 4.30 mm 2 and 1.13 ± 2.78 mm 2 at Month 12 to 6.09 ± 10.79 mm 2 and 2.14 ± 4.41 mm 2 at Month 18 and 10.00 ± 17.63 mm 2 and 3.26 ± 7.05 mm 2 at Month 24, respectively. In the PRP follow-up group, NV area declined from 5.44 ± 14.55 mm 2 at Month 12 to 1.22 ± 1.67 mm 2 at Month 18, but increased again to 4.05 ± 11.66 mm 2 at Month 24. During the observational phase, only 2 (6;8) patients in the ranibizumab (PRP;combination) follow-up group were treated with anti-VEGF medications, while 17 (6;10) patients received PRP laser therapy., Conclusion: Discontinuation of ranibizumab treatment in PDR patients may result in an increase of NV area and VA loss. Tight monitoring of disease activity and continued treatment beyond the first year is needed to maintain disease control., (© 2021 Novartis Pharma GmbH. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Competing Interests: Gabriele E. Lang: Vorträge für Carl Zeiss Meditec Inc.

Competing Interests: Gabriele E. Lang: Carl Zeiss Meditec Vortragstätigkeit. Die anderen Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Background: Intravitreal treatment (IVT) is one of the most common ophthalmological procedures. Therapeutic effectiveness is however dependent on patient compliance. Unwanted treatment cessation rates are high though. The authors therefore decided to analyse the patient's knowledge and treatment expectations, as discrepancies are known to negatively affect compliance and thus treatment outcomes., Patients and Methods: The study was designed as an exploratory survey. In total, 100 patients presenting to an outpatient clinic of a tertiary care centre from October to December 2016 were included. A structured, anonymised questionnaire was handed out, consisting mainly of question items with closed code lists as response domains. Solely descriptive analysis of results was performed., Results: The median age of patients was 73 years. 70% had received more than 3 IVTs in at least one eye. Age-related macula degeneration was the most common underlying cause (52%). 64% expected improvement of visual acuity after IVT. 42% could not name one medication used in their IVT. 55% felt that the information provided during informed consent had been adequate. 69% did not know the post-surgical occurrence of endophthalmitis. Three patients were confident of being able to drive a car directly after IVT., Conclusion: Patient's knowledge of their underlying disease, treatment goals and complications rates exhibited some deficiencies. Standardised patient information sheets could be of significant use and were actively suggested by patients to improve the informed consent process., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Contradictory behavior of microvascular retinal endothelial cells (REC) - a reliable in vitro model to study retinal diseases - have recently been reported which might result from cultivating the cells in standard DMEM not optimized for this cell type. Therefore, we studied DMEM's effects on phenotype and behavior of immortalized bovine REC. Cells were cultivated in endothelial cell growth medium (ECGM) until a confluent monolayer was reached and then further kept for 1-4 days in ECGM, DMEM, or mixes thereof all supplemented with 5% fetal bovine serum, endothelial cell growth supplement, 90 μg/ml heparin, and 100 nM hydrocortisone. Within hours of cultivation in DMEM, the cell index - measured to assess the cell layer's barrier function - dropped to ~5% of the initial value and only slowly recovered, not only accompanied by stronger expression of HSP70 mRNA and secretion of interleukin-6, but also by lower expressions of tight junction proteins claudin-5, claudin-1 or of the marker of cell type conversion caveolin-1. Altered subcellular localizations of EC-typic claudin-5, vascular endothelial cadherin and von Willebrand factor were also observed. Taken together, all experiments with (retinal) EC cultivated in common DMEM need to be interpreted very cautiously and should at least include phenotypic validation., Competing Interests: The authors declare no conflict of interest., (© 2021 The Author(s).)

Purpose: Panretinal photocoagulation (PRP) is the current standard of care in proliferative diabetic retinopathy (PDR). However, treatment with anti-vascular endothelial growth factor agents might offer better patient outcomes with fewer side-effects. The PRIDE study aimed to assess the efficacy and safety of ranibizumab with or without PRP compared with PRP alone in patients with PDR., Methods: A total of 106 PDR patients without diabetic macular oedema were randomized to receive ranibizumab 0.5 mg monotherapy (n = 35), PRP (n = 35) or combined ranibizumab 0.5 mg/PRP (n = 36). The primary objective of this 12-month, multicentre, phase II study was to investigate the change in area of retinal neovascularization (NV). Complete regression of leakage and best-corrected visual acuity (BCVA) were key secondary end-points., Results: At Month 12, there was a statistically significant difference of -2.83 mm² in the least square mean change in NV area between the ranibizumab monotherapy and PRP group, favouring ranibizumab (95% CI [-5.45; -0.21], p = 0.0344). At Month 3, 67%/0%/67% of the patients in the ranibizumab/PRP/combination groups, respectively, showed complete regression of leakage from NVs, while at Month 12, 28%/8%/18% showed complete regression of leakage from NVs. BCVA change was greater in the ranibizumab group compared with the PRP monotherapy group at Month 12 (+1.6 letters; 95% CI [-2.3; 5.5] versus -3.9 letters; 95% CI [-7.8; -0.1], p = 0.0495)., Conclusions: Ranibizumab monotherapy is an alternative treatment option to laser treatment in patients with PDR. Ranibizumab showed stronger effects on NV leakage and area reduction while offering better visual acuity results than PRP alone., (© 2019 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Background: Retinal artery occlusion leads to dramatic and irreversible vision loss. There is currently no evidence-based standard therapy. According to the German guidelines on retinal artery occlusions, intravenous fibrinolysis therapy can be performed up to a time window of 4 h 30 min., Methods: Two patients were treated accordingly., Results: In patient 1, systemic lysis therapy was used in branch retinal artery occlusion (BRAO) of the inferior temporal retinal artery with macular involvement 4 h 15 min after symptom onset. Immediately after the therapy, the patient reported significant improvement in symptoms. Three months after therapy, retinal function was good, but with subtle atrophy of the inner neurosensory retina. Patient 2, 2 h 30 min after onset of symptoms of the inferior temporal BRAO, the patient experienced further deterioration, with clinical signs of a central retinal artery occlusion (CRAO). Visual acuity deteriorated to light perception. Emergency intravenous lysis therapy, administered 3 h later, gave an improvement in visual acuity with preservation of the inferior visual field. In both patients, a marked improvement in visual acuity was observed immediately after the lysis therapy: Patient 1: right eye, best corrected visual acuity (BCVA) initial 0.5, BCVA 3 days after lysis therapy 1.0, no defects in Goldmann visual field. Patient 2: left eye, BCVA initial 0.4, then sudden deterioration to light perception, BCVA 1 month after lysis therapy 0.6, persisting visual field defects in the superior hemisphere with preservation of the inferior visual field., Conclusions: Two patients with acute retinal artery occlusion were treated successfully with systemic intravenous fibrinolysis., Competing Interests: F. Raber: keine. K. Reinkling: keine. S. Schmitz-Valckenberg: Unterstützung von Forschungsprojekten und klinischen Studien durch Alcon/Novartis, Allergan, Bayer, Bioeq/Formycon, Centervue, Genentech/Roche, Heidelberg Engineering, Katairo, Optos, ZeissMeditec; Beratung, Honorare, Reisekosten: Alcon/Novartis, Allergan, Bayer, Galimedix, Genentech/Roche, Zeiss Meditec. K. Althaus: Vortragstätigkeit Boehringer Ingelheim. O. Kaut: keine. M. Witry: keine. G. E. Lang: Vortragstätigkeit Carl Zeiss Meditec., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: The bradykinin 1 receptor may be important in inflammatory retinal vascular leakage in diabetic macular edema. BI 1026706 is an antagonist of bradykinin 1 receptor that has demonstrated efficacy in preclinical studies. Boehringer Ingelheim trial 1320.22 (NCT02732951) was a randomized, double-blind, placebo-controlled study. The pharmacodynamics, safety, and tolerability of oral BI 1026706 for 12 weeks were evaluated in patients with type 1 or type 2 diabetes mellitus and mild visual impairment owing to center-involved diabetic macular edema., Methods: Patients ( n = 105) were randomized to receive either oral BI 1026706 100 mg twice daily (morning and evening) or placebo for 12 weeks. The primary end point of the study was week 12 change from baseline in central subfield foveal thickness (CSFT) by spectral domain optical coherence tomography. Additional end points included absolute CSFT values, safety, and pharmacokinetics., Results: After 12 weeks of treatment, there was no meaningful change from baseline in the adjusted mean CSFT in either treatment group (BI 1026706, 10.3 µm; placebo, -6.2 µm; adjusted mean treatment difference, 16.5 µm [95% confidence interval, -16.2 to 49.1]). There were also no differences in best-corrected visual acuity outcomes between treatment groups. Most reported adverse events were of mild or moderate intensity, and were balanced between treatment groups., Conclusions: BI 1026706 was not superior to placebo in CSFT week-12 change from baseline. Therefore, BI 1026706 does not reduce CSFT, a morphologic sign of diabetic macular edema., Translational Relevance: Kinin-kallikrein inhibition effects may not be apparent over 12 weeks for bradykinin 1 receptor inhibition alone., Competing Interests: Disclosure: G.E. Lang, Novartis Pharma GmbH (F, C, S), Allergan (C, S), Alcon Pharma GmbH (C, S), Bayer AG (F, S), Boehringer Ingelheim (C, S), Carl Zeiss Meditec (F, S), Alimera Sciences (S); R. Tadayoni, Alcon Laboratories Inc. (C), Alimera Sciences, Inc. (C), Allergan (C), Bausch & Lomb (C), Bayer HealthCare Pharmaceuticals (C), Carl Zeiss Meditec (C), Chibret International (C), FCI Ophthalmics (C), Genentech (C), Moria (C), Novartis (C), Roche (C), ThromboGenics, Inc. (C); W. Tang, Boehringer Ingelheim (E); C. Barth, Boehringer Ingelheim (E); C. Weiss-Haljiti, Boehringer Ingelheim (E); V. Chong, Boehringer Ingelheim (E), (Copyright 2020 The Authors.)

Background: The patient's knowledge about their illness, as well as their expectations regarding pre-intervention, consultation and treatment, may differ from the physician's assumptions. Therefore, it is of great importance that the physician can identify misconceptions and missing knowledge and to focus on those points in the preoperative consultation, as well as meeting patient expectations as to the consultation itself. The aim of this study was to identify such expectations and the knowledge gaps of patients scheduled for ophthalmologic treatment., Method: An anonymous questionnaire containing predominantly closed questions was handed out to 100 patients in an ophthalmological outpatient clinic of a tertiary care center. Answers were mostly single choice items on a rating scale., Results: 55% of patients had received ophthalmological interventions prior to receiving the questionnaire; 36% received more than two. More than half had not informed themselves about the planned procedure prior to their appointment. They were worried the most about complications (59%) and least about the anaesthesia (29%). When asked, patients attributed the highest priority to provision of information regarding complications and most often requested information on implications of the planned surgery on daily activities., Conclusion: Roughly half of the patients came without having informed themselves prior to the consultation. A comprehensive explanation with regard to success rates and possible post-surgical impairments appears to be essential. Possibilities of new media, such as the internet, surprisingly do not seem to be of importance to patients in this context., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

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

Background: Invasive soft tissue infections by Streptococcus pyogenes are rapidly progressive and potentially life-threatening infectious diseases. These can also affect the eyelid. Aggressive virulence factors and the synthesis of exotoxins can lead to complications, such as periorbital necrotizing fasciitis (PONF) and streptococcal toxic shock syndrome (STSS). The clinical picture is characterized by four patients with invasive eyelid infections., Materials and Methods: Photographic documentation, radiological imaging, laboratory and smear diagnostics and intravenous antibiotic therapy were performed on all patients according to the recommendations of the German Robert Koch Institute and the local infectiology board., Results: In all patients, Streptococcus pyogenes was culturally detected in a direct swab. The antibiogram showed sensitivity to the common intravenous antibiotics. The time interval between symptom onset and presentation at the clinic was between two days and one week. All patients had high systemic inflammatory parameters on admission: Pat. 1: CRP 259 mg/l, leukocytes 20.1 giga/l; Pat. 2: CRP 375 mg/l, leukocytes 15.6 giga/l; Pat. 3: CRP 378 mg/l, leukocytes 38.7 giga/l; Pat. 4: CRP 483 mg/l, leukocytes 1.7 giga/l; normal values: CRP < 5 mg/l, leucocytes 4.4 - 11.3 giga/l. In Pat. 2 and 3, a periorbital necrotizing fasciitis was diagnosed due to rapidly progressing necrosis in the area of cutis and subcutis and systemic toxicity. Pat. 3 and 4 met the diagnostic criteria of STSS. Pat. 2, 3 and 4 had to be relocated to an intermediate or intensive care unit with sepsis, despite immediate intravenous antibiotic therapy. Patient 3 underwent surgical debridement during the stay in the intensive care unit. Thanks to interdisciplinary management (ophthalmology, infectiology, ear, nose and throat medicine, internal medicine and intensive care medicine), all patients were finally discharged from our inpatient treatment in a significantly improved general condition., Conclusion: Invasive streptococcal infections represent a challenge in the daily routine of an ophthalmologist. Interdisciplinary management and immediate onset of high-dose intravenous antibiotic therapy are crucial for successful treatment., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

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

Background: Currently, no validated clinical endpoints for treatment studies exist for intermediate age-related macular degeneration (iAMD)., Objective: The European MACUSTAR study aims to develop and clinically validate adequate clinical endpoints for future treatment studies in iAMD and to identify early determinants of disease progression to late stage AMD., Material and Methods: The MACUSTAR study protocol was developed by an international consortium of researchers from academia, the pharmaceutical industry and medical device companies. The MACUSTAR project is funded by the Innovative Medicines Initiative 2 (IMI2) of the European Union., Results: The MACUSTAR study consists of a cross-sectional and a longitudinal investigation. A total of 750 subjects with early, intermediate and late AMD as well as control subjects with no signs of AMD will be included with a follow-up period of 3 years. Overall, 20 European study centers are involved., Conclusion: The MACUSTAR project will generate large high-quality datasets, which will allow clinical validation of novel endpoints for future interventional trials in iAMD. The aim is that these endpoints will be accepted as suitable for medication approval studies by the regulatory authorities and that understanding of the disease process will be improved.

Objective: A comparison between automated and manual measurements of a foveal avascular zone in optical coherence tomography angiography (OCTA) in patients with diabetic retinopathy (DR)., Material and Methods: Consecutive patients with non-proliferative DR were included in this study. All patients received an OCTA, with a 3 × 3 mm scan of the macular region taken with the Zeiss OCT CIRRUS 5000 with the AngioPlex module. The size of the foveal avascular zone (FAZ) was determined both manually and with the help of the automated measurement metrics. Next, the measurements obtained using manual and automated methods were compared. In addition, the circularity index determined in metrics was examined for correlations with the size and area of the FAZ., Results: Thirty-four eyes from 28 patients with non-proliferative diabetic retinopathy with a mean age of 63 years were included. The mean size of the foveal avascular zone was 0.34 ± 0.12 mm 2 (0.08 - 0.65 mm 2 ) for manual evaluation and 0.23 ± 0.11 mm 2 (range 0.03 - 0.49 mm 2 ) in metrics. The circularity index in metrics averaged 0.58 and showed a statistically significant correlation with the size of the manually measured FAZ., Conclusion: There was a comparable result for the size of the FAZ in both measurement methods. Automated measurements with metrics can reliably represent changes in the FAZ for most patients, based on the calculated area, as well as on the circumference and the circularity index., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Comparison of retinal neovascularizations of the disc (NVD) and elsewhere (NVE) in optical coherence tomography angiography (OCTA) and fluorescein angiography (FA) in patients with proliferative diabetic retinopathy., Materials and Methods: 15 consecutive patients were included in this study. All patients received an OCTA with a 3 × 3 mm scan of the region of interest with the ZEISS OCT Cirrus 5000 with the AngioPlex module. The size of the neovascularization (NV) was determined manually in OCTA and FA and compared between the two methods., Results: 20 eyes of 15 patients with proliferative diabetic retinopathy with an average age of 57 years were included. The mean size of NVDs was 3.44 mm 2 in OCTA and 3.75 mm 2 in FA, the mean size of NVDs was 1.06 mm 2 in OCTA and 1.54 mm 2 in FA. Taking into account a generally larger area measured in the FA, the two methods showed good overall agreement., Conclusion: There was a good agreement for the size of the NVs in both methods. OCTA can be used as a simple and non-invasive method to visualize retinal neovascularizations., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Retinal vein occlusions (RVO) are common retinal diseases. They are caused by an obstruction of retinal veins. RVO often result in visual deterioration and, in rare cases, can lead to blindness, but also be asymptomatic. The prognosis is various and depends on the extent, the localization of the occlusion and the retinal perfusion, especially in the macular area. The etiology often is a thrombosis caused by vascular sclerosis, rarely a vasculitis. Because often an underlying disease is present the medical clarification is necessary. The ophthalmological treatment of the macular edema includes intravitreal injection of VEGF inhibitors and steroids. Laser photocoagulation is being proposed as second line treatment. Neovascular complications like preretinal neovascularizations with and without vitreous hemorrhage are treated with laser or vitrectomy. Iris neovascularization can also occur and is treated with laser photocoagulation or cyclophotocoagulation., Competing Interests: Die Autoren geben an, dass keine Interessenkonflikte vorliegen., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To assess efficacy and safety of intravitreal ranibizumab 0.5 mg plus laser (COMBI) versus laser monotherapy (LASER) in patients with visual impairment due to diabetic macular oedema (DME) in either nonproliferative diabetic retinopathy (NPDR) or proliferative diabetic retinopathy (PDR) and to analyse the relevance of inner versus outer retinal thickness., Methods: In this double-masked, multicentre phase IIIb study, patients (N = 128) were randomized (2:1) to receive COMBI (n = 85) versus LASER (n = 43). Patients received four initial monthly injections of ranibizumab 0.5 mg (COMBI) or sham (LASER) followed by pro re nata (PRN) injections. In both groups, patients received laser at baseline and additional laser at 3 monthly intervals, as needed. The study was started in 2010 and was prematurely terminated due to approval of ranibizumab for DME., Results: The least squares (LS) mean change in mean best-corrected visual acuity (BCVA) from baseline to month 12 was higher in the COMBI (6.5) versus LASER (2.3) group (LS mean difference: 4.2 [95% CI 0.9; 7.4] letters, p = 0.01, primary end-point). There was also a tendency in the same direction for the subgroup of 26 patients with PDR (LS mean difference 14.7, p = 0.11). Mean central retinal thickness decreased by 107.3 μm in the COMBI group and by 80.3 μm in the LASER group from baseline to month 12 (p = 0.28). Ranibizumab was well tolerated., Conclusion: This study showed that ranibizumab plus laser is a valuable treatment option for the management of DME. Patients with DME in PDR might also benefit from combined therapy compared to laser alone., (© 2017 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Retinal artery occlusions are acute vascular diseases. Very often they are caused by an embolisation. Rarely a thrombosis is caused by an arteriitis. In the acute phase diagnosis in most of the cases can be made by ophthalmoscopy due to the whitish retinal edema and in central retinal artery occlusion the cherry red spot. Difficulties in making the diagnosis can occur in the chronic stage, especially after reperfusion of the retinal vessels, when the fundus colour returned to normal again. Several diagnostic procedures help to make the diagnosis. Unfortunately there is no generally accepted therapeutic approach for retinal artery occlusions. The visual prognosis often is poor. It is very important to rule out underlying diseases because the patients have an increased risk for stroke or cardiovascular events., Competing Interests: Interessenkonflikt: Die Autoren hatten während der letzten 3 Jahre Verbindungen mit der Carl Zeiss Meditec AG., (Georg Thieme Verlag KG Stuttgart · New York.)

Background Optical coherence tomography angiography (OCTA) provides, non-invasively, a three-dimensional visualization of the microvasculature of the retina and choroid. However, image artifacts may occur in OCTA and have an impact on clinical interpretation. The aim of this article is to describe image artifacts of OCTA and to present a nomenclature. Methods OCTA examinations were performed with the AngioPlex ™ OCTA-technology in combination with the CIRRUS HD-OCT 5000 (Carl Zeiss Meditec, Inc., Dublin, USA) as well as with the PlexElite 9000 (Carl Zeiss Meditec, Inc., Dublin, USA). Typical artifacts identified in the OCTA images are described and their causes are explained. Results There are three main groups of artifacts that can be distinguished: (a) artifacts that are inherent in the OCTA technology and occur with all types of devices (projection artifacts, masking, unmasking, loss of signal); (b) artifacts caused by data and image processing algorithms and whose frequency or severity may depend on the device type used (segmentation artifacts, duplications of vessels); (c) motion artifacts that vary in frequency and severity depending on the type of device used, as different methods (e.g., eye tracker) are used to reduce them. The occurrence of artifacts is also dependent on patient cooperation, the clarity of the optical media, and the pathology of the retina. Conclusion As in any other imaging method, artifacts also occur in OCTA images. Nevertheless, qualitative assessment of OCTA images is almost always possible and provides indispensable findings on the morphology and perfusion status of the retina and choroid. A good knowledge of possible artifacts, and a critical analysis of the complete OCTA data set, allows a correct interpretation and is essential for making a precise clinical diagnosis., Competing Interests: Interessenkonflikt: Finanzielle Unterstützung einschließlich Open-Access-Publikationsgebühr durch Carl Zeiss Meditec Vertriebsgesellschaft mbH, Oberkochen., (Georg Thieme Verlag KG Stuttgart · New York.)

Background Retinal artery occlusion (RAO) is the most common primary angiopathy of the retina. With an incidence of 0.01 - 0.15%, this it is a rather rare disease, but is associated with irreversible damage to the retina and a poor prognosis for visual acuity. Since the 1960s - when fluorescence angiography (FA) was developed -, there has been little change in diagnostic investigations. FA is still the standard procedure for the assessment of retinal artery occlusions. With the development of OCT angiography (OCT-A), new multimodal imaging procedures have become possible. Patients/Methods We used Zeiss AngioPlex ® -OCT-A technology in combination with the CIRRUS ™ HD-OCT 5000 (Carl Zeiss Meditec, Inc., Dublin, USA) to create 6 × 6 mm and 3 × 3 mm volume scans of the area of non-perfusion in patients with RAO. Qualitative OCT-A analysis was performed on retinal images segmented into the superficial and deep retinal capillary plexus. In addition to this, volumetric scans can be segmented to any specific depth of the retina. On the basis of 4 cases, we demonstrate that OCT-A can be used to evaluate RAO. We present typical OCT-A findings. Results OCT-A images allow the detection of non-perfused areas in patients with acute and chronic RAO. The zones of reduced vascular perfusion are differently distributed in the superficial and deep retinal capillary plexus. In both acute and chronic cases of RAO, OCT-A offers important information on retinal vascular perfusion. Conclusion OCT-A can be used in the diagnosis and monitoring of acute and chronic cases of RAO. The advantages of OCT-A are that this technique is non-invasive and allows three dimensional microvascular visualisation within seconds. Although artefacts and the currently limited field of view can make it difficult to interpret OCT-A images reliably, these findings suggest that OCT-A may in future replace FA in the assessment of RAO in most patients., Competing Interests: Interessenkonflikt: Gabriele E. Lang: Beratung, Forschungsförderung, Referentin Carl Zeiss Meditec AG., (Georg Thieme Verlag KG Stuttgart · New York.)

Quality management improves the structures, processes and results of organizations of all kinds. Many practices and clinics have their existing quality management system certified according to ISO 9001, (e.g., to check their own quality management system or to obtain a testimonial against third parties). The latest version ISO 9001:2015 contains some changes, both structurally and in terms of content. These changes can be met with reasonable efforts. An ISO 9001:2015 certification represents a value for your organization, but these advantages are often not directly measurable., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To compare the efficacy and safety of the European labels of ranibizumab 0.5 mg vs dexamethasone 0.7 mg in patients with macular edema secondary to central retinal vein occlusion (CRVO)., Design: Phase IIIb, multicenter, double-masked, randomized clinical trial., Methods: Patients were randomized (1:1) to receive either monthly ranibizumab followed by pro re nata (PRN) treatment (n = 124) or 1 sustained-release dexamethasone implant followed by PRN sham injections (n = 119). Main outcomes were mean average change in best-corrected visual acuity (BCVA) from baseline to month 1 through month 6, mean change in BCVA, and adverse events (AEs)., Results: Of 243 patients, 185 (76.1%) completed the study. No difference was observed in BCVA between ranibizumab and dexamethasone at months 1 and 2. From month 3 to month 6, there was significant difference in BCVA gains in favor of ranibizumab. At month 6, mean average BCVA gain was significantly higher with ranibizumab than with dexamethasone (12.86 vs 2.96 letters; difference 9.91 letters, 95% confidence interval [6.51-13.30]; P < .0001). Mean injection number of ranibizumab was 4.52. Ocular AEs were reported in more patients in the dexamethasone than in the ranibizumab group (86.6% vs 55.6%)., Conclusions: Using the European labels, similar efficacy was observed for ranibizumab and dexamethasone at months 1 and 2. However, ranibizumab maintained its efficacy throughout the study, whereas dexamethasone declined from month 3 onward. The main limitation of the study was that dexamethasone patients received only a single treatment during the 6-month study. In clinical practice, dexamethasone retreatment may be required earlier than 6 months. Safety findings were similar to those previously reported., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Inhibition of vascular endothelial growth factor (VEGF) is a promising strategy to treat retinal complications of diabetes. In contrast to VEGF-A binding ranibizumab, aflibercept also binds to other members of the VEGF family including VEGF-B, but potential effects of this factor on permeability and angiogenic processes are unclear. Therefore, we studied how VEGF-B variants as single agents or together with VEGF-A165 might affect proliferation, migration, or barrier function of retinal endothelial cells (REC). Also investigated was the normalization of REC properties with both VEGF-inhibitors to explore if additional targeting of VEGF-B is relevant., Methods: Stimulation of proliferation or migration of immortalized bovine REC (iBREC) and disturbance of their barrier by exposure to VEGF-B variants (as single factors or together with VEGF-A165) was determined with or without VEGF-binding proteins being added. Permeability of iBREC was assessed by measuring their transendothelial resistance (TER) and expression of the tight junction protein claudin-1., Results: VEGF-B167 and VEGF-B186 enhanced proliferation of iBREC but these isoforms did not affect cell migration. Interestingly, ranibizumab completely blocked both migration and proliferation induced by VEGF-A plus VEGF-B. Both VEGF-B variants did also not affect barrier function or claudin-1 expression in a normal or high-glucose environment. Accordingly, binding VEGF-A was enough to normalize a reduced TER and reinstate claudin-1 lost during treatment with this factor in combination with VEGF-B., Conclusions: Important properties and functions of REC seem not to be affected by any VEGF-B variant and targeting the key factor VEGF-A is sufficient to normalize growth factor-disturbed cells of this type.

Background: Proliferation and migration of retinal endothelial cells (REC) are associated with the development of proliferative diabetic retinopathy. REC proliferation is stimulated by isoforms of vascular endothelial growth factor-A (i.e., VEGF₁₂₁ and VEGF₁₆₅), basic fibroblast growth factor (bFGF), and insulin-like growth factor (IGF-1) of which VEGF₁₆₅ also enhances migration of REC. Effects induced by VEGF-A can be blocked with ranibizumab, a VEGF-binding Fab fragment used in therapy of diabetic macular edema. In this study, we investigated potential angiogenic effects of placental growth factors (PlGF-1, PlGF-2) as other members of the VEGF family and whether the primary action of VEGF₁₆₅ is modulated in the presence of bFGF, IGF-1 and PlGF-1/-2. We also studied how effects of growth factor combinations can be attenuated with ranibizumab., Methods: Effects of single growth factors or their combinations on proliferation and migration of immortalized bovine retinal endothelial cells (iBREC) were studied with or without ranibizumab or the inhibitor of VEGF receptors KRN951., Results: Proliferation of iBREC was significantly stimulated by 1-100 ng/ml PlGF-1 or PlGF-2, but additive effects were not observed with various combinations of the tested growth factors. Ranibizumab neutralized VEGF's effect on proliferation but was not effective when the other growth factors were used in combination with VEGF. bFGF and IGF-1 but not PlGF-1 or PlGF-2 stimulated iBREC migration as single agents, and they further enhanced VEGF-induced migration. The effects of such growth factor combinations including VEGF on migration were efficiently blocked by targeting only VEGF with ranibizumab. Migration induced by VEGF plus bFGF and IGF-1 was also almost completely inhibited by KRN951 interfering with VEGF receptor signalling., Conclusions: Migration but not proliferation of iBREC induced by combinations of bFGF, IGF-1, PlGF-1 or PlGF-2 together with VEGF is efficiently suppressed by ranibizumab. VEGF-mediated signalling through VEGFR2 seems to control REC migration dominantly in the presence of other growth factors.

Purpose: Pathogenesis of diabetic macular edema is driven by deregulated expression of VEGF. A study of long-term exposure of immortalized bovine retinal endothelial cells (iBRECs) to VEGF(165) clearly confirmed the role of the tight junction protein claudin-1, which almost completely disappeared within 24 hours, an effect that was completely reversed by addition of the VEGF-binding Fab fragment ranibizumab. This study was conducted to investigate whether the VEGF(165)-induced loss of claudin-1 is regulated by protein kinase C (PKC) and indeed affects the barrier function of iBRECs., Methods: The effects of various PKC inhibitors on claudin-1 expression and cellular localization in iBRECs treated with VEGF(165) for up to 2 days were studied by Western blot analyses and immunofluorescence microscopy. The permeability of the cell layers was determined by transendothelial electrical resistance measurements., Results: Activation of PKC led to decreased expression of claudin-1, which was blocked by inhibitors of PKCdelta. However, none of the PKC inhibitors significantly affected VEGF(165)-induced effects on cellular localization or expression of claudin-1. Also VEGF(165)-induced higher permeability of iBREC layers could be reversed or prevented by ranibizumab but not by PKC inhibitors. In addition, low claudin-1 expression and its delocalization from the plasma membrane were significantly associated with elevated permeability., Conclusions: In iBRECs, PKC isoforms are not crucially involved in the VEGF(165)-initiated signal transduction that affects permeability and expression of claudin-1. This finding is in contrast to published results concerning only short-term effects of VEGF(165). The results also confirmed that claudin-1 is a highly relevant component of functional tight junctions in retinal endothelial cells.

Members of the tetraspanin protein family are modulators of several fundamental cellular processes in various cell types. However, expression and function of these proteins have not been studied in microvascular endothelial cells despite their (patho-)physiological importance. Western blotting, FACS or RT-PCR analyses confirmed that CD9 and other tetraspanins are expressed in immortalized microvascular endothelial cells of the bovine retina (iBREC). In subconfluent cultures, most of the detected CD9 was located intracellularly as well as in the plasma membrane at cell-cell contact sites and in long spike-like extensions, whereas cells in confluent cultures predominantly showed plasma membrane staining. In wound healing assays, CD9 delocalized from the plasma membrane to its intracellular compartment in cells located at the gap border, and the gap closure was retarded by the addition of an anti-CD9 antibody. Migration of iBREC towards fibronectin and their adhesion to fibronectin were also strongly inhibited in the presence of an anti-CD9 antibody whereas other anti-tetraspanin antibodies had no effect. In summary, iBREC express members of the tetraspanin family of which CD9 was demonstrated to have a function in migration and adhesion of these cells.

Despite better options of controlling diabetes mellitus and although the prognosis of diabetic retinopathy has markedly improved by laser treatment and vitreoretinal surgery, diabetic retinopathy is still the leading cause of blindness in working-age people in industrialized countries. Little has changed in the last decades concerning the prognosis of ocular complications in diabetes mellitus. Therefore, we need better tools for prevention and treatment of diabetic ocular complications due to diabetic retinopathy that go beyond reduction in glycemia, blood pressure and cholesterol levels. Newer therapeutic options are directed at the causative mechanisms of diabetic retinopathy. Experimental and clinical evidence suggests that pharmacological compounds like protein kinase C subtype Beta (PKC-Beta) inhibitors may be effective in the treatment of diabetic retinopathy. One important pathomechanism in the development of diabetic retinopathy is the activation of PKC induced by high glucose due to an increased diacylglycerol level. The selective PKC-Beta inhibitor ruboxistaurin mesylate enables a new therapeutical approach for the treatment of diabetic retinopathy and diabetic macular edema. Ongoing prospective clinical trials investigate if treatment with the specific PKC-Beta inhibitor ruboxistaurin mesylate can prevent the progression of diabetic retinopathy and diabetic macular edema.

Ophthalmoscopy, fundus photography and fluorescein angiography are the common tools to diagnose diabetic retinopathy and diabetic macular edema. However, there is an increasing demand for high-resolution imaging of ocular tissues to improve the diagnosis and management of diabetic retinopathy. Optical coherence tomography (OCT) provides important additional information about the retina. It produces reliable, reproducible and objective retinal images especially in diabetic macular edema and provides information about vitreoretinal relationships that can clearly only be detected with OCT. It enhances the ability to exactly diagnose diabetic macular edema, epiretinal membranes, vitreomacular or vitroretinal traction. OCT also brings new insights into morphological changes of the retina in diabetic retinopathy. It demonstrates that macular edema is a complex clinical entity with various morphology. With the OCT, structural changes and quantitative assessment of macular edema have become feasible as determined with retinal thickness and volume. OCT is more sensitive to small changes in retinal thickness than slit-lamp biomicroscopy.

Laser treatment of diabetic retinopathy is still the gold standard of treatment for focal and diffuse diabetic macular edema and proliferative diabetic retinopathy. When properly treated, the 5-year risk of blindness is reduced by 90% in patients with proliferative diabetic retinopathy and the risk of visual loss from macular edema is reduced by 50%. However, only about 35-50% of patients with diabetes mellitus receive regular eye examinations, which are important for timely diagnosis and proper treatment. The necessary goals are better patient education to improve the control of diabetes and better screening programs to reduce the risk of blindness from diabetic retinopathy.

Transforming growth factor beta (TGFbeta) both inhibits proliferation of macrovascular endothelial cells and promotes their transdifferentiation to alpha-smooth-muscle-actin (alphaSMA)-expressing mesenchymal cells in vitro. Recently, we have confirmed that proliferation of immortalized bovine retinal microvascular endothelial cells (iBREC) is strongly inhibited by TGFbeta2. We now demonstrate a complete transition of both parental iBREC and single cell-derived subclones from cobblestone morphology to a ragged appearance as a consequence of incubation for a few days with 10 ng/ml TGFbeta1 or TGFbeta2. Depending on the type of culture medium, 5-40% of these cells strongly expressed alphaSMA after approximately 6 days whereas expression of the endothelial cell-specific marker proteins von Willebrand factor and VE Cadherin (CD144) declined. Expression of alphaSMA, associated with formation of stress fibers, was first detected in single cells and then spread to adjacent cells, and declined slowly after prolonged cultivation in medium without TGFbeta2. However, re-constitution of vWF expression was not observed. TGFbeta2-induced phenotypic alterations were specific, as they were not caused by treatment of iBREC with VEGF, IGF-1 or bFGF. Induction of alphaSMA expression but not effects on morphology was strongly inhibited by bFGF, whereas IGF-1 enhanced TGFbeta2-induced alphaSMA expression. These findings may have an important impact on the understanding of development of microvascular complications of diabetes such as diabetic retinopathy.

Primary retina-derived endothelial cells isolated from bovine and other animal tissues are extremely useful for studying the molecular mechanisms involved in the pathogenesis of diabetic retinopathy. Preparations of primary bovine retinal endothelial cells (BREC), however, usually contain a number of contaminating non-endothelial cells, e.g. pericytes which have been shown to inhibit proliferation of endothelial cells. To overcome this major drawback, we immortalized BREC by reconstitution of telomerase activity as a consequence of CMV promoter-driven expression of the catalytic domain of human telomerase. Immortal BREC (iBREC) have the capacity to proliferate for >90 passages over 10 months and constantly express endothelial marker proteins. In addition, iBREC behave like BREC with respect to stimulation of proliferation with VEGF, IGF-1 and bFGF, indicating that we have generated a stable endothelial cell line closely related to the corresponding primary cells.

Background: The purpose of the study was to evaluate porcine lens epithelial cell (LEC) adhesion and viability on three different intraocular lens (IOL) materials., Methods: The IOL materials tested were poly(methylmethacrylate) (PMMA), silicone and hydrophobic acrylate. Primary porcine LECs were cultured on four discs of each material over a period of 10 days and, additionally, on six discs of the hydrophobic acrylate over a period of 20 days. Cells grown on untreated wells of a 96-well microtiter plate served as a control. Cell adhesion was photodocumentated on days 1, 2, 3, 4, 6, 8, 10, 14,17 and 20. A cell viability test using the LIVE/DEAD kit (Molecular Probes) was carried out at the end of the investigation. Experiments were run in triplicate. Statistical analysis was performed using the Student's t-test., Results: Confluent cell growth was reached on the hydrophobic acrylate discs and the control wells within 1 day and remained stable during the experiment. Only a few round cells were adherent on PMMA and silicone discs, and their number decreased during the experiment. After 10 days of culturing, the viability test (mean +/- SD) revealed 81.79 +/- 51.74% live cells on acrylate discs, which was not different from the control (105.83 +/- 21.78%, P=0.1589). Significantly lower relative numbers of live cells (P>0.0001) were found on PMMA (-0.62 +/- 2.24%) and silicone (21.47 +/- 8.42%) discs. The percentage of dead cells was significantly higher (P<0.0001) on hydrophobic acrylate discs (29.69 +/- 12.61%) compared to the control (-1.49 +/- 4.13%). After a culture period of 20 days, the percentage of live cells on hydrophobic acrylate discs (49.45 +/- 27.98%) was lower compared to day 10, but was not significantly different from control wells (58.77 +/- 10.71%) (P=0.2299)., Conclusions: Significantly fewer cells grew on PMMA and silicone discs compared to the control. Confluent cell growth and numbers of viable cells comparable to the control were observed on hydrophobic acrylate discs after a culture period of 20 days with a significantly higher percentage of dead cells.

Background: Crohn's disease is a chronic inflammatory bowel disease, leading to ocular manifestations in 4 - 8 % of patients. We report on a patient with Crohn's disease, who developed in association with epidermolysis bullosa acquisita a progressive corneal ulcer., Patient: A 26-year old patient with a 3-year history of Crohn's disease presented with a peripheral corneal ulcer of the right eye. The anterior chamber was deep and quiet. Fundus examination was normal. Corneal smears displayed no bacterial growth. Visual acuity of the right eye was 20/25. Examination of the left eye was normal. Furthermore, he had developed cutaneous blisters on the arms and legs. Despite treatment with topical antibiotics and systemic immunosuppressive therapy with tacrolimus, azathioprine and methylprednisolone the corneal manifestation deteriorated. Therefore, an amniotic membrane was transplanted for treatment of the corneal ulcer; however, this was followed by melting of the amniotic membrane within a few days. Additional therapeutic procedures including further amniotic membrane transplantations and autologous conjunctival grafts have been performed. This was regularly unsuccessful. The corneal ulcer increased in size and extended into the sclera. Therefore a tectonic sclerokeratoplasty was necessary. Histologic examination of the excised corneoscleral tissue revealed an extensive stromal thinning associated with inflammatory infiltration of the cornea and sclera., Conclusions: Corneal complications in patients with Crohn's disease are very rare in contrast to conjunctivitis, episcleritis und uveitis. To the best of our knowledge, this is the first description of a patient with Crohn's disease and epidermolysis bullosa acquisita developing progressive corneal ulcer. How closely an assumed autoimmune mechanism in the cornea is related to Crohn's disease or epidermolysis bullosa acquisita, is not known.

Background: Evulsion of the optic nerve is a rare form of traumatic optic neuropathy. It is a rupture of the optic nerve at the disc without damage of its sheaths occurring in association with a blunt skull trauma or a blunt bulbar trauma., Method: We report on a 13-year old girl with complete evulsion of the optic nerve after blunt bulbar trauma and give a literature review., Results: While swinging on a liana the patient had crashed into a tree. The initial examination 3 hours after the accident revealed at the right eye an amaurosis without any afferent reaction of the pupil to light. Ophthalmoscopy displayed a vitreous haemorrhage at the optic disc, peripapillar white retina and interruption of the blood flow of all visible retinal vessels. Fluorescein angiogram showed no retinal perfusion and a detatched retina above the disc. Echographic examination revealed a vitreous haemorrhage at the disc shaped like a mushroom. From the eighth day, examination of the retina became impossible due to disseminating vitreous haemorrhage. After 8 months vitreous haemorrhage had disappeared revealing a white fibrosis at the area of the optic disc. Since first histological description of an optic nerve evulsion by His in 1856, 42 patients with complete and 23 with partial evulsion of the optic nerve were reported in the literature. In our review different mechanisms of injury are discussed., Conclusion: Evulsion of the optic nerve is rarely reported. It is possible that it may occur more frequently, because it cannot be seen in blunt or also penetrating bulbar traumas with severe intraocular cloudiness.

Background: Bird spiders, known in the US as tarantulas, are large hairy spiders that have become increasingly popular as pets in the Western world. We present a patient with a red irritated eye from exposure to the hairs of a spider of the Theraphosidae family, and review the literature., Patient and Methods: We report on a 28-year old patient who was referred to our clinic with a red irritated eye following playing with a Chilean rose-haired bird spider (known in the US as tarantula). In addition, we reviewed the literature concerning similar cases using the Medline database and cited literature in the retrieved articles., Results: Our patient displayed theraphosidae (tarantula) hairs in the cornea of the right eye and developed a uveitis and a retinochoroiditis with associated vitritis. Treatment with topical corticosteroids resulted in an improvement of signs and symptoms, although the improvement was slow and incomplete. The disease process consists of a granulomatous reaction to the spider hairs. Hairs of Theraphosidae spiders (tarantulas) may cause inflammation at all levels of the eye, from the conjunctiva to retina. We were able to identify 14 cases of Ophthalmia nodosa secondary to the exposure to the tarantula hairs in the literature. Therapy includes removal of the offending hairs when possible and topical treatment with steroids., Conclusion: Although the large hairy bird spiders (tarantulas) are considered harmless pets, ophthalmia nodosa is a potential danger when handling them. Ophthalmia nodosa has an unknown prognosis and may be difficult to manage.

Hyperglycemic control in diabetes mellitus is a major key to prevent the development and progression of diabetic retinopathy. One important pathomechanism in the development of diabetic complications is the activation of protein kinase C (PKC) induced by high glucose due to an increased diacylglycerol (DAG) level. Resulting vascular dysfunctions are increased vascular permeability and contractility, increased production of extracellular matrix and cell proliferation. The PKC isoenzyme family plays a fundamental role in the cellular signal transduction via phosphorylation and modification of enzymes, receptors, transcription factors and kinases. The PKC activation influences the gene transcription and ion transport. Different PKC isoenzymes function as mediators but also as inhibitors of the insulin effects. The hyperglycemia induced DAG production seems to predominantly activate PKC-beta in retinal vascular endothelial cells. The development of selective PKC-beta inhibitors enables new pharmacological therapeutical approaches for treatment of diabetic retinopathy. Ongoing clinical studies investigate if the treatment with specific PKC-beta inhibitors can prevent the progression of diabetic retinopathy and diabetic macular edema.