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Zusammenfassung Hintergrund Die okuläre Toxoplasmose (OT) ist die häufigste infektiöse Ursache einer posterioren Uveitis. Diese Erhebung soll das derzeitige diagnostische und therapeutische Vorgehen bei OT in Deutschland evaluieren. Material und Methoden Ein detaillierter Fragebogen mit spezifischen Patientenbeispielen wurde im Juli 2021 an die Mitglieder der Sektion Uveitis der Deutschen Ophthalmologischen Gesellschaft (DOG) und der Retinologischen Gesellschaft (RG) versandt. Ergebnisse Der Fragebogen wurde von 53 (29 RG und 24 DOG) Ophthalmologen beantwortet. Sechzehn (30 %) Befragte arbeiten in einer Praxis, 18 (34 %) in einer Klinik und 19 (36 %) in einer Universitätsklinik. Neun (17 %) Augenärzte (AÄ) betreuen weniger als 50, 28 (53 %) 50 bis 200 und 16 (30 %) mehr als 200 Uveitispatienten pro Jahr. Der klinische Befund gilt weiterhin als Goldstandard (87 %) für die Diagnose der OT und wird bei Erstmanifestation in 60 % durch spezifische serologische Antikörperuntersuchungen unterstützt. Eine Diagnose allein anhand des klinischen Befundes stellen 10 von 53 (19 %) AÄ, 25 (47 %) Befragte stützen sich auf einen Ig(Immunglobulin)M-Test, 6 (11 %) erwarteten einen IgG-Titer-Anstieg und einer (2 %) den Nachweis spezifischer IgA-Antikörper. Die Mehrheit (n = 28 [53 %]) der AÄ würde die Diagnose im Zweifelsfall durch eine Vorderkammerpunktion sichern; dabei präferieren 20 (38 %) die Polymerasekettenreaktion (PCR), 3 (6 %) die Bestimmung des Goldmann-Witmer-Koeffizienten und 5 (9 %) eine Kombination beider Verfahren. Zur Therapie wurde am häufigsten Clindamycin eingesetzt (n = 21 [40 %]), gefolgt von Pyrimethamin/Sulfadiazin (n = 17 [32 %]) und Trimethoprim + Sulfamethoxazol (TMP/SMX) (n = 10 [19 %]); Letzteres wird auch (n = 40 [75 %]) zur Sekundärprophylaxe eingesetzt. Schlussfolgerungen Die Ergebnisse lassen neben dem klinischen Befund als „Goldstandard“ zur Diagnosestellung kein einheitliches Vorgehen zu Diagnose und Therapie der OT erkennen. Die hohe Nachfrage nach Serum-IgM-Antikörpern weist auf eine weitverbreitete Unsicherheit über die Bedeutung serologischer Befunde hin. Dies ist angesichts der weiterhin hohen Seroprävalenz in Deutschland kritisch zu werten.

Ocular toxoplasmosis (OT) is the most common infectious cause of posterior uveitis. This survey aimed to evaluate the current diagnostic and therapeutic approach to OT in Germany.A detailed questionnaire with specific patient examples was sent in July 2021 to the members of the Uveitis Section of the German Ophthalmological Society (DOG) and the Retinological Society (RG).The questionnaire was answered by 53 (29 RG and 24 DOG) ophthalmologists. Of the respondents 16 (30%) work in private practice, 18 (34%) in a clinical facility and 19 (36%) in university hospital, 9 (17%) colleagues see 50, 28 (53%) 50-200 and 16 (30%) more than 200 uveitis patients per year. The clinical results are still the gold standard (87%) for the diagnosis of OT and in cases of first manifestation 60% are supported by serological antibody investigations, while 10 out of 53 (19%) ophthalmologists rely on the clinical presentation only. An IgM test is requested by 25 (47%) respondents, 6 expected an increase in IgG titer (11%) and 1 the detection of specific IgA antibodies (2%). The majority (n = 28, 53%) of ophthalmologists would aim at confirming the diagnosis by an anterior chamber puncture, from which 20 (38%) prefer PCR, 3 (6%) determination of Goldmann-Witmer coefficients (GW) and 5 (9%) a combination of both methods. Clindamycin was most frequently used for treatment (n = 21, 40%), followed by pyrimethamine/sulfadiazine (n = 17, 32%) and trimethoprime + sulfamethoxazole (TMP/SMX) (n = 10, 19%); the latter was also used (n = 40, 75%) for secondary prophylaxis.The results show that apart from the clinical results as the gold standard for the diagnosis, there is no uniform approach to diagnosis and treatment of OT. The high request rate for serum IgM antibodies indicates a widespread uncertainty about the importance of serological findings. This should be viewed critically, given the continued high seroprevalence in Germany.HINTERGRUND: Die okuläre Toxoplasmose (OT) ist die häufigste infektiöse Ursache einer posterioren Uveitis. Diese Erhebung soll das derzeitige diagnostische und therapeutische Vorgehen bei OT in Deutschland evaluieren.Ein detaillierter Fragebogen mit spezifischen Patientenbeispielen wurde im Juli 2021 an die Mitglieder der Sektion Uveitis der Deutschen Ophthalmologischen Gesellschaft (DOG) und der Retinologischen Gesellschaft (RG) versandt.Der Fragebogen wurde von 53 (29 RG und 24 DOG) Ophthalmologen beantwortet. Sechzehn (30 %) Befragte arbeiten in einer Praxis, 18 (34 %) in einer Klinik und 19 (36 %) in einer Universitätsklinik. Neun (17 %) Augenärzte (AÄ) betreuen weniger als 50, 28 (53 %) 50 bis 200 und 16 (30 %) mehr als 200 Uveitispatienten pro Jahr. Der klinische Befund gilt weiterhin als Goldstandard (87 %) für die Diagnose der OT und wird bei Erstmanifestation in 60 % durch spezifische serologische Antikörperuntersuchungen unterstützt. Eine Diagnose allein anhand des klinischen Befundes stellen 10 von 53 (19 %) AÄ, 25 (47 %) Befragte stützen sich auf einen Ig(Immunglobulin)M-Test, 6 (11 %) erwarteten einen IgG-Titer-Anstieg und einer (2 %) den Nachweis spezifischer IgA-Antikörper. Die Mehrheit (n = 28 [53 %]) der AÄ würde die Diagnose im Zweifelsfall durch eine Vorderkammerpunktion sichern; dabei präferieren 20 (38 %) die Polymerasekettenreaktion (PCR), 3 (6 %) die Bestimmung des Goldmann-Witmer-Koeffizienten und 5 (9 %) eine Kombination beider Verfahren. Zur Therapie wurde am häufigsten Clindamycin eingesetzt (n = 21 [40 %]), gefolgt von Pyrimethamin/Sulfadiazin (n = 17 [32 %]) und Trimethoprim + Sulfamethoxazol (TMP/SMX) (n = 10 [19 %]); Letzteres wird auch (n = 40 [75 %]) zur Sekundärprophylaxe eingesetzt.Die Ergebnisse lassen neben dem klinischen Befund als „Goldstandard“ zur Diagnosestellung kein einheitliches Vorgehen zu Diagnose und Therapie der OT erkennen. Die hohe Nachfrage nach Serum-IgM-Antikörpern weist auf eine weitverbreitete Unsicherheit über die Bedeutung serologischer Befunde hin. Dies ist angesichts der weiterhin hohen Seroprävalenz in Deutschland kritisch zu werten.

Background Uveitis in juvenile idiopathic arthritis (JIAU) is frequently associated with the development of complications and visual loss. Topical corticosteroids are the first line therapy, and disease modifying anti-rheumatic drugs (DMARDs) are commonly used. However, treatment has not been standardized. Methods Interdisciplinary guideline were developed with representatives from the German Ophthalmological Society, Society for Paediatric Rheumatology, Professional Association of Ophthalmologists, German Society for Rheumatology, parents’ group, moderated by the Association of the Scientific Medical Societies in Germany. A systematic literature analysis in MEDLINE was performed, evidence and recommendations were graded, an algorithm for anti-inflammatory treatment and final statements were discussed in a consensus meeting (Nominal Group Technique), a preliminary draft was fine-tuned and discussed thereafter by all participants (Delphi procedure). Results Consensus was reached on recommendations, including a standardized treatment strategy according to uveitis severity in the individual patient. Thus, methotrexate shall be introduced for uveitis not responding to low-dose (≤ 2 applications/day) topical corticosteroids, and a TNFalpha antibody (preferably adalimumab) used, if uveitis inactivity is not achieved. In very severe active uveitis with uveitis-related deterioration of vision, systemic corticosteroids should be considered for bridging until DMARDs take effect. If TNFalpha antibodies fail to take effect or lose effect, another biological should be selected (tocilizumab, abatacept or rituximab). De-escalation of DMARDs should be preceded by a period of ≥ 2 years of uveitis inactivity. Conclusions An interdisciplinary, evidence-based treatment guideline for JIAU is presented.

BackgroundPatients with acute anterior uveitis (AAU) have an increased risk for concomitant spondyloarthritis (SpA). Different referral strategies have been proposed to identify AAU patients with high probability of SpA, among them an Assessment of SpondyloArthritis international Society(ASAS)-based referral strategy focusing on patients with chronic back pain starting before the age of 45 years and the Dublin Uveitis Evaluation Tool (DUET) also including psoriasis, HLA-B27 and arthralgia (Poddubnyy et al., Haroon et al., both ARD 2015).ObjectivesTo analyse the prevalence of SpA in patients with AAU, to identify parameters associated with SpA presence, and to evaluate referral algorithms.MethodsPatients with non-infectious AAU underwent structured rheumatologic assessment including magnetic resonance imaging of sacroiliac joints allowing a definitive diagnosis/exclusion of concomitant SpA. Fisher’s exact test and Mann–Whitney U test were used to compare AAU patients with and without SpA. Furthermore, logistic regression analyses were performed. Sensitivity, specificity, positive predictive value, positive and negative likelihood ratios were analysed for referral strategies.ResultsThe 189 AAU patients with complete rheumatologic assessment and SIJ imaging were 40.8 years old, and 55% were males. SpA was diagnosed in 106 AAU patients (56%). The majority (93%) had predominantly axial SpA, 7 patients peripheral SpA. In 74 patients (70%), the SpA diagnosis was established for the first time. Pelvic X-rays were available for 88 (89%) of the axSpA patients, 66% of whom were classified as having radiographic axSpA.SpA was equally frequent in patients experiencing the first episode of AAU and in patients with recurrent disease. In our cohort, AAU patients with and without underlying SpA showed no differences in their ophthalmologic examination. In multivariable logistic regression analysis, psoriasis (OR 12.5 [95%CI 1.3-120.2]), HLA-B27 positivity (OR 6.3 [95%CI 2.4-16.4]), elevated CRP (OR 4.8 [95%CI 1.9-12.4]) and male sex (OR 2.1 [95%CI 1.1-4.2]) were associated with SpA presence.Table 1.Parameters associated with the presence of spondyloarthritis in patients with acute anterior uveitis.univariablemultivariableOR95%CIOR95%CIPsoriasis (ever)14.6(1.9; 112.4)12.5(1.3; 120.2)HLA-B27 positivity6.2(2.7; 14.6)6.3(2.4; 16.4)Elevated CRP (≥ 5 mg/l)4.1(1.8; 9.0)4.8(1.9; 12.4)Male sex2.2(1.2; 4.0)2.1(1.1; 4.2)Inflammatory back pain (ASAS definition)2.1(1.2; 3.9)1.9(0.9; 4.0)Any peripheral manifestation (ever)1.9(1.1; 3.5)1.9(0.9; 3.8)Age in years1.0(1.0; 1.0)1.0(1.0; 1.0)Univariable and multivariable logistic regression analyses. ASAS Assessment of SpondyloArthritis international Society; CRP C-reactive protein; OR odds ratio; CI confidence interval.The Dublin Uveitis Evaluation Tool showed higher specificity for SpA recognition than the ASAS referral tool (42% vs. 28%), which had slightly higher sensitivity (78% vs. 80%). However, both referral strategies would have missed more than 20% of SpA patients.ConclusionWe revealed a high prevalence of overall and previously undiagnosed SpA in AAU patients. Therefore, we propose rheumatologic evaluation for all AAU patients with musculoskeletal symptoms. Rheumatologists should consider that SpA in AAU patients might present “atypically” with back pain starting after 45 years and lasting shorter than 3 months.Figure 1.Performance of Referral Strategies in Patients with Acute Anterior Uveitis. Dublin Uveitis Evaluation Tool (DUET) and an ASAS-based referral tool (ASAS). + respective tool fulfilled, - not fulfilled. ASAS Assessment of SpondyloArthritis international Society; AxSpA axial spondyloarthritis, pSpA peripheral spondyloarthritis.AcknowledgementsThe authors would like to thank the rheumatologists S. Lüders, B. Muche and A.-K. Weber for participating in the clinical data acquisition; and A. Langdon and L. Meinke for their support monitoring and coordinating this study. Furthermore, we are grateful to all participating ophthalmologists who included their patients in this study and to all patients. The study was supported by an unrestricted research grant from AbbVie. AbbVie had no role in the study design or in the collection, analysis, or interpretation of the data, the writing of the manuscript, or the decision to submit the manuscript for publication. Dr. Judith Rademacher and Dr. Dominika Pohlmann are participants in the BIH-Charité Clinician Scientist Program funded by the Charité –Universitätsmedizin Berlin and the Berlin Institute of Health.Disclosure of InterestsJudith Rademacher: None declared, Hanna Müllner: None declared, Torsten Diekhoff Speakers bureau: AbbVie, MSD, Novartis, Canon MS, Consultant of: Lilly, Hildrun Haibel Speakers bureau: AbbVie, MSD, Janssen, Roche, Pfizer, Sobi, Consultant of: Janssen, Sobi, Novartis, Sabrina Igel: None declared, Dominika Pohlmann Speakers bureau: Bayer, Consultant of: AbbVie, Celgene, Janssen, Novartis, UCB, Grant/research support from: Bayer, Allergan, Fabian Proft Speakers bureau: AMGEN, AbbVie, BMS, Celgene, Janssen, MSD, Novartis, Pfizer, Roche, UCB, Consultant of: AbbVie, Celgene, Janssen, Novartis, UCB, Grant/research support from: UCB, Novartis, Lilly, Mikhail Protopopov Consultant of: Novartis, Valeria Rios Rodriguez Consultant of: AbbVie, Falk e.V., Murat Torgutalp: None declared, Uwe Pleyer Shareholder of: stock or stock options from Novartis, BionTec, Speakers bureau: AbbVie, Alimera, Novartis, Grant/research support from: AbbVie, Denis Poddubnyy Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer and UCB, Consultant of: AbbVie, Biorad, Eli Lilly, Gilead, GlaxoSmithKline, Janssen, MSD, Novartis, Pfizer, Samsung Bioepis and UCB, Grant/research support from: AbbVie, Eli Lilly, MSD, Novartis, Pfizer

This article reports on the sixth scientific workshop of the European Crohn's and Colitis Organisation [ECCO] on the pathogenesis of extraintestinal manifestations [EIMs] in inflammatory bowel disease [IBD]. This paper has been drafted by 15 ECCO members and 6 external experts [in rheumatology, dermatology, ophthalmology, and immunology] from 10 European countries and the USA. Within the workshop, contributors formed subgroups to address specific areas. Following a comprehensive literature search, the supporting text was finalized under the leadership of the heads of the working groups before being integrated by the group consensus leaders.

Multiple sclerosis (MS) is a chronic inflammatory disorder of the brain and the spinal cord occurring mostly in young adults and is associated with temporary or permanent neurological deficits. An association between uveitis and MS has been recognized for a long time. Current data indicate an approximately 10 times higher prevalence of uveitis in patients with MS compared to the general population. In particular, MS is associated with intermediate uveitis and typically with concomitant retinal vasculitis. The treatment of uveitis should not only take the severity of intraocular inflammation into account but a coordination of the active agents must also consider the neurological manifestations. Since uveitis and MS are pathogenetically based on an immune-mediated genesis, immunomodulatory treatment approaches are dominant but it is important to bear in mind that tumor necrosis factor(TNF)-alpha blocking agents may worsen MS.

Sarcoidosis is a multisystem disorder of unknown cause. Ophthalmic involvement occurs in up to 60% of all patients, often as the first manifestation of sarcoidosis. Because of the heterogeneous clinical presentation diagnosis can be difficult; therefore the International Workshop on Ocular Sarcoidosis (IWOS 2009) diagnostic criteria based on clinical presentation, laboratory investigations and imaging techniques enable establishment of the diagnosis. Patients suffering from sarcoidosis should be treated by both ophthalmologists and internal physicians. Corticosteroids are commonly used for treatment, although in some patients the therapy has to be escalated by further immunosuppressants. Finally, a good cooperation between ophthalmologists and internal physicians results in a mostly good prognosis.

Die durch Adenoviren ausgeloste Keratoconjunctivitis (epidemica, KCE; ICD-10 B30.0+) ist haufig, kann schwer verlaufen und verursacht eine erhebliche Morbiditat. In der Fruhphase ist es oft schwierig, allein aufgrund des klinischen Befundes die KCE von anderen Ursachen eines anderen „roten Auges“ zu unterscheiden. Aufgrund hoher Kontagiositat kann sich die Erkrankung rasch zu einem epidemischen Geschehen auswachsen. Daher bleibt eine rasche Virusidentifikation und Vermeidung weiterer Ausbreitung der Infektion eine wesentliche Herausforderung. Da es schwierig ist, kurzfristig den labortechnischen Erregernachweis zu fuhren, wird der Anfangsverdacht zunachst rein klinisch geausert. Neuentwicklungen wie Screeningtests sind von praktischer Bedeutung und konnen die Fruhdiagnose unterstutzen. Adenoviren sind klinisch problematisch, da sie eine hohe Resistenz gegenuber Umweltfaktoren aufweisen und hoch entwickelte „Escape-Mechanismen“ eine Persistenz des Virus auch uber lange Zeit an der Augenoberflache ermoglichen. Bestandteile der Virusproteine verbleiben haufig in der Hornhaut, vor allem in der Bowman-Schicht. Hier fuhren sie zu immunologischen Reaktionen und den typischen subepithelialen Infiltraten („Nummuli“). Die Behandlung der KCE beschrankt sich zurzeit auf symptomatische Oberflachenpflege. Das Hauptproblem, die Persistenz subepithelialer Infiltrate, ist schwierig anzugehen. Eine risikoarme Option ist die Anwendung von Ciclosporin-A-Augentropfen. Die Behandlung mit topischen Steroiden ist eher problematisch, kann jedoch in allen Krankheitsstadien diskutiert werden. Da die Verbreitung von Adenoviren oft nosokomial erfolgt, bleibt die Pravention der Infektion eine zentrale Verantwortung der Ophthalmologen.

Seasonal allergic conjunctivitis (SAC) is a frequent disease, which is often associated with allergic rhinitis and subsequently manifested as allergic rhinoconjunctivitis. In contrast to other types of chronic allergic conjunctivitis, the course of SAC is not sight-threatening. Pathogenetically, the underlying cause of SAC is an immunoglobulin E (IgE) mediated, Th2-driven type 1 hypersensitivity reaction. Clinically it presents with itching, light-red conjunctival injection as well as chemosis that exceeds the extent of conjunctival injection. The goals of treatment are relief of acute signs and symptoms, control of the underlying inflammatory process and utilization of preventive options. Dually effective local therapeutics combine the advantages of rapid action with a relatively long-lasting effect by a two-fold active approach. Specific immunotherapy is useful in selected patients.

Purpose To evaluate the long-term safety of DEX in patients treated for RVO-related macular edema (ME) or NIPSU in clinical practice. Methods Multicenter (102 sites in France, Germany, Spain, United Kingdom), prospective, observational, post-authorization safety study in adult patients treated with DEX. Treatment and follow-up were at physicians’ discretion. Data collected up to 2 years after enrollment included serious adverse events (SAEs) and adverse events of special interest (AESIs; adverse drug reactions with DEX as listed in the Summary of Product Characteristics). Results Overall, 753 patients (610 RVO, 143 NIPSU) received on-study DEX treatment and 73.0% completed 24 months follow-up; 74.0% had not used DEX previously. Median number of on-study injections per treated eye was 2 (range, 1–7) with median re-injection interval of 27 weeks; 36.4% of patients received >2 injections. Non-ocular SAEs affected 8.9% of patients; none were considered related to DEX. Ocular SAEs (most common: cataract progression) were reported in 3.4% of treated eyes. Non-ocular and ocular SAEs were similar in eyes stratified by previous DEX use and number of on-study DEX injections (≤2 or >2), regardless of indication (RVO or NIPSU). The most common AESIs reported were increased intraocular pressure (IOP) in 19.3% of treated eyes, cataract progression and cataract formation in 19.5% and 19.3% of treated phakic eyes (n=528), and vitreous hemorrhage in 3.2% of treated eyes. Cataract progression and vitreous hemorrhage were more frequent in eyes that received >2 DEX injections. Among eyes with RVO, cataract progression was more frequent in eyes previously treated with DEX. Conclusions The long-term safety profile of DEX was acceptable. The 2-year incidence of cataract and increased IOP was lower than previously reported (LOUVRE study). No new safety concerns were identified.

The eye has all the mechanisms necessary for detection and processing (afferent immune reaction) as well as adequate initiation of an (efferent) immune response. Apart from the typical antigen-processing cells, locally present elements (e.g. glial cells and retinal pigment epithelium) can also be involved in the afferent reaction. For the efferent mechanisms a complex regulative system exists, which includes cellular and humoral responses and is essentially determined by surface molecules. In addition, the ocular environment is rich in immunosuppressive molecules that contribute to the regulation of immune cells. The adaptation of the anatomical and biochemical mechanisms for the creation of an immune-privileged microenvironment makes this sense organ unique. The purpose of this article is to highlight the specific features of the eye and to establish a reference to frequent ocular manifestations in rheumatic diseases.

Inflammation of the sclera includes a wide range of morphological changes, which often occur in association with systemic diseases. While episcleritis is mainly harmless, scleritis often proceeds and is characterised by a destructive course. This may lead to important complications, that present as ulcerative keratitis, uveitis or secondary increases in intraocular pressure. As this form of inflammation is severe and there are often underlying diseases, this contribution focusses on differential diagnosis and current therapeutic approaches.Die Skleritis umfasst ein breites Spektrum morphologischer Veränderungen, die häufig im Rahmen systemischer Erkrankungen auftreten. Während die Episkleritis meist unproblematisch verläuft, ist die Skleritis oft durch einen destruierenden Verlauf charakterisiert. Dies führt nicht selten zu visusrelevanten Folgekomplikationen, die sich als ulzerative Keratitis, Uveitis oder sekundäre intraokulare Drucksteigerung präsentieren. Aufgrund der Schwere dieser Entzündungsform und der häufig zugrunde liegenden Grunderkrankungen soll der Fokus des Beitrags auf die differenzialdiagnostischen Überlegungen und die aktuellen therapeutischen Optionen gelegt werden.

ZusammenfassungIntraokulare Entzündungen sind im Kindesalter eine der häufigsten Ursachen gesetzlicher Blindheit in Europa. Daher kommt der Diagnostik und Behandlung der Uveitis im Kindesalter besondere Bedeutung zu. Der oft asymptomatische Beginn der Entzündung und die dadurch verzögerte Diagnose führen nicht selten zu einer funktionell schlechteren Prognose gegenüber Erkrankungen im späteren Lebensalter. Bei etwa 20–30 % betroffener Augen verbleiben irreversible Schäden. Ziel dieses Beitrages ist es, auf die diagnostischen und therapeutischen Besonderheiten einzugehen, um Risiken und Komplikationen auf ein Minimum zu reduzieren.

Anterior uveitis is a potentially sight-threatening disease, which affects either one or both eyes. Although the etiology is not fully understood, important associations with systemic diseases and infections have been established. A thorough clinical investigation with the slit lamp may reveal important findings leading to diagnosis and therapy. Additional diagnostic procedures are usually required only with the occurrence of relapses. Most anterior uveitis cases with an underlying autoimmune etiology respond very well to topical steroids and mydriasis while systemic treatment is rarely needed. In contrast, infectious causes typically require systemic medication. Anterior uveitis has a good prognosis if treated adequately despite some complications like cataract, macular edema, or increase of intraocular pressure, which cannot be prevented in all cases.

Treatment of autoimmune diseases has undergone significant changes and developments in recent years. New classes of active substances, in particular biologics and small molecules have resulted in previously unknown success in the treatment of many diseases. In particular patients suffering from autoimmune rheumatic or dermatological diseases have benefited. For autoimmune uveitis there are numerous reports indicating excellent therapeutic and preventive effects; however, statutory approval for therapy in adults is still pending. This article outlines recent advances and future therapeutic options for the treatment of posterior segment noninfectious uveitis.

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

Medical eye care in developing countries is very different from the situation in industrialized nations. In order to prevent rising numbers of blind people worldwide due to increased life expectancy and population growth, the global initiative Vision 2020 "The Right to Sight" was established in 1999. Coordinated initiatives are important as most causes of blindness are either preventable or curable (e.g. cataract surgery); however, due to a lack of resources eye care in developing countries cannot implement all necessary preventive and therapeutic measures at present. The epidemiology of causes of blindness and the situation of ophthalmic care are discussed. Because of increased mobility of people and goods (e.g. air travel and trucking), imported eye diseases are of increasing importance. The difference between travel medicine, which deals with the medical situation of travelers and international ophthalmology (i.e. diseases in tropical countries) is discussed and illustrated on the basis of several important disease patterns.

Currently, the identification of apoptotic or damaged human corneal endothelial (HCE) cells is limited to a morphological assessment and vital staining. Specific electrophysiological investigations may prospectively help to identify damaged HCE cells at an earlier stage. Besides calcium imaging, the so-called patch-clamp technique is an important test method enabling one to assay the effect of various substances on ion channels and receptors of the cell membrane. First electrophysiological pilot experiments with cultivated and freshly isolated HCE cells have revealed promising results. In this way, the expression of certain transient receptor potential channels (TRPs) could be demonstrated. However, the function of these channels is still not fully elucidated. In humans, TRPs play a crucial role in the sense of taste, pheromones, temperature and pain and are involved in osmolarity. This review summarises the current literature on the electrophysiology of the human corneal endothelium and deduces potential approaches to a sensitive vitality and function test under utilisation of the electrophysiological properties of HCE cells.

An involvement of the visual system can be found in many neurologic diseases. Especially demyelinating processes of the central nervous system (CNS) and multiple sclerosis (MS) in particular present with a variety of ophthalmological abnormalities. While optic neuritis (ON) is known to be a positive predictor for the development of MS and can be considered a symptom of the disease, the high frequency of uveitis observed in MS patients seems to occur rather in the context of a general predisposition for autoimmune disorders. However, MS-associated uveitis can precede the onset of neurological symptoms by many years and shows response to treatment with steroids and interferons, suggesting the presence of similar underlying pathogenic mechanisms. Therefore, further studies are warranted in order to reveal whether administration of early immunomodulatory therapy can delay or even prevent the clinical manifestation of MS in a distinct subgroup of patients presenting with uveitis.

Keratoconjunctivitis caused by adenoviruses (epidemic keratoconjunctivitis, EKC, ICD-10 B30.0+) is common, can be severe and may cause significant morbidity. In the early stages of adenoviral infections it is often difficult to differentiate the clinical presentation from other causes of a red eye. Because of its highly contagious nature that can rapidly lead to epidemic outbreaks, prompt viral identification and prevention of further spread are major challenges. Even today the diagnosis is still mainly clinical, with laboratory tests only rarely contributing. New diagnostic tests, such as the Rapid Pathogen Detector (RPS, Sarasota FL) AdenoPlus detection kit, that are practical, rapid and inexpensive to use in the general practice may obviate these problems. Because of its highly resistant properties to desiccation and highly developed escape mechanisms which protect the virus from the host's immune response, long-term problems often remain. Remnants of viral proteins often persist on the corneal surface of Bowman's layer for a long time and may lead to the formation of subepithelial infiltrates. No treatment other than symptomatic eye drops is available. The major sequelae are subepithelial infiltrates, which are difficult to treat. Cyclosporin A eye drops are a good option with a low risk profile. The use of topical steroids can possibly be disadvantageous but can be discussed at all stages of the disease. As nosocomial spread of adenoviruses is relatively common, preventive measures remain a major responsibility for ophthalmologists.

Acute annular outer retinopathy (AAOR) is a very rare variant of acute zonal occult outer retinopathy (AZOOR). Both variants are characterized by the perception of a progressive visual field defect and can be accompanied by photopsia. In contrast to AZOOR, a progressive whitish and annular demarcation of the involved retina is observed in AAOR using ophthalmoscopy. Optical coherence tomography (OCT) reveals morphological changes predominantly in the outer retinal layers. Although there is no proof of an effective therapy, in the case presented here further progression could be stopped by a combination of antiviral and immunosuppressive therapy.

In September 2011 the cornea section of the German Ophthalmological Society (DOG) established the first German Acanthamoeba keratitis registry. The data of this multicenter survey are being collected, compiled and evaluated at the Department of Ophthalmology at the Saarland University. The aim of this article is to present an intermediate report.Data from 172 eyes with Acanthamoeba keratitis were collected during the last 10 years. For this interim report we actually evaluated 121 eyes (60.2 % female patients, average age 41.3 years) and collected the following data: date of onset of symptoms, date and method of diagnosis, initial diagnosis, anamnestic data, clinical symptoms and signs at diagnosis and during follow-up, conservative and surgical therapy. Criteria for inclusion in the Acanthamoeba registry was the established diagnosis of an Acanthamoeba keratitis with at least one of the methods described in this article.Acanthamoeba keratitis could be histologically proven in 55.3 % of the cases, via PCR in 25.6 %, with confocal microscopy in 20.4 % and using in vitro cultivation in 15.5 %. Clinical symptoms and signs in Acanthamoeba keratitis were pain in 67.0 %, ring infiltrates in 53.4 %, pseudodendritiform epitheliopathy in 11.7 % and keratoneuritis in 5.8 %. In 47.6 % of the cases the initial diagnosis was herpes simplex virus keratitis followed by bacterial keratitis in 25.2 % and fungal keratitis in 3.9 %. Acanthamoeba keratitis was the correct initial diagnosis in only 23.2 % of cases. The average time period between first symptoms and diagnosis was 2.8 ± 4.0 months (range 0-23 months). A triple therapy with Brolene® Lavasept® and antibiotic eye drops at least 5 ×/day was used in 54.5 % of eyes (n = 66). Penetrating keratoplasty was performed in 40.4 %, in 18 cases in combination with cryotherapy of the cornea. The mean graft diameter was 7.9 ± 1.1 mm (range 3.5-11.0 mm). The final visual acuity (Snellen visual acuity chart at 5 m) was comparable in the two groups of eyes with (5/40 ± 5/25) and without (5/32 ± 5/25) keratoplasty.Acanthamoeba keratitis is a rare and often very late diagnosed disease and two thirds of the cases were initially misdiagnosed. The early recognition of the typical symptoms is crucial for the prognosis of the disease. All ophthalmological departments in Germany are invited to submit further data of all confirmed cases (berthold.seitz@uks.eu), whether retrospectively or prospectively in order to generate an adequate standardized diagnostic and therapeutic approach for this potentially devastating disease.

Die Keratoconjunctivitis vernalis (VKC) ist eine beidseitige, rezidivierende Bindehautentzundung, die schubweise – bevorzugt im Fruhjahr – auftritt. Klinisches Charakteristikum sind die Ausbildung von Riesenpapillen im Tarsusbereich (Durchmesser > 1 mm) und/oder limbusnahe Veranderungen („Trantas dots“). Die Atiologie und Pathophysiologie der VKC ist weiterhin unklar. Klinische Befunde und immunhistologische Untersuchungen lassen vermuten, dass komplexe (sowohl IgE-abhangige als auch IgE-unabhangige immunpathologische) Veranderungen zugrunde liegen. Pradisponierende Faktoren schliesen endokrine, genetische, neurogene sowie Umwelt- und soziookonomische Einflusse ein. Antihistaminika, Mastzellstabilisatoren und ggf. topische Steroide haben sich als Akuttherapie der VKC bewahrt. Allerdings ist dieser Behandlungsansatz bei schweren Verlaufen unzureichend und kann Rezidive nicht vollig vermeiden. Immunmodulatoren wie Ciclosporin A und Tacrolimus stellen alternative Wirkstoffe vor allem fur die Langzeittherapie dar. Bei den meisten Kindern liegt ein selbstlimitierender Verlauf vor, der nach der Pubertat abklingt. Bei einem Teil der Patienten treten visusbedrohliche Komplikationen ein. Diese werden uberwiegend durch Hornhautkomplikationen und iatrogen durch langerfristige Steroidbehandlung verursacht.

BACKGROUND: Interferons are a complex group of glycoproteins with antiviral, antiproliferative and immunomodulatory activity. They are used to treat different types of human neoplasms and chronic hepatitis C. Several case reports have described interferon-induced ocular side effects since the first case in 1990. PATIENT AND METHODS: We report about a 61-year-old female undergoing interferon 2alpha treatment who developed bilateral retinopathy during systemic therapy and provide a summary about ocular side effects and their consequences. CONCLUSIONS: Patients should be monitored by ophthalmologists before, during and after interferon therapy in order to avoid side effects like retinal neovascularisation and to prevent potential serious side effects.

The quality of an article depends first and foremost on its scientific content. However, the way in which the scientific material is presented may determine whether it will receive proper attention. The aim of this presentation is to point out general characteristics of good papers. The title can decide whether a potential reader will give your article a proper look. A good title is descriptive and may also give a statement if the journal style allows. The abstract is the most important part of your article. People will proceed to read the article only if they find the abstract interesting. Describe the material or patients and the methods in brief. It is advisable to specify the study design. Present the most important results in a brief manner. Give quantitative data with confidence limits whenever applicable. The reader wants to know what your results were, not just whether they were “statistically significant”. In the discussion, put your data into context with the clinical practice, literature or both. What have we learned? A common mistake is to include general conclusions which are not specifically supported by the data presented. Please check that the conclusions are in line with the stated aim of the study.

Objective and design: To examine the effects of the nitric oxide synthase (NOS) inhibitors aminoguanidine (AG) and L-NAME on leukocyte adhesion in endotoxin-induced uveitis (EIU).¶Material: Uveitis was induced in Lewis rats (n = 124) by LPS injection (Salmonella typhimurium).¶Treatment: Rats either (1) did not receive any LPS or other treatments (controls), received (2) only subcutaneous saline injections with LPS administration, (3) a single s.c. dose of AG (100 mg/kg body weight) at the time of LPS administration, (4) a single s.c. injection of AG 8 h after LPS injection, (5) s.c. injections of AG at the time of LPS administration and 8 h after LPS injection or (6) received a single dose of L-NAME (75 mg/kg body weight) at the time of LPS administration.¶Methods: Intravital microscopy (IVM) of iris vessels was performed at 2, 4, 8, 16, 24 and 48 h after endotoxin injection. Aqueous humor analysis for protein concentration and cell count was performed after IVM.¶Results: At 2 h after the induction of uveitis, significantly more rolling leukocytes were detected in the AG and L-NAME-treated group than in untreated EIU (4.8 ± 0.31 and 9.83 ± 0.64 vs. 2.85 ± 0.37 %, mean ± SEM, p < 0.01). However, at 16 h the percentage of rolling leukocytes was significantly reduced in all groups which had received AG (LPS: 8.08 ± 0.37 %; LPS/AG 0h: 3.78 ± 0.25 %; LPS/AG 8 h: 5.34 ± 0.3 %; LPS/AG 0 + 8 h: 3.86 ± 0.31 %). L-NAME enhanced leukocyte rolling even at 24 h after LPS (12.38 ± 0.64 %). Early treatment of EIU with AG significantly reduced the number of sticking leukocytes at 4, 8 and 24 h (306 ± 13 vs. 571 ± 41, 228 ± 12 vs. 345 ± 19 and 240 ± 14 vs. 469 ± 23 cells/mm2, respectively). L-NAME inhibited LPS-induced sticking of leukocytes at all observed time points and this effect was most pronounced at 24 h (147 ± 10 vs. 469 ± 23 cells/mm2).¶Conclusions: In EIU, administration of AG or L-NAME causes enhanced leukocyte rolling in the early inflammatory response. However, firm adhesion of leukocytes to the vascular endothelium decreases and this effect prevails, ameliorating leukocyte infiltration.