German Ophthalmological Research Articles

Cooperation of German ophthalmologists in routine care of patients with neovascular age-related macular degeneration: results of the non-interventional BRIDGE study.

In the non-interventional ophthalmological study 'BRIDGE' the routine care of patients with neovascular age-related macular degeneration (nAMD) treated with ranibizumab was observed in Germany. A patient regularly sees the general ophthalmologist (GO) for monitoring and, if needed, the injecting ophthalmologist (IO) for intravitreal injections (IVI). Thus, patients are routinely treated by two ophthalmologists in parallel and patient care depends on their collaboration. This cooperation was evaluated based on network questionnaires. 'BRIDGE' was a multicenter, national, open-label, prospective, observational study, conducted between July 2010 and December 2012. The network questionnaire for GOs consisted of 51 questions, while the similar questionnaire for IOs consisted of 43 questions, addressing the type and details of the individual collaboration. The statistical analysis was purely descriptive. The network questionnaire for GOs was completed by 152 GOs, regularly cooperating with 2.5 ± 1.1 IOs, while the questionnaire for IOs was completed by 43 IOs, regularly cooperating with 23.2 ± 23.6 GOs. Generally, both GOs and IOs stated that they regularly exchange information regarding the patients' situation. Diagnostic standards were only established for 15% of the GOs' collaborations and for 35% of the IOs' collaborations. After initial treatment, both GOs and IOs agreed on the medical significance of regular monitoring visits performed by the GOs. Agreements on re-treatment criteria were only established in the case of 16% of the GOs and 28% of the IOs. Overall, both GOs and IOs were satisfied with the current situation, with regard to the medical treatment situation for patients and to the cooperation within the networks. The network questionnaires revealed well-established cooperation between IOs and GOs in Germany with an accepted division of responsibilities for the routine care of patients with nAMD. However, the cooperation between two ophthalmologists treating one patient harbors risks. Agreements on diagnostic and re-treatment criteria would help to improve network performance and outcomes.

Acute Retinal Necrosis: Diagnostic and Treatment Strategies in Germany

Purpose: To analyze the preferred practice respective diagnosis, treatment, and complications in patients with acute retinal necrosis in Germany.Methods: The uveitis-section of the German Ophthalmologic Society developed a questionnaire with 12 questions concerning patients with acute retinal necrosis seen in the 5 years up to August 2009.Results: In total, 35 eye hospitals answered the questionnaire and reported 213 patients with acute retinal necrosis. Diagnosis was made clinically in 86%. Anterior chamber tap, vitreous biopsy, diagnostic vitrectomy, and serology were performed for confirmation. Therapy was started with acyclovir in all institutions, and continued with ganciclovir, foscarnet and brivudine in some cases. Intravitreal injections were performed in 46%. Additional oral steroids were given in 80%. A following oral antiviral treatment was performed in 94%.Conclusions: Relevant variations were seen in diagnosis and treatment practices. The survey outlines the need for a unique diagnostic and therapeutic guideline.

Anti-VEGF therapy for neovascular age-related macular degeneration -therapeutic strategies: statement of the German Ophthalmological Society, the German Retina Society and the Professional Association of Ophthalmologists in Germany - November 2014

Anti-VEGF therapy for neovascular age-related macular degeneration -therapeutic strategies: statement of the German Ophthalmological Society, the German Retina Society and the Professional Association of Ophthalmologists in Germany - November 2014

Are entry criteria for cataract surgery justified?

PurposeThe German Ophthalmological Society (GOS) recently proposed surgical entry criteria, i.e. 300 cataract surgeries. We herein correlate the surgical hands-on experience with the risk of posterior capsule ruptures in order to assess whether this number is appropriate.MethodsWe identified all cataract operations that had been performed at the University Eye Hospital Freiburg since 1995. For each surgeon, we assigned a running number to his/her procedures in the order they had been performed. Thereafter, we excluded all combined procedures and the second eyes. We then selected the 5475 surgical reports between November 2008 and November 2012 for detailed review. We additionally classified each surgery into low- vs. high- à priori risk for posterior capsule ruptures. We fitted a multifactorial logistic regression model to assess the GOS recommendation of 300 surgeries under supervision. In the low-risk group, we additionally visualized the 'typical' learning curve by plotting the posterior capsule ruptures against the respective rank numbers.ResultsThe odds ratio for posterior capsule ruptures of 'learning-mode' (one of the respective surgeon's 300 first procedures) vs. the non-learning-mode was 3.8 (p<0.0001). By contrast, classification into the low-risk group lowered the risk of posterior capsule ruptures three fold (p<0.0001). According to the low-risk plot, the surgeons started with a complication rate of 4% and continuously improved towards 0.5% after 1500 operations. Thereafter, the rate increased again and stabilized around one percent.ConclusionThe learning curve with respect to posterior capsule ruptures is surprisingly flat. The GOS entry criterion of 300 cataract procedures is therefore most likely justified. Careful selection of low-risk patients for the training surgeons may help in reducing the rate of posterior capsule ruptures during training.

The relevance of individual health services in German ophthalmology

Individual health services (ihs) have gained importance in the German health-care system. This article describes the economic impact and the daily practice of individual health services from the perspective of ophthalmologists. An online survey to examine the role of individual health services in ophthalmology was sent to the members of the German Ophthalmological Society (DOG) and the Professional Association of Ophthalmologists in Germany (BVA). 1,361 ophthalmologists (one fifth of all ophthalmologists in Germany) responded to the poll. 87.5 % of the ophthalmologists agree that the quality of ophthalmic care could suffer if the necessary individual health services were not performed. 78.9 % consider individual health services to be financially feasible for the patient. 65.6 % responded to be hardly able to survive economically without individual health services. For approximately half of the ophthalmologists, individual health services represent more than 10 % of their overall income. 57.5 % wish to abolish individual health services and to extend the service catalogue of the statutory health insurances. In contrast to official reports about the benefit from individual health services, the ophthalmologists do see a medical need for individual health services. Obviously there is a discrepancy in the perspective between health insurers and ophthalmologists.

Attitudes toward postmortem cornea donation in Germany: a multicenter survey.

To analyse the willingness for postmortem cornea donation in Germany. Employees in two cities (UKM, UKS), and university hospitals (STM, STE), members of the German Ophthalmological Society (DOG), and employees of an automobile company (BO) participated in a questionnaire about postmortem cornea donation attitudes. The questionnaire consisted of demographic items, motives concerning postmortem cornea donation, general attitudes toward donation, and questions concerning the perceived needs for information about donation. The statistical analyses included logistic regression with the target parameter of 'willingness to donate cornea postmortem'. Of the participants, 67.7 % (UKM, UKS), 70.9 % (STM, STE), 70.8 % (BO), and 79.4 % (DOG) declared their intention to donate their corneas postmortem. Younger age (p < 0.001), poorer general health (p < 0.05), faith in an eternal life (p < 0.05), disagreement with brain death diagnostics (p < 0.001), fear of receiving worse medical treatment (p < 0.001), and fear of the commercialization of organs (p < 0.001) were found to be risk factors for a negative attitude toward postmortem cornea. The majority of participants (57.4 %) indicated that additional information about donation would be appreciated, and the internet (69.9 %) was considered the most appropriate means for conveying this information. Emotional items were revealed to be the most relevant factors influencing the willingness to donate cornea postmortem, which may be counteracted by means of public education. The relatively low willingness among the medical staff contrasts with previous observations in a professional ophthalmologic society.

Fractionated gamma knife radiosurgery for benign perioptic tumors: outcomes of 38 patients in a single institute.

BackgroundThis study was performed to evaluate the efficacy and safety of fractionated Gamma Knife radiosurgery (GKRS) for perioptic lesions.MethodsThirty-eight patients with perioptic tumors were treated at our institute from May 2004 to December 2008. All patients had a lesion in close contact with the optic apparatus. Twenty-four of these patients had undergone surgical resection before fractionated GKRS. Radiation was delivered in four sessions with 12 hours intervals between sessions. The mean target volume was 3,851 mm3 and the median cumulative marginal dose was 20 Gy. The median follow-up was 38.2 months. Visual acuity and visual fields were analyzed according to visual impairment score using the German Ophthalmological Society guidelines.ResultsTumor control was achieved in 35 (94.6%) of the 37 patients with available follow-up images. Progressive tumor growth was observed in two craniopharyngioma patients (5.4%). Favorable visual outcomes in the postoperative period were achieved in 94.7% of cases (36/38). Sixteen patients showed visual function after fractionated GKRS, twenty cases were stationary, and two patients showed visual function deterioration after GKRS.ConclusionGKRS is a safe and effective alternative to either surgery or fractionated radiotherapy for selected benign lesions that are adjacent to the optic apparatus.

An epidemiological study of neovascular age-related macular degeneration in Germany

Objective:Neovascular or wet age-related macular degeneration (AMD) is one of the leading causes of blindness in industrialized countries; however, there is a lack of recent epidemiological data from Germany. The aim of this study was to collect epidemiological data from patients in Germany with suspected neovascular AMD and evaluate the diagnostic procedures performed and treatments used at clinics.Methods:This was a Germany-based, multicentre, retrospective review of data from patients with suspected neovascular AMD visiting ophthalmology clinics over an 18 month period in 2008–10. Clinical characteristics, functional symptoms and examination results were recorded. In addition, ophthalmologists completed a questionnaire on neovascular AMD diagnosis and treatment.Results:Ten sites collected data from 2498 patients (64.0% female) with a mean decimal visual acuity of 0.4 ± 0.3 at the time of diagnosis of neovascular AMD. The mean age at the time of diagnosis was 76.9 ± 8.9 years for patients with the right eye affected and 77.0 ± 8.3 years for patients with the left eye affected. The most frequent pathological findings detected by routine ophthalmic examination were old lesions (31.2%), intra/subretinal fluid (18.1%), new lesions (13.0%), and intra/subretinal haemorrhage (11.4%). A confirmed diagnosis of neovascular AMD was most frequently based on fundoscopy (67.3%), fluorescein angiography (39.6%), and biomicroscopy (35.7%) tests but rarely on optical coherence tomography (8.9%). The most frequently documented comorbidity with neovascular AMD was hypertension and other cardiovascular diseases (57.5%). Seven ophthalmologists completed the questionnaire with the majority of ophthalmologists agreeing that regular ophthalmic examination can prevent the development of late-stage neovascular AMD.Conclusion:Neovascular AMD is a frequent diagnosis in German ophthalmology clinics. As visual acuity is already poor in most patients with suspected neovascular AMD, regular preventive ophthalmologic examinations should be considered in high risk patients.Study limitations:Limitations of the study include the lack of a comparator cohort, which limited the amount of analyses that could be performed. Additionally, a study eye was not defined and information was collected separately for each affected eye and therefore analysed separately. Furthermore, a small number of ophthalmologists completed the questionnaire, limiting the objectivity.

Tuberculum sellae meningiomas: A series of 41 cases; surgical and ophthalmological outcomes with proposal of a new prognostic scoring system

Context:Tuberculum sellae meningiomas have proved difficult to treat, partly because of their intimate association with the optic nerves and chiasma, hypothalamus, and internal carotid arteries.Aims:The aim of this study is to analyze the degree of influence of various prognostic factors affecting visual outcome; the pattern of visual recovery and develop a scoring system for prognostication.Settings and Design:This is a retrospective study carried out from January 2004 till June 2011.Materials and Methods:Patients were analyzed on the basis of clinical, radiological, and surgical factors that appeared to affect the outcome. A special scoring system (according to the guidelines of the German Ophthalmological Society) was adopted to quantify the extent of ophthalmological disturbances.Statistical Analysis Used:Comparison of categorical variables between the two was performed using chi-square test and a P value of ≤ 0.05 was considered significant. Logistic regression was used when multivariate analysis was required.Results:Vision improved in 27% and deteriorated in 7.3%. A prognostic scoring system (score 4–13) was developed depending on the degree of influence of significant prognostic factors. The patients with a score of ≤6 had improved vision postoperatively (44%), whereas none of those with a score > 6 improved. Completeness of visual recovery was perceived in 100% of patients within 3 months. Complete resectability was achieved in 73% of patients.Conclusions:The proposed scoring system is very useful in prognosticating the visual outcome of these patients. The patients with a score of ≤6 have the best visual outcome postoperatively. Complete resectability is better achieved with extended bifrontal and unilateral frontal approaches. Short-term postoperative visual outcome is a strong indicator of permanent visual outcome after surgery.

Ergebnisse einer internetbasierten Umfrage zur Hornhautspendebereitschaft bei DOG-Mitgliedern

Analysis of willingness for postmortem cornea donation by professionals in ophthalmology and their motives in favor of or against donation. 3887 members of the German Ophthalmological Society received an anonymous questionnaire concerning sociodemographic background, physical health, experiences with organ explantation and their former engagement and motives concerning organ and cornea donation. 722 of the questionnaires were partially and 533 completely answered with an average willingness for cornea donation of 79.4%. Significant parameters for cornea donation were gender, former experience with organ explantation, ophthalmological health and fear of false diagnosis of brain death, worse medical treatment or organ commercialization. Of the participants 53.9% suggested the internet as a favorite source of information in this matter. The factors which had a significant impact on cornea donation in this survey seem to be mainly a result of insufficient information. Detailed information regarding this topic should preferentially be presented on internet pages of professional societies and could probably increase donation approval of DOG members.

Auswirkungen intrastromaler Presbyopiebehandlung mittels Femtosekundenlaser (INTRACOR) auf die mesopische Kontrastsensitivität

The aim of this study was to examine the mesopic contrast sensitivity (CS) and glare sensitivity following intrastromal femtosecond laser correction of presbyopia (INTRACOR). In this study 25 patients with slight hyperopia and presbyopia underwent femtosecond laser correction in the non-dominant eye. Mesotest II measurements (OCULUS Optikgeräte, Wetzlar, Germany) were performed with and without glare at each of four different contrast levels preoperatively as well as 3, 6, 12, 18 and 24 months postoperatively. Data were compared using the Wilcoxon-test with a level of significance of p < 0.05. After 24 months the median CS decreased from 1:2 to 1:2.7 without glare and from 1:23 to 0 with glare. Of all patients 36% showed loss in CS without and 52% with glare and CS did not show any statistically significant differences between the treated and the untreated fellow eyes after 12 and 24 months. Overall 9 out of 18 monocular treated patients showed no binocular night driving ability according to the recommendations of the German Society of Ophthalmology (DOG) and the Professional Association of German Ophthalmologists (BVA) 24 months following INTRACOR. INTRACOR can lead to a slight reduction of mesopic contrast sensitivity and an increase of glare sensitivity. Possible consequences on night driving ability should be discussed with the patients prior to treatment.

Ocular signs in Wilson disease

A known patient of Wilson disease was admitted for fever. He was not on regular therapy for the same. His brother also suffered from the same illness. On examination, he had bilateral sunflower cataracts and Kayser-Fleischer (KF) rings [Figure 1]. He also had bilateral rigidity and batwing tremor.Figure 1: Sunflower cataract and Kayser-Fleischer ringWilson disease is an autosomal-recessive disorder of copper metabolism due to mutation of the ATP7B gene in chromosome 13 (13q14.3). Ocular signs of Wilson disease are sunflower cataract and KF rings. Sunflower cataract was first described by Siemerling and Oloff in 1922.[1] It occurs due to copper deposition in the anterior capsule. Posterior capsule deposition appears to be uniform. The sunflower consists of a central disc with radiating folds at the periphery. The radiating folds are thought to be due to the impression of the posterior surface of the iris on the anterior lens capsule, as proposed by Duke-Elder. The shape of the sunflower may be distorted if there is pupillary abnormality. This mechanism may not fully explain the sunflower shape as this appearance can also occur in the posterior capsule. Sunflower cataract has been reported to occur in other conditions like intraocular copper bodies (chalcosis) and primary biliary cirrhosis, and have been shown to regress either partially or completely following penicillamine therapy. Hereditary hyperferritinemia cataract syndrome (HHCS) is a newly described autosomal-dominant disorder characterized by early-onset cataracts and increased serum L-ferritin concentration, but without iron overload. These cataracts have a characteristic sunflower-like appearance and are due to crystalline deposition of ferritin.[2] KF was described by the German ophthalmologists Bernhard Kayser in 1902 and Bruno Fleischer in 1903.[3] This is not to be confused with Fleicher ring, seen in Keratoconus, which is due to iron deposition in the corneal limbus. KF ring is due to copper deposition in the descemet membrane of the cornea at the limbus. It starts from the Schwalbe line and extends till 5 mm on the corneal surface. It starts in the superior pole as an arc from the 10- to the 2 o’clock position, followed by a similar arc in the inferior pole, and finally encircles the cornea.[4] Free copper loosely bound to albumin enters the aqueous humor and then enters the descemet membrane. The peripheral deposition is attributed to the direction of the aqueous humor.[5] KF rings are usually detected by slit lamp examination, but can also be visible to the naked eye and do not obstruct vision. KF ring is seen in 95% of the patients with neurological manifestations and 65% with liver dysfunction. KF rings can also occur in intraocular copper bodies (chalcosis) and primary biliary cirrhosis. The ring resolves in the reverse order either completely or partially following penicillamine therapy[5] and after liver transplant.

Evidence-based, interdisciplinary guidelines for anti-inflammatory treatment of uveitis associated with juvenile idiopathic arthritis

Uveitis in juvenile idiopathic arthritis (JIA) is frequently associated with the development of complications and visual loss. Topical corticosteroids are the first-choice therapy, and immunosuppression is commonly used. However, treatment has not been standardized. Representatives from the German Ophthalmological Society, Society for Childhood and Adolescent Rheumatology, and the German Society for Rheumatology reached consensus on a standardized treatment strategy according to disease severity in the individual patient. The recommendations were based on a systematic literature analysis in MEDLINE and consensus expert meetings. Evidence and recommendations were graded, and an algorithm for anti-inflammatory treatment and final statements confirmed in a Delphi method. An interdisciplinary, evidence-based treatment guideline for JIA uveitis is presented.

Web-based training in German university eye hospitals - Education 2.0?

Purpose: To analyse web-based training in ophthalmology offered by German university eye hospitals. Methods: In January 2010 the websites of all 36 German university hospitals were searched for information provided for visitors, students and doctors alike. We evaluated the offer in terms of quantity and quality. Results: All websites could be accessed at the time of the study. 28 pages provided information for students and doctors, one page only for students, three exclusively for doctors. Four pages didn’t offer any information for these target groups. The websites offered information on events like congresses or students curricular education, there were also material for download for these events or for other purposes. We found complex e-learning-platforms on 9 pages. These dealt with special ophthalmological topics in a didactic arrangement. In spite of the extensive possibilities offered by the technology of Web 2.0, many conceivable tools were only rarely made available. It was not always possible to determine if the information provided was up-to-date, very often the last actualization of the content was long ago. On one page the date for the last change was stated as 2004. Conclusion: Currently there are 9 functional e-learning-applications offered by German university eye hospitals. Two additional hospitals present links to a project of the German Ophthalmological Society. There was a considerable variation in quantity and quality. No website made use of crediting successful studying, e.g. with CME-points or OSCE-credits. All German university eye hospitals present themselves in the World Wide Web. However, the lack of modern, technical as well as didactical state-of-the-art learning applications is alarming as it leaves an essential medium of today’s communication unused.

Leistungsbericht der Deutschen Hornhautbanken 2009

In Germany, human tissue for corneal and amniotic transplantation is supplied by 27 cornea banks. The Section for Tissue Transplantation and Biotechnology of the German Ophthalmological Society records the cornea banks' activities by means of an annual questionnaire. In 2009, a total of 4,818 corneal grafts were processed by 21 responding cornea banks, and 57% were deemed suitable for transplantation. This ratio is slightly higher than the European average. In addition, German cornea banks released 1,257 amniotic grafts in 2009. German cornea banks are currently facing new regulatory issues due to updated legislation regarding tissue transplantation. Recent updates in European law have limited the cutoff time for postmortem blood sampling to 24 h, and this regulation may lead to a significant reduction in potential donors.

Children With Problems at School

The Professional Association of German Ophthalmologists (Berufsverband der Augenarzte Deutschlands, BVA) and the Ophthalmologische Gesellschaft (DOG, the medical scientific association of ophthalmology in Germany) protested against IQWiG’s rejection of vision screening in preschool children, in some cases insulting and blaming the institute’s staff. As Professor Lagreze showed in his article, this was unjustified. Vision screening was intended to identify in particular amblyopia with strabismus, in order to prevent bilateral sight impairment in case additional eye disorders were to develop in old age. However, this should be completed if possible by the 3rd year of life because the chance of a cure notably decreases after that age. Transferring preventive eye investigations in early childhood from pediatricians to ophthalmologists would make sense. Screening measures at any later stage therefore hardly make any sense. In my long years’ experience with many thousands of affected children, something that really puts a burden on children after the 6th year of life, when they have entered school, are latent binocular vision impairments, which affect children’s ability to perform and thus endanger their academic and later professional careers. Severe asthenopic symptoms with headache/migraine, impaired gross and fine motor skills, difficulties in reading/spelling, and AD(H)D will then lead to severe performance impairments. Children with problems at school should therefore be investigated for associated heterophorias (latent strabismus in which one eye tends to deviate either medially or laterally) with the Pola-test according to Haase’s particularly effective measurement and correction method, in order to prevent maldevelopments. Ophthalmologists, pediatricians, psychologists, and optometrists, as well as educators have joined forces to be contacted under the umbrella of the International Association for Binocular Fullcorrection (IVBV).

Welcome to the Ipad generation

Graefe’s Archive has a long tradition that is tightly connected with the history of German ophthalmology and ophthalmology at the Charite in Berlin. In 1853, Albrecht von Graefes was appointed teacher of ophthalmology at the university of Berlin and the Charite; in 1858, he became an Extraordinary Professor, and in 1866 an Ordinary Professor. Graefe contributed greatly to ophthalmological science, particularly by the establishment in 1855 of his Archiv fur Ophthalmologie, in which Carl Ferdinand von Arlt and Franciscus Donders collaborated. Graefe’s Archives is now returning to the Charite in Berlin and again will profit from a collaborative editorship—nowadays “worldwide” shared between Berlin and Hong Kong. With this, we hope to promote the excellence of the journal both in Europe and abroad. When reflecting that Gutenberg invented the printing press in 1445, he changed the lives of people in Europe. For the first time, books became affordable and education was no longer the preserve of the wealthy. The spread of knowledge eventually fueled the Renaissance. The advent of the Internet arguably has had an even greater impact on the way we live today. Like cheap books, the Internet has made information more accessible. In fact, many doctors and scientists receive complimentary online journals via their hospitals and universities. As a result, libraries are stopping subscriptions to paper copies. This in turn threatens the profitability of publishing. The lag time in publication means that many of us are reading the epub abstracts long before they appear in print, and when we do read, we are increasingly likely to do so using an Ipad or some other smart portable devices. The ease of using databases such as PubMed and Medline means that we are much more exhaustive in our literature searches. References and bibliographies are becoming longer. This has the effect of increasing citation, which in turn raises the impact factor of most medical journals. In fact, there are so many references that it has become “acceptable” to selective quote a chosen few. Even as little as 20 years ago, this would have been frowned upon as being unscholarly. Like carrying out Google searches, few of us these days are interested beyond the top 20 results. Some things, however, remain the same. When it comes to journal submission, the top ranking journal always attracts the best articles. The best articles are quoted often and the ranking of that goes up even higher. Quite simply, the rich gets richer. Under the editorship of Prof. Bernd Kirchhof, the impact factor of the journal has increased from 1.279 to 2.102 and the ranking from 21 to 19 over the last 6 years. This is due to one man’s hard work, dedication, and a keen editorial sense that could differentiate the newsworthy from the mundane. The new editors are A. Joussen Department of Ophthalmology, Charite, University Medicine Berlin, Virchowklinikum (CVK), Augustenburger Platz 1, 13353 Berlin Klinikum Steglitz (CBF) Hindenburgdamm 3

Interobserver variability for retreatment indications after Ranibizumab loading doses in neovascular age-related macular degeneration

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

Periocular plastic surgery.

Good vision depends on the normal anatomy and function of the eyelids and orbital structures. The goals of periocular ophthalmic plastic surgery are the anatomical and functional preservation and restoration of the lids, orbits, and periorbital structures when they are affected by congenital or acquired malpositions, defects and mass lesions. In this region, functional and esthetic considerations are closely linked. This review is based on selected articles retrieved by a PubMed search, the guidelines of the German Ophthalmologists' Association (Bundesverband der Augenärzte, BVA) and German Ophthalmological Society (Deutsche Ophthalmologische Gesellschaft, DOG), and the authors' own clinical and scientific experience. The surgical correction of eyelid malpositions is based on the restoration of normal anatomy with attention to function. Eyelids are reconstructed with a combination of local flaps and free grafts, preferably from the periorbital structures. Orbital procedures are usually performed in specialized centers, by multidisciplinary surgical teams if necessary. The surgical approaches are becoming ever smaller and cosmetically less noticeable. For patients with acquired anophthalmos, the use of orbital implants is essential for optimal fitting of the prosthesis. Modern periocular plastic surgery exploits an extensive range of specialized surgical techniques to treat a wide variety of abnormalities and diseases in this region. The success of such procedures depends on thorough knowledge of the complex anatomy and physiology of these structures as well as on the surgeon's expertise in microsurgical techniques.

Intravitreal bevacizumab for choroidal neovascularization secondary to inflammation

Editor, T he intravitreal administration of the full-length monoclonal humanized vascular endothelial growth factor (VEGF) antibody bevacizumab may be associated with an intraocular inflammatory response, possibly related to immunogenic factors which are still unknown (Pieramici et al. 2006). Nevertheless, anti-VEGF treatment has been reported to be an effective treatment option in cases of inflammatory ocular diseases complicated by choroidal neovascularization (CNV) (Adan et al. 2007; Kurup et al. 2008). Herein, we report on the effect of intravitreally applied bevazicumab in patients suffering from CNV associated with inflammatory chorioretinal diseases. This retrospective evaluation of five eyes in four patients covers a longterm follow-up of 19–34 months. All of our patients presented with CNV secondary to chorioretinitis. Four eyes had already undergone alternative treatments targeting the CNV, including photodynamic therapy (PDT) (n = 3) and intravitreal triamcinolone injection over a period of 1–7 months prior to the antiVEGF treatment. Before injection, all patients underwent thorough clinical examination, fluorescein angiography (FA) and measurement of best corrected visual acuity (VA) using the ETDRS (Early Treatment Diabetic Retinopathy Study) chart. Inflammatory activity was ruled out prior to the injection of bevacizumab and at each follow-up visit performed at 4–12-week intervals. All patients were informed about the off-label nature of the treatment before each injection. All patients gave written informed consent and female patients were counselled to use contraception. All but one patient (case 5) received systemic immunosuppressive therapy that was not changed during intravitreal treatment. Intravitreal injection was performed according to the Guidelines of the Deutsche Ophthalmologische Gesellschaft (DOG [German Ophthalmological Association]). The study was