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Purpose Vasoproliferative tumours (VPT) are a rare but benign entity that can lead to severe visual acuity deterioration. There is no standard of care, and depending on the degree of clinical features, including tumour size and dissemination, visual acuity and subretinal fluid, treatment options include observation, cryotherapy and brachytherapy. Particularly in larger tumours, brachytherapy has advantages over other options, although higher radiation doses and the need for surgical application are disadvantages of this otherwise effective treatment option. CyberKnife radiosurgery might represent an alternative therapeutic option as no surgical intervention is needed and radiation doses are lower. Methods All patients diagnosed with vasoproliferative tumors who were treated with CyberKnife radiosurgery with a minimum follow-up time of 12 months were included in this case series. We recorded visual acuity, number of lesions, central retinal thickness with optical coherence tomography (OCT) and reflectivity using A-scan standardizes echography every three months. Results A total of four patients with a median age of 34 years (range: 24 - 51) who were observed over an average of 26.5 months (range: 17 - 49 months) matched our inclusion criteria. We appreciated stabilization or increase in visual acuity in all four patients and a regression in tumour thickness with subsequent increase in internal reflectivity as a marker of increasing fibrosis. Conclusion We observed good visual and functional outcome following CyberKnife therapy for VPT. We believe that further studies should be pursued to evaluate CyberKnife therapy for the treatment of VPT not treatable with cryo- or lasertherapy.

Gene therapy using recombinant adeno‐associated virus (rAAV) vectors to treat blinding retinal dystrophies has become clinical reality. Therapeutically impactful targeting of photoreceptors still relies on subretinal vector delivery, which detaches the retina and harbours substantial risks of collateral damage, often without achieving widespread photoreceptor transduction. Herein, we report the development of novel engineered rAAV vectors that enable efficient targeting of photoreceptors via less invasive intravitreal administration. A unique in vivo selection procedure was performed, where an AAV2‐based peptide‐display library was intravenously administered in mice, followed by isolation of vector DNA from target cells after only 24 h. This stringent selection yielded novel vectors, termed AAV2.GL and AAV2.NN, which mediate widespread and high‐level retinal transduction after intravitreal injection in mice, dogs and non‐human primates. Importantly, both vectors efficiently transduce photoreceptors in human retinal explant cultures. As proof‐of‐concept, intravitreal Cnga3 delivery using AAV2.GL lead to cone‐specific expression of Cnga3 protein and rescued photopic cone responses in the Cnga3−/− mouse model of achromatopsia. These novel rAAV vectors expand the clinical applicability of gene therapy for blinding human retinal dystrophies.

PurposeDifferent modalities of radiation therapy nowadays allow for effective treatment of uveal melanoma combined with the advantage of eye preservation. However, this advantage can secondarily be impaired by radiation-related side effects. After local recurrence, secondary glaucoma (SG) has been described as second most frequent complication leading to need of enucleation. This study compares the incidence of SG after conventional Ruthenium (Ru)-106 brachytherapy (BT) versus CyberKnife robotic radiosurgery (RRS) which has been gaining importance lately as an efficient treatment option offering improved patient comfort. MethodsMedical records of all patients diagnosed with uveal melanoma in the Eye Clinic of the Ludwig-Maximilians-University Munich between 2007 and 2013 were reviewed. A total of 268 eyes of 268 patients treated with Ru-106 BT or CyberKnife-RRS as monotherapy were entered in this retrospective cohort study. Incidence of SG was correlated with treatment modality and baseline tumour characteristics. ResultsFifty-three patients (19.8%) developed SG. At 5years, SG was significantly more frequent after RRS (46.7%) than BT (11.1%);however, tumour thickness (maximum apical height) as a marker of tumour progress was more pronounced in the RRS group. Subgroup analysis of 178 patients for tumours amenable to both BT and RRS (thickness 6mm) revealed comparable results at 3years (RRS: 13.8 versus BT: 11.2%), but a trend towards increased incidence after RRS beyond year three. However, this difference was not significant at 5years (28.2% versus 11.2%, p=0.138). Tumour thickness was significantly associated with incidence of SG. ConclusionIn tumours 6mm thickness, RRS and BT seem to offer a comparable safety profile in terms of SG. Beyond year three, SG was tendentially, but not significantly more frequent after RRS. Increasing tumour thickness is associated with risk of SG.

Purpose To assess quality of life (QoL) status via the National Comprehensive Cancer Network (NCCN ) distress thermometer as a psychooncological screening tool in uveal melanoma patients. Methods One hundred and six consecutive patients suffering from uveal melanoma completed the distress thermometer between 04/2018 and 12/2018. Practical, emotional, family concerned, spiritual, physical and overall distress levels, distribution of distress and subgroup analyses defining groups of potential high distress levels in need of intervention were assessed. Descriptive statistics, cross‐tabulations, chi‐square and Fisher's exact test as well as correlation coefficients (Spearman's rho) and receiver operating characteristic (ROC ) were used for analysis. Results Patients with higher T‐category had significantly more emotional problems and spiritual concerns (p = 0.046 and p = 0.023, respectively). Female patients accounted for higher rates of physical issues (p = 0.034). Lower best corrected visual acuity (BCVA ) was correlated with higher distress levels (p = 0.037). Patients resulting in loss of BCVA of ≥3 lines reported higher distress levels (p = 0.029). A distress threshold of 5 on the basis of ROC analysis showed a corresponding sensitivity of 100% and specificity of 76%. Conclusion The NCCN distress thermometer could be integrated well into our clinical routine and proved to be a rapid, yet sensible screening tool for emotional and physical distress in patients with uveal melanoma. Special attention should be paid to patients with higher T‐category and patients resulting in lower levels of BCVA . As in patients with different tumour entities, the established distress threshold of ≥5 proposing intervention proved to be adequate for uveal melanoma patients.

Purpose: To evaluate the potential of heavier-than-water brilliant blue G (BBG-D20) to stain the internal limiting membrane (ILM) during chromovitrectomy. Methods: In a nonrandomized, prospective, clinical multicentre study, 71 consecutive chromovitrectomy interventions in 71 patients were analysed. During routine 23-gauge vitrectomy, conventional 0.25 mg/ml BBG was employed in 21 and 0.25 mg/ml BBG-D20 in 50 patients. All interventions were videotaped. Post-operatively, video frames were viewed and dye performance assessed subjectively and objectively. Main outcome measure was the chromaticity difference between the stained ILM and the unstained underlying retina, measured by means of an objective and quantitative analysis method to describe colour contrast strengths as they are perceived by the human eye. Results: Removal of the ILM was possible in all interventions without additional vital dyes. BBG-D20 readily sank to the retinal surface, while conventional BBG tended to swirl up throughout the vitreous cavity. Conventional BBG was removed either with active suction or with a flute needle. Brilliant blue G-D20 needed to be whirled up from the retinal surface with a flute needle before aspiration. Objective chromaticity measurements yielded a mean chromaticity score of 7.98 for BBG-D20 and 6.51 for BBG (p = 0.09). Conclusions: Brilliant blue G-D20 readily sinks to the retinal surface after injection and can be conveniently removed with a flute needle or active suction during chromovitrectomy. Based on the premises of the chromaticity measurements in this study, BBG’s ILM staining capacity was not significantly improved through the recent revision its preparation, although a tendency towards slightly improved contrasts between the ILM and the underlying retina was observed.

Purpose: To evaluate the potential of brilliant blue G (BBG) for intraoperative staining of the inner limiting membrane (ILM) with respect to staining properties and surgical outcome. Methods: In a retrospective, non-comparative clinical case series, we analysed 17 consecutive chromovitrectomy interventions for surgery of macular holes, ERMs, vitreoretinal traction syndromes and cystoid macular oedema. Following complete posterior vitreous detachment, BBG was injected into the vitreous cavity at a concentration of 0.25 mg/ml, followed by immediate washout. Main outcome measures were staining properties, visual acuity, central visual field testing and optical coherence tomography (OCT) measurements over a mean follow-up period of 3 months. Results: ILM staining was somewhat less intensive for BBG than for average indocyanine green (ICG) chromovitrectomy. However, the ILM was removed successfully without additional ICG in 15/17 patients. Postoperative visual acuity was improved in 16/17 patients and remained unchanged in one patient. Central retinal OCT thickness showed a postoperative reduction, with values ranging from +7 to -295 mum (median -89 mum). Neither visual field defects nor any other adverse events were recorded. Conclusion: BBG permits sufficient staining for safe ILM removal. In this short-term study, good anatomical and functional results were achieved and no adverse events were observed.

Purpose: To compare the results of two different surgical techniques: 'Cuppers technique', in which the torque of oculomotor rectus muscles is reduced by suturing the muscle to the globe in the posterior half of the globe; and 'Y-split recessions', in which the muscle torque is reduced by Y-splitting the rectus muscles, and reattaching the two halves at an angle to each other. Methods: We carried out a retrospective analysis of the outcome of surgery on 100 patients with infantile esotropia. Results: Both techniques show a sufficient reduction of strabismus angle vari- ability, and minimal and maximal strabismus angle. Conclusions: Both techniques achieve satisfactory results. In addition, the Y-split technique allows for accurate control of the muscle torque and requires no access to the posterior half of the eye, which can facilitate the surgical approach. For a reduction in muscle torque, the Y-split recession is a good alternative to the established Cuppers technique.

Purpose: To compare the amount and pattern of fluorescein leakage in diabetic macular oedema with the retinal thickness maps obtained with the retinal thickness analyser (RTA) and optical coherence tomography (OCT). Methods: A consecutive series of 30 eyes from 30 patients with diabetic macular oedema was included. On fluorescein angiography (FA) the macula was analysed in 10 subfields as defined by the ETDRS. The amount and source of leakage for each field were determined. Retinal thickness was measured by OCT and RTA maps in each of the 10 fields and compared with the FA grading. Results: Foveal retinal thickness on OCT was most influenced by the overall FA leakage, which was the only significant covariate on multivariate analysis. The source and amount of leakage correlated significantly with the topography of retinal thickness in the four peripheral fields between 1500 µm and 3000 µm from the macular centre (r = 0.54, p = 0.002). The mean amount and source of leakage in those fields also showed the highest correlation with central macular thickness on OCT (r = 0.46, p = 0.01). Similar results were obtained by RTA when excluding ischaemic cases (r = 0.44, p = 0.04). For both instruments, FA leakage within the four central fields

The consequences of changes in the oculomotor system on the three-dimensional eye movements are difficult to grasp. Although changes to the rectus muscles can still be approximately understood with simplified geometric models, this approach no longer works with the oblique muscles. It is shown how SEE++, a biomechanical model of the oculomotor plant that was built on the ideas of Miller and Robinson (1984) can improve the understanding of the effects of changes to the oblique eye muscles. By displaying only selected muscles, and by illustrating the relative contribution of these muscles through color-coding the bulb surface, the functional properties of the oblique muscles can be presented in a much clearer way. Investigating the effects of a hyperactive inferior oblique muscle shows that this type of model can help to clarify the functional cause of a pathology, which can otherwise be unclear, even for common pathologies.

We report the case of a patient presenting with serous retinal detachment following radial optic neurotomy for central retinal vein occlusion. Initially, the retinal detachment was successfully treated by a second vitrectomy and laser coagulation. After reabsorption of the gas tamponade, a recurrence of the retinal detachment was seen with no detectable retinal break. Although other mechanisms should be taken into account, this case indicates that it is possible to create a fistula between the subarachnoid and subretinal space. We conclude from this observation that special attention should be paid to the depth of the radial incision into the optic nerve head.