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Objectives To validate cut-off values of quantitative high-resolution temporal artery compression sonography (TCS) for the diagnosis of cranial GCA (cGCA) in patients with acute arterial ocular occlusions and in an independent control group. Methods Consecutive patients who underwent TCS as part of the diagnostic workup of acute arterial ocular occlusions and controls not suffering from ocular ischaemia/systemic vasculitis were included. The diagnostic accuracy of the established TCS cut-off value of maximum temporal artery wall thickness (≥0.7 mm) and a novel numeric TCS score incorporating the degree of wall thickening in the four temporal artery segments assessed (0–3 points per segment) was tested by receiver operating characteristics analysis. Subgroup analyses were performed for female and male patients and patients older and younger than age of 70 years. Results Of 114 patients with acute ocular arterial occlusions, 30 patients received a final clinical diagnosis of cGCA. The sensitivity and specificity of the ≥0.7 mm TCS cut-off for the diagnosis of cGCA were 100 and 84.5% in the overall cohort. The TCS score did not improve the diagnostic yield (cut-off ≥5; sensitivity 100%, specificity 85.7%). In male patients >70 years of age, the specificity of TCS was limited, secondary to age- and sex-related differences in temporal artery wall thickness, which we confirmed in the independent control group. Conclusion TCS yields high diagnostic accuracy in the diagnosis of cGCA in patients with acute ocular arterial occlusions. Age- and sex-related differences in temporal artery wall thickness influence the diagnostic accuracy of TCS.

Was ist neu? Zentralarterienverschluss (ZAV) und ischämische Optikusneuropathie (ION) Ischämische Erkrankungen der Retina bei ZAV sowie des Sehnervs bei ION sind häufige Ursachen von irreversiblem Sehverlust bei älteren Patienten und bedürfen einer intensiven internistischen Mitbetreuung. Internistische Diagnostik bei ZAV und ION Im ersten Schritt sollte eine Riesenzellarteriitis (RZA) gesichert bzw. ausgeschlossen werden. Die internistische Diagnostik von nichtarteriitischem ZAV und nichtarteriitischer ION (nAION) zielt insbesondere auf die Erfassung des kardiovaskulären Risikoprofils ab. Beim nichtarteriitischen ZAV ist die Emboliequellensuche zentrale diagnostische Aufgabe. Bei Patienten mit nAION sollte ein Schlafapnoe-Screening erfolgen. Transorbitale Sonografie Bei Darstellung eines Spot-Zeichens im Sehnervenkopf kann ein embolischer ZAV gesichert werden. Ein Spot-Zeichen schließt eine arteriitische Genese eines ZAV aus.

ZusammenfassungDrei Wochen nach komplikationsloser kombinierter minimal-invasiver Glaukom- und Kataraktoperation kam es zu einer Sehverschlechterung durch die Eintrübung der Intraokularlinse. Durch die Nichtanwendung der postoperativen antiinflammatorischen Lokaltherapie kam es zu einer homogenen Fibrinbildung auf der Linsenvorderfläche sowie einer beginnenden Vernarbung des Sickerkissens. Wir führten ein Needling mit 5‑Fluorouracil sowie eine Linsenpolitur mit dem Nd:YAG-Laser durch und erreichten so eine suffiziente Druckkontrolle und Sehverbesserung.

Measuring and controlling intraocular pressure (IOP) provide the foundation for glaucoma treatment. Self-tonometry has been proposed as an alternative to measure IOP throughout the entire day better. The novel EYEMATE-SC sensor (Implandata) is implanted in the suprachoroidal space to enable contactless continual IOP monitoring. The aim of the present study was to investigate the 1-year safety, performance, and accuracy of the EYEMATE-SC in patients with primary open-angle glaucoma undergoing simultaneous nonpenetrating glaucoma surgery (NPGS).Prospective, multicenter, open-label, single-arm, interventional clinical trial.Twenty-four eyes of 24 patients with primary open-angle glaucoma who were due to undergo NPGS (canaloplasty or deep sclerectomy).An EYEMATE-SC sensor was implanted during NPGS. Goldmann applanation tonometry (GAT) measurements were compared with the sensors' IOP measurements at all postoperative visits through 12 months.Device position and adverse events.Fifteen eyes underwent canaloplasty, and 9 underwent deep sclerectomy. Successful implantation of the sensor was achieved in all eyes with no reported intraoperative difficulties. Through the 12-month follow-up, no device migration, dislocation, or serious device-related complications were recorded. A total of 536 EYEMATE-SC measurements were pairwise included in the IOP agreement analysis. The overall mean difference between GAT and EYEMATE-SC measurements was 0.8 mmHg (95% confidence interval [CI] of the limits of agreement [LoA], -5.1 to 6.7 mmHg). The agreement gradually improved, and from 3 months after surgery until the end of the follow-up, the mean difference was -0.2 mmHg (95% CI of LoA, -4.6 to 4.2 mmHg) over a total of 264 EYEMATE-SC measurements, and 100% of measurements were within ±5 mmHg of GAT.The EYEMATE-SC sensor was safe and well tolerated through 12 months. Moreover, it allowed accurate, continuous IOP monitoring.

This retrospective, single-center study evaluates the safety and efficacy of PreserfloTM MicroShunt (MicroShunt) implantations compared to trabeculectomies (TETs) in patients diagnosed with pseudoexfoliation glaucoma (PEXG). A total of 31 eyes from 28 patients received a MicroShunt implantation, and 29 eyes from 26 patients received a TET. Surgical success was defined as an intraocular pressure (IOP) between 5 mmHg and 17 mmHg at the end of the follow-up period, no need for surgical revisions or secondary glaucoma surgery, and no loss of light perception. In the MicroShunt group, the mean IOP dropped from 20.8 ± 5.9 mmHg at baseline to 12.4 ± 2.8 mmHg (p < 0.0001) after one year. In the TET group, the mean IOP dropped from 22.3 ± 6.5 mmHg to 11.1 ± 3.7 mmHg (p < 0.0001) after 12 months. In both of the groups, the mean number of medications was reduced significantly (MicroShunt from 2.7 ± 1.2 to 0.2 ± 0.7; p < 0.0001 vs. TET from 2.9 ± 1.2 to 0.3 ± 0.9; p < 0.0001). Considering the success rates, 83.9% of the MicroShunt eyes achieved complete success, and 90.3% qualified for success at the end of the follow-up period. In the TET group, the rates were 82.8% and 93.1%, respectively. The postoperative complications were comparable between both groups. In conclusion, the MicroShunt implantation demonstrated non-inferiority regarding its efficacy and safety profile compared to TET in PEXG at a follow-up of one year.

Pseudoexfoliation (PEX) syndrome is a common, worldwide occurring and age-related disorder characterised by the deposition of extracellular fibrillar material. It is a systemic disease with significant ocular manifestations, including cataract and glaucoma. All structures of the anterior segment are affected leading to multiple specific findings in slit lamp examination. The most prominent findings are white, dandruff like deposits on the anterior surface of the lens or the pupillary border of the iris. Furthermore, PEX syndrome is the most common identifiable cause of open angle glaucoma. PEX glaucoma generally takes a more rapidly progressive course than primary open angle glaucoma. Patients therefore typically need earlier surgical intervention. PEX syndrome is often accompanied by nuclear cataract formation. Cataract extraction tends to be complicated and remains a challenge. Several technique modifications and new devices help to reduce the complication rate. The purpose of this paper is to summarize information regarding ocular manifestations of PEX-syndrome to facilitate an early diagnosis and to present a general view of the treatment of PEX glaucoma.

Purpose To compare the safety and efficacy of microshunt implantation augmented with Mitomycin C in patients with pseudoexfoliation glaucoma (PEXG) and primary open-angle glaucoma (POAG). Methods In this retrospective, single centre, interventional study, 46 eyes of 41 patients with PEXG (20 eyes) and POAG (26 eyes) underwent microshunt implantation. Definition of failure was an intraocular pressure (IOP) lower than 5 or higher than 17mmHg on two consecutive visits, an IOP reduction lower than 20% on two consecutive visits, the need of surgical revisions or reoperations or loss of light perception. Outcome was rated as complete success if achieved without medication, otherwise as qualified success. Furthermore, postoperative complications and interventions were compared between the two groups. Results Patient demographics were similar, except for older age in the PEXG group (70.9±8.6 versus 77.6±8; p = 0.02). Mean IOP dropped from 21.5±5.8mmHg (PEXG) and 18.2±4.5mmHg (POAG) at baseline to 12.8±3.0mmHg (ppppp = 0.04) and choroidal detachment (p = 0.03) in the PEXG group. Conclusion Microshunt implantation demonstrated similar efficacy results in PEXG and POAG eyes at a follow-up of 12 months. Higher rates of transient hypotony and choroidal detachment were observed in PEXG eyes.

PURPOSE: To compare different new-generation biometric formulas and ray-tracing for small-aperture intraocular lens (IOL) (IC-8; Acufocus, Inc) implantation in patients undergoing cataract and refractive lens exchange surgery with highly irregular corneas. METHODS: This monocenter study included 17 eyes of 17 patients with highly irregular corneas of different genesis. Biometric and topographic corneal data were assessed using the IOLMaster 700 (Carl Zeiss Meditec) and Pentacam (Oculus Optkigeräte GmbH). Prediction and absolute error were compared after 3 months based on manifest refraction. Furthermore, change of total corneal refractive power in different corneal pathologies was also evaluated. For IOL power calculation, three fourth-generation IOL formulas were compared (Haigis, SRK-T, and Barrett Universal II). The dataset was then checked against ray-tracing and analyzed to improve prediction error in these highly irregular corneas. RESULTS: All patients showed an improvement in visual acuity postoperatively with a mean spherical equivalent of −1.22 ± 0.49 diopters (D). Overall comparison of the three formulas showed the Haigis formula to be superior in terms of the smallest deviation of predictive and absolute error. IOL calculations with ray-tracing were possible in all eyes, but showed inaccurate results with keratometric values of 48.00 D and greater. CONCLUSIONS: The IC-8 IOL is well suited for patients with lens exchange in highly irregular corneas. The Haigis formula seemed to be the most accurate in the patient group. Ray-tracing confirmed the results of biometric formulas up to a keratometric value of 48.00 D and should be compared with standard biometric formulas to address corneal irregularities and to minimize refractive surprises after surgery. A comparison with ray-tracing in eyes with a keratometric value of greater than 48.00 D should not be considered due to the inaccurate results. [ J Refract Surg . 2021;37(5):312–317.]

Pigment dispersion syndrome (PDS) is a disorder predominantly affecting young, myopic adults. It is characterised by the liberation of pigment of the iris and deposition of it on various structures of the anterior segment leading to multiple specific findings in slit lamp examination. Typical alterations are a deposition of pigment on the central corneal endothelium, circular iris transillumination defects in the mid periphery, a posterior bowing of the iris and increased pigmentation of the trabecular meshwork. Findings are usually bilateral symmetric. Posterior bowing of the iris causes rubbing of the pigmented iris epithelium against lens structures like zonular fibres with a consecutive liberation of pigment. Trabecular meshwork changes because of pigment deposition reduce aqueous outflow facility with the risk of elevated intraocular pressure and glaucoma. Pigmentary glaucoma (PG) is a secondary open angle glaucoma. Treatment of PG is similar to primary open angle glaucoma, including medical therapy, laser therapy and surgery. Peripheral laser iridotomy was shown to change iris configuration but its efficacy in the prevention of PG has not been confirmed in the literature. The purpose of this paper is to summarize information regarding ocular manifestations of PDS to facilitate an early diagnosis and to present a general view of the treatment of PG.

Background: Risk stratification based on pre-test probability may improve the diagnostic accuracy of temporal artery high-resolution compression sonography (hrTCS) in the diagnostic workup of cranial giant cell arteritis (cGCA). Methods: A logistic regression model with candidate items was derived from a cohort of patients with suspected cGCA (n = 87). The diagnostic accuracy of the model was tested in the derivation cohort and in an independent validation cohort (n = 114) by receiver operator characteristics (ROC) analysis. The clinical items were composed of a clinical prediction rule, integrated into a stepwise diagnostic algorithm together with C-reactive protein (CRP) values and hrTCS values. Results: The model consisted of four clinical variables (age &gt, 70, headache, jaw claudication, and anterior ischemic optic neuropathy). The diagnostic accuracy of the model for discrimination of patients with and without a final clinical diagnosis of cGCA was excellent in both cohorts (area under the curve (AUC) 0.96 and AUC 0.92, respectively). The diagnostic algorithm improved the positive predictive value of hrCTS substantially. Within the algorithm, 32.8% of patients (derivation cohort) and 49.1% (validation cohort) would not have been tested by hrTCS. None of these patients had a final diagnosis of cGCA. Conclusion: A diagnostic algorithm based on a clinical prediction rule improves the diagnostic accuracy of hrTCS.

ObjectiveIntraocular lens (IOL) opacification may cause severe visual impairment. The pathogenesis remains unclear. The aim of this study was to analyse opacification patterns in different IOLs. Therefore, this multicentre, retrospective, observational study was conducted at Ludwig-Maximilians-University, Munich, Germany and University-Hospital Basel, Switzerland.Methods and analysisIn this study, 75 opacified IOLs were identified and classified after extraction. Macroscopical photo documentation, light and electron microscopic analysis were done.Results68 acrylic-hydrophilic single-piece-IOLs, 1 acrylic-hydrophilic 3-piece-IOL, 6 acrylic-hydrophobic 3-piece-IOLs were extracted. The dataset comprised IOLs known for opacification and IOLs not having been reported yet. 67 IOLs showed a fine-granular and 8 IOLs a crust-like opacification pattern. According to literature, 62 of the fine-granular opacified IOLs were graded into type 1 (processing/packaging-induced primary opacification) and 13 into type 2 (secondary opacification of unknown aetiology). The anterior surface of the IOLs was affected in all 75 IOLs, the posterior surface only in 23 cases. Of all 67 fine-granular IOLs, 43 had a central defect and 21 had a zone without opacification (clear islet).ConclusionIn our series, the morphology of IOL opacification did not follow the existing pathogenetic classification that strictly discriminates between primary and secondary causes. Fine-granular IOL opacification occurs with similar patterns in both type 1 and type 2 IOL opacification, while a crust-like pattern was only detected in type 2 IOL opacifications. Consequently, susceptibility of an IOL to opacification is caused by a multifactorial combination of material and processing properties as well as individual (pathological) conditions of the patient., publishedVersion

Ischemia of the retina in central retinal artery occlusion (CRAO) and of the optic nerve in ischemic optic neuropathy (ION) are common causes of irreversible vision loss in elderly patients and require a thorough diagnostic work-up. First and foremost, giant cell arteritis should be confirmed or ruled out. The further work-up of non-arteritic CRAO and non-arteritic ION (nAION) aims to determine the cardiovascular risk profile. Patients with nAION should be screened for sleep apnoea. In non-arteritic CRAO, the search for embolic sources is the most important diagnostic task. A "white spot sign" seen on transorbital ultrasound confirms the diagnosis of embolic CRAO and rules out an arteritic etiology of CRAO.ZENTRALARTERIENVERSCHLUSS (ZAV) UND ISCHäMISCHE OPTIKUSNEUROPATHIE (ION): Ischämische Erkrankungen der Retina bei ZAV sowie des Sehnervs bei ION sind häufige Ursachen von irreversiblem Sehverlust bei älteren Patienten und bedürfen einer intensiven internistischen Mitbetreuung. INTERNISTISCHE DIAGNOSTIK BEI ZAV UND ION: Im ersten Schritt sollte eine Riesenzellarteriitis (RZA) gesichert bzw. ausgeschlossen werden. Die internistische Diagnostik von nichtarteriitischem ZAV und nichtarteriitischer ION (nAION) zielt insbesondere auf die Erfassung des kardiovaskulären Risikoprofils ab. Beim nichtarteriitischen ZAV ist die Emboliequellensuche zentrale diagnostische Aufgabe. Bei Patienten mit nAION sollte ein Schlafapnoe-Screening erfolgen. TRANSORBITALE SONOGRAFIE: Bei Darstellung eines Spot-Zeichens im Sehnervenkopf kann ein embolischer ZAV gesichert werden. Ein Spot-Zeichen schließt eine arteriitische Genese eines ZAV aus.

Although the introduction of BRAF and MEK inhibitors has greatly enhanced treatment possibilities in advanced BRAFV600-mutated melanoma, class-related toxicities are rather frequent and often involve the eye. Ophthalmologic side effects most commonly include central/diffuse serous retinopathy and retinal vein occlusion. Affection of the optic nerve head however has not been described clinically.A 29-year-old man presented in our eye clinic with bilateral blurred vision. Seventeen days earlier, he had been started on trametinib and dabrafenib combination therapy for metastasized melanoma of unknown origin. Visual field testing revealed diffuse bilateral defects, which regressed spontaneously on pause of MEK and BRAF inhibitor treatment.In addition to the widely known class-related retinal toxicity, MEK and BRAF inhibitor-associated adverse events may also involve the optic nerve head, causing visual field defects probably regressing spontaneously after discontinuation of targeted oncologic therapy. In such cases, repeat brain imaging and exclusion of melanoma-associated retinopathy is recommended. Reinitiation of treatment and subsequent dose escalation seem to be feasible, but should be monitored by an ophthalmologist.

A 78-year-old man suffered sudden visual loss of his right eye. Five years earlier, he had experienced vision loss of his left eye due to central retinal artery occlusion (CRAO); back then, the etiology for the CRAO was not established. Current ocular ultrasound depicted a hyperechoic spot within the optic nerve in both eyes. Echocardiography identified a calcified mass adherent to the mitral valve as the embolic source of the CRAO. This case shows the value of ocular B-mode ultrasound in demonstration and proof of the etiology for CRAO.

Purpose To investigate preoperative ocular risk factors and indications for secondary intraocular lens (IOL) implantation and compare postoperative complications, visual and refractive outcomes in a tertiary referral center. Methods Patients older than 14 years that underwent secondary IOL implantation and had a minimum follow-up of 3 months were enrolled in this retrospective case series. Preoperative ocular risk factors, indications for surgery, postoperative complications, and visual and refractive outcomes including prediction error (PE) and absolute error (AE) were evaluated. IOLs were fixated in following positions: anterior chamber (AC), retropupillary iris-claw (IC), sulcus, and capsular bag or sclera. Results One-hundred eighty-two eyes of 174 patients with mean follow-up of 17 ± 13.6 months were evaluated. Leading cause for surgery was IOL dislocation (75%), followed by secondary aphakia (19%) and IOL opacifications (6%). Previous vitrectomy was the major preoperative ocular risk factor (43%). Mean corrected distance visual acuity improved from preoperative 0.68 ± 0.55 to 0.42 ± 0.31LogMAR by the last follow-up (p = 0.001). PE and AE differed highly depending on the indication for surgery (p = 0.041 and p = 0.008, respectively) and the IOL fixation (p = 0.011 and p = 0.028, respectively), with IC-IOLs showing the lowest PE and AE. Postoperative AC-hemorrhage occurred mainly after IC-IOLs (p = 0.003), and postoperative hypotony was significantly higher in eyes with previous uveitis (p = 0.026). Conclusions Previous vitrectomy seems to be a major underreported risk factor in eyes that undergo secondary IOL implantation. Refractive outcomes depend on indication for surgery and fixation type, with retropupillary IC-IOLs providing the best refractive results, though not statistically significant compared to other IOL positions.

PURPOSE To implant a small-aperture intraocular lens (IOL) (IC-8) in eyes with severe corneal irregularities to reduce higher-order aberrations and provide better central visual acuity. SETTING University Hospital, LMU Munich, Germany. DESIGN Prospective nonrandomized interventional case series. METHODS Eyes with severe corneal irregularities due to keratoconus, previous penetrating keratoplasty, status postradial keratotomy, or scarring after ocular trauma were enrolled. Exclusion criteria were progressive keratoconus, pseudoexfoliation, glaucoma, maculopathy, reduced endothelial cells (

Drei Wochen nach komplikationsloser kombinierter minimal-invasiver Glaukom- und Kataraktoperation kam es zu einer Sehverschlechterung durch die Eintrubung der Intraokularlinse. Durch die Nichtanwendung der postoperativen antiinflammatorischen Lokaltherapie kam es zu einer homogenen Fibrinbildung auf der Linsenvorderflache sowie einer beginnenden Vernarbung des Sickerkissens. Wir fuhrten ein Needling mit 5‑Fluorouracil sowie eine Linsenpolitur mit dem Nd:YAG-Laser durch und erreichten so eine suffiziente Druckkontrolle und Sehverbesserung.

To identify independent risk factors for permanent visual loss (PVL) in patients with giant cell arteritis (GCA), with a special focus on sonographic findings of the temporal, carotid and subclavian/axillary arteries, and on established scoring systems of ischaemia risk assessment.Consecutive patients with a diagnosis of GCA between 2002 and 2013 were retrospectively identified from a prospectively maintained database. Data on clinical characteristics including ophthalmological findings, laboratory values, and sonographic findings of the temporal, carotid an axillary arteries were extracted. CHADS2- and CHA2DS2-VASc-score were calculated. Clinical, laboratory and sonographic characteristics of patients with and without PVL were compared. Multiple logistic regression models were calculated to identify variables independently associated with PVL.One-hundred-fifty-two patients were included in the analysis. PVL occurred in 30.2% of patients, with anterior ischaemic optic neuropathy as predominant underlying cause (91.3%). The frequency of PVL was strongly dependent on the age at diagnosis, with a significant increase after the age of 70 years. In multivariate analysis, axillary artery vasculitis with an odds ratio (OR) of 0.3 and constitutional symptoms with an OR of 0.1 were negatively associated with PVL. A CHADS2-score of 1 (OR 10.7) or ≥2 (OR 25) was associated with a significantly increased risk of PVL.The risk of PVL secondary to GCA increases with age but is lower in patients presenting with constitutional symptoms and/or exhibiting axillary artery involvement. The CHADS2-score may help to discriminate patients with low vs. high risk of PVL.

Child protective service caseworkers need validated instruments to assist them in assessing safety and risk factors for child maltreatment. The literature provides growing evidence that actuarial risk assessments can be valid tools for classifying families according to risk of future maltreatment. However, compared to validity, we know less about the reliability of both whole assessments and individual items. In this study we tested interrater reliability for 108 individual risk and safety items. We used 31 realistic case vignettes for testing. Each item was completed six times for each vignette. Fifty-four caseworkers and supervisors participated in rating, generating a total of 20,088 ratings for analysis. To determine item reliability, we used measures of prevalence and percentage agreement and the Fleiss's kappa statistic. RESULTS show that interrater reliability varies widely from item to item. Items with higher prevalence and items documenting demographics, current CPS system involvement, substance abuse, or mental health issues tend to be most reliable. We provide an overview of the testing process, which is replicable in other contexts. We also discuss implications for child protective services practice and for developing or revising risk and safety assessment instruments.

The purpose of this study was to determine the quantity and distribution of antigen presenting cells (APC) in various inflammatory and non-inflammatory corneal diseases, comparing in vivo confocal microscopy (IVCM) and immunohistochemistry.Corneae of 41 eyes, composed of group 1 (status post herpes-keratitis), group 2 (keratoconus) and group 3 (graft rejection after keratoplasty) were investigated. IVCM was used preoperatively to assess the distribution and density of dendritic cells in the corneal center versus the paracentral area. Afterwards, all patients underwent penetrating keratoplasty. The host corneas were analyzed by immunohistochemistry for antigen presenting cell distribution, density and characterization by using specific markers for CD207/Langerin, CD209/DC-SIGN and HLA-DR. The IVCM findings were compared with immunohistochemistry results in the corneal epithelium.Cells with branching dendritic morphology were visualized by IVCM mainly in the basal epithelial layer and subepithelial nerve plexus of the central and paracentral cornea. The density of APC in IVCM decreased in all groups towards the central part of the cornea. The highest gradient was observed in group 2, followed by groups 1 and 3. The corneal paracenter showed similiar distribution of APC in group 1 and 2 (76.7 cells/mm(2) and 74.4 cells/mm(2)). The highest density of central APC was observed in group 1 (53.76 cells/mm(2)), followed by group 3 (27.0 cells/mm(2)) and group 2 (24.2 cells/mm(2)). In immunohistochemistry positive stained, APC were distributed similarly to IVCM but with a higher density (p0.05).Distribution, density and stage of maturation of corneal epithelial APCs can be evaluated on morphological basis by IVCM. However, the corneal APCs density was about three-fold lower compared to immunohistochemistry findings.

To analyze the appearance of conjunctival pigmented tumors as seen by in vivo confocal microscopy. Twenty-eight pigmented conjunctival tumors including 6 nevi, 13 acquired melanoses, 7 conjunctival melanomas, and 2 extrascleral growths of uveal melanomas were examined by in vivo confocal microscopy using the Heidelberg Retina Tomograph (HRTII)/Rostock Cornea Modul (RCM). Confocal images were analyzed using predefined criteria by an observer masked to final histological diagnosis and a preliminary diagnosis was established. After excision, histology and immunohistochemistry using antibodies against S-100, Melan-A, HMB-45, Ki-67, CD3, and CD68 were performed in all specimens and compared with in vivo confocal images of the same lesions. Confocal microscopy images confirmed typical histopathological features of conjunctival pigmented tumors. Nest or diffuse collections of medium-sized uniform hyper- or hyperreflective cells in the stroma and stromal cysts lined with a multilayered epithelium were visible in 100% of conjunctival nevi. Small dendritic cells were typically observed in 100% of primary acquired melanoses (PAM) without atypia and in 2 out of 6 nevi. Large networks of hyperreflective dendritic cells were present in 100% of PAM with atypia. Whereas images of PAM without atypia and secondary complexion-associated melanosis showed hyperreflective granules confined to the basal epithelium in 67% of lesions, PAM with atypia presented with hyperreflective granules and patches throughout the epithelium in all cases. Malignant melanomas of the conjunctiva and extrascleral growths of uveal melanomas demonstrated large hyperreflective cells with prominent nuclei and nucleoli. In vivo confocal microscopy showed a sensitivity of 89% and a specificity of 100% to establish the correct diagnosis of conjunctival melanoma compared with histology. High correlations were found between in vivo confocal microscopy using near-infrared laser light and histology in the diagnosis of pigmented conjunctival lesions. In vivo confocal microscopy seems to be a valuable new tool in the differential diagnosis and follow-up of pigmented conjunctival tumors. It does not replace histology, but may assist in performing guided biopsy in tumors suspected clinically and/or with in vivo microscopy. In addition, in vivo confocal microscopy may support the clinical diagnosis of extrascleral involvement in uveal melanoma.

A dense cataract prevents detailed fundus examination which may lead to delayed diagnosis of undiscovered intraocular pathology before cataract surgery. We report two cases where large choroidal melanomas were diagnosed after cataract surgery and/or Nd:Yag laser capsulotomy. In the first case, a dense cataract prevented proper examination of the fundus of an 84-year-old female. A brownish choroidal lesion was seen after cataract surgery and diagnosed as postoperative choroidal detachment. As this lesion persisted over months, the patient was sent to our hospital for evaluation where a diagnosis of choroidal melanoma with extrascleral growth was made and an enucleation with implantation of a dermis-fat graft was performed without complication 10 days later. In the second case, a 58-year-old female patient had Nd:Yag laser treatment 2 years after cataract surgery had been performed. During fundus examination 1 day after treatment, the ophthalmologist noticed a choroidal lesion which he suspected to be a reaction to the laser treatment and referred the patient to our hospital where a diagnosis of a mushroom-shaped choroidal melanoma with serous retinal detachment was made. These cases show that preoperative evaluation of the posterior segment prior to cataract surgery or other therapeutic interventions is essential in order to identify any pathology. In case of a dense cataract, additional imaging such as ultrasound sonography is recommended in order to exclude intraocular lesions and to visualize the optic disc in suspected glaucoma.

Corneal cross-linking is widely used to treat keratoconus. However, to date, only limited data from randomized trials support its efficacy. The efficacy and safety of corneal cross-linking for halting progression of keratoconus were investigated in a prospective, randomized, blinded, placebo controlled, multicentre trial. Twenty-nine keratoconus patients were randomized in three trial centres. The mean age at inclusion was 28 years. Longitudinal changes in corneal refraction were assessed by linear regression. The best corrected visual acuity, surface defects and corneal inflammation were also assessed. These data were analysed with a multifactorial linear regression model. A total of 15 eyes were randomized to the treatment and 14 to the control group. Follow-up averaged 1098 days. Corneal refractive power decreased on average (+/−standard deviation) by 0.35 +/− 0.58 dioptres/year in the treatment group. The controls showed an increase of 0.11 +/− 0.61 dioptres/year. This difference was statistically significant (p = 0.02). Our data suggest that corneal cross-linking is an effective treatment for some patients to halt the progression of keratoconus. However, some of the treated patients still progressed, whereas some untreated controls improved. Therefore, further investigations are necessary to decide which patients require treatment and which do not. NCT00626717 , Date of registration: February 20, 2008.

To analyze the appearance of normal conjunctiva and conjunctival inflammation by in vivo confocal microscopy.Conjunctiva of 15 normal patients and 21 patients with conjunctivitis including bacterial, papillary, follicular, granulomatous, and cicatrizing disease were analyzed by the Heidelberg retina tomograph (HRTII)/Rostock cornea modul (RCM).Scans of normal bulbar and tarsal conjunctiva corresponded well to the established anatomy except for a prominent, thickened epithelial basement membrane observed by in vivo microscopy. Presumed goblet cells were visible throughout the conjunctival epithelium. Adenoid structures and hair follicles were discernible in the tarsal conjunctiva in vivo. Conjunctival perfusion could be observed directly. Acute and chronic inflammatory cells, conjunctival papillary, and follicular reactions, as well as conjunctival cicatrization, could be discriminated. In a patient with conjunctival granuloma, in vivo confocal microscopy disclosed suture material inside the lesion.Confocal microscopy using near-infrared laser light is a useful new tool in the analysis of conjunctival tissue in vivo. It is a valuable aid in the differential diagnosis of conjunctival inflammation and thus may guide therapeutical decisions.

To analyze filtering blebs after trabeculectomy by means of in vivo confocal microscopy and to correlate the images with clinical bleb appearance and function.In vivo confocal microscopy using the Heidelberg Retina Tomograph/Rostock Cornea Module (Heidelberg Engineering, Heidelberg, Germany) was performed in 53 filtering blebs in 45 patients 6 days to 30 years postoperatively.In vivo confocal microscopic findings significantly correlated with good bleb function included the number of epithelial microcysts (P = .03), a large total stromal cyst area (P = .009), the absence of encapsulated stromal cysts (P = .002), minimal vascularization (P = .05), and the absence of tortuous conjunctival vessels (P = .01). In contrast, a hyperreflective condensed bleb stroma was significantly associated with bleb failure (P.001). Bleb stroma mainly consisting of a rarified collagenlike network was significantly linked to trabeculectomy performed with mitomycin C (P = .001). Epithelial and stromal inflammation were observed at a median of 1 and 4 months after surgery, respectively.In vivo confocal microscopy using the Heidelberg Retina Tomograph/Rostock Cornea Module permits diagnostic imaging of filtering blebs and differentiation between good and insufficient bleb function. Moreover, the postoperative inflammatory reaction can be monitored directly for adapted postoperative anti-inflammatory treatment.