Comparability of input parameters in the German Retina.net ROP registry and the EU-ROP registry - An exemplary comparison between 2011 and 2021

PURPOSE

The German Retina.net ROP registry and its Europe-wide successor, the EU-ROP registry, collect data from patients treated for ROP. This analysis compares input parameters of these two registries to establish a procedure for joint analyses of different registry data using exemplary datasets from the two registries.

METHODS

Exemplary datasets from the two databases over a 1-year period each (German Retina.net ROP Registry, 2011, 22 infants; EU-ROP Registry, 2021, 44 infants) were compared. The parameters documented in the two databases were aligned and analysed regarding demographic parameters, treatment modalities, complications within first 24 h and retreatments.

RESULTS

The current analysis showed that data can be aligned for joint analyses with some adjustments within the data structure. The registry with more detailed data collection (EU-ROP) needs to be reduced regarding granularity in order to align the different registries, as the registry with lower granularity determines the level of analyses that can be performed in a comparative approach. In the exemplary datasets, we observed that the overall most common ROP severity in both registries was zone II, 3+ (2011: 70.5%; 2021: 65%), with decreasing numbers of clock hours showing preretinal neovascularisations (2011: 10-12 clock hours in 29% of cases, 2021: 4-6 clock hours in 38%). The most prevalent treatment method was laser coagulation in 2011 (75%) and anti-VEGF therapy in 2021 (86.1%). Within the anti-VEGF group, all patients were treated with bevacizumab in 2011 and with ranibizumab in 2021. Retreatment rates were comparable in 2011 and 2021.

CONCLUSION

Data from two different ROP registries can be aligned and jointly analysed. The analysis reveals a paradigm shift in treatment modalities, from predominantly laser to anti-VEGF, and within the anti-VEGF group from bevacizumab to ranibizumab in Germany. In addition, there was a trend towards earlier treatment in 2021.

[Staging and systemic treatment of ocular and periocular metastases]

Metastases of malignant diseases are the most frequent tumors diagnosed in the human eye. They occur in approximately 5-10% of patients with solid tumors during the course of the disease. Their frequency is particularly high in patients with breast and lung cancer. Many highly sensitive periorbital tissues can be affected by the localization of the metastatic lesions and pose a number of clinical challenges. The main goal of the therapy of ocular metastases consists of the control of tumor growth (including the control of other possible manifestations throughout the body), the preservation of the affected eye and the minimization of potential iatrogenic damage to adjacent tissues. Overall, the purpose of this strategy is also to maintain the quality of life and especially the eyes and vision of the patient. Furthermore, pain should be avoided or at least alleviated. Of special importance is the differentiation between a curative or palliative situation. Patients with ocular metastases usually undergo systemic treatment appropriate for the underlying tumor entity, which is often accompanied by concomitant or sequential radiotherapy. In addition to classical chemotherapy, targeted treatment, treatment with monoclonal antibodies and antibody-drug conjugates as well as immunotherapy with checkpoint antibodies are currently available for many cancer types. This review article gives an overview of the currently available treatment options for patients with ocular metastases of solid tumors.

[Clinical approach for solid intraocular metastases]

BACKGROUND

Intraocular metastases arising from solid tumors are found in approximately 2% of patients with metastatic tumor diseases and are therefore more frequent than originally assumed. They often affect the uvea and are associated with a poor prognosis. Due to the difficult diagnosis and an inconsistent treatment regimen, ophthalmologists have a special responsibility here.

OBJECTIVE

This article gives a summary of the various types of intraocular metastases with respect to clinical features, diagnostics, treatment and prognosis as well as recommendations for follow-up care.

METHODS

A selective literature search was carried out on the topic of intraocular metastases using PubMed and Google Scholar.

RESULTS

Intraocular metastases most frequently affect the uvea, specifically the choroid. In most cases the underlying disease is breast or lung cancer, but other rarer primary tumors have also been reported in the literature. Metastatic lesions can show very different morphological manifestations but can be distinguished based on the corresponding structure of manifestation in the eye and with the aid of targeted staging, thus providing valid information on the type of primary tumor. The treatment is partly experimental and usually depends on the primary tumor and leading symptoms of the patient. A differentiation between a curative or palliative treatment situation must always be made.

CONCLUSION

Intraocular metastases are the most frequent intraocular tumor and are usually associated with a poor prognosis. Accurate diagnostics for finding the treatment as well as interdisciplinary collaboration and the presentation of the patient on the tumor board are essential.

Quercetin Impairs the Growth of Uveal Melanoma Cells by Interfering with Glucose Uptake and Metabolism

Monosomy 3 in uveal melanoma (UM) increases the risk of lethal metastases, mainly in the liver, which serves as the major site for the storage of excessive glucose and the metabolization of the dietary flavonoid quercetin. Although primary UMs with monosomy 3 exhibit a higher potential for basal glucose uptake, it remains unknown as to whether glycolytic capacity is altered in such tumors. Herein, we initially analyzed the expression of n = 151 genes involved in glycolysis and its interconnected branch, the "pentose phosphate pathway (PPP)", in the UM cohort of The Cancer Genome Atlas Study and validated the differentially expressed genes in two independent cohorts. We also evaluated the effects of quercetin on the growth, survival, and glucose metabolism of the UM cell line 92.1. The rate-limiting glycolytic enzyme PFKP was overexpressed whereas the ZBTB20 gene (locus: 3q13.31) was downregulated in the patients with metastases in all cohorts. Quercetin was able to impair proliferation, viability, glucose uptake, glycolysis, ATP synthesis, and PPP rate-limiting enzyme activity while increasing oxidative stress. UMs with monosomy 3 display a stronger potential to utilize glucose for the generation of energy and biomass. Quercetin can prevent the growth of UM cells by interfering with glucose metabolism.

Declining incidence and improving survival of ocular and orbital lymphomas in the US between 1995 and 2018

This epidemiological study examined ocular and orbital lymphomas in the United States from 1995 to 2018, using data from the North American Association of Central Cancer Registries database of 87,543 patients with ocular and adnexal malignancies. We identified 17,878 patients (20.4%) with ocular and orbital lymphomas, with an age-standardized incidence rate (ASIR) of 2.6 persons per million (ppm). The incidence was the highest in the orbit (ASIR = 1.24), followed by the conjunctiva (ASIR = 0.57). Non-Hodgkin B-cell lymphoma was the most prevalent subtype (85.4%), particularly marginal-zone lymphoma (45.7%). Racial disparities were noted, with Asia-Pacific Islanders showing the highest incidence (orbit, 1.3 ppm). The incidence increased significantly from 1995 to 2003 (Average Percent Change, APC = 2.1%) but declined thereafter until 2018 (APC = - 0.7%). 5-year relative survival (RS) rates varied, with the highest rate for conjunctival lymphoma (100%) and the lowest for intraocular lymphoma (70.6%). Survival rates have generally improved, with an annual increase in the 5-year RS of 0.45%. This study highlights the changing epidemiological landscape, pointing to initial increases and subsequent decreases in incidence until 2003, with survival improvements likely due to advancements in treatment. These findings underscore the need for further research to investigate the root causes of these shifts and the declining incidence of ocular lymphoma.

[Medicamentous Therapy of Malignant Eyelid Tumors]

INTRODUCTION

 Although surgical therapy is often the first-line treatment for malignant eyelid tumors, pharmacological treatment approaches can also be included and pursued in the treatment plan.

METHODS

Narrative review with a selective literature search on PubMed and Google Scholar.

RESULTS

 Various pharmacological therapeutic principles are currently available. One option is the local application of agents within the tumor area. This can be achieved through cytostatically active drugs such as 5-fluorouracil for superficial basal cell carcinomas and precursors of squamous cell carcinomas, or through mitomycin C in specific cases of sebaceous gland carcinoma. Another form of pharmacological local therapy is local immunomodulation using Imiquimod for superficial basal cell carcinomas, actinic keratosis, and Bowen's disease. Furthermore, there are systemic pharmacological therapies like chemotherapies, for example in sebaceous cell carcinoma, or systemic immunomodulation using checkpoint inhibitors for example in basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, and melanoma. Additionally, targeted therapies offer yet another treatment modality that exploits the molecular biological characteristics of various tumor entities. Examples of this include Hedgehog inhibitors for basal cell carcinomas, EGFR inhibitors for squamous cell carcinomas, or BRAF inhibitors for melanomas. This review addresses these treatment options for malignant tumors of the eyelid and systematically organizes them for the reader.

CONCLUSION

 Even though the data on these eye tumors is still limited, the reported case studies using systemic therapies for malignant eyelid tumors demonstrate the potential of this treatment modality. However, the need for further research is high especially concerning the combination of different therapy principles for increasing the effectiveness of eyelid tumor therapy.

Impact of Nintedanib and Anti-Angiogenic Agents on Uveal Melanoma Cell Behavior

Purpose

The purpose of this study was to investigate the direct impact of the combined angiokinase inhibitor nintedanib as well as the anti-angiogenic agents ranibizumab, bevacizumab, and aflibercept on the primary uveal melanoma (UM) cell line Mel270 and liver metastasis UM cell line OMM2.5.

Methods

The metabolic activity, viability, and oxidative stress levels were analyzed by the Thiazolyl Blue Tetrazolium Bromide (MTT), LIVE/DEAD, and reactive oxygen species (ROS) assays. Expression of intracellular VEGF-A165 and VEGF receptor-2 was detected by immunofluorescent staining. The secretion of VEGF-A165 into the cell culture supernatants was evaluated by VEGF-A165 ELISA.

Results

Nintedanib, at a concentration of 1 µg/mL, resulted in a median reduction of metabolic activity (for Mel270 of approximately 38% and for OMM2.5 of 46% compared to the untreated control) without exerting toxicity in either cell line, whereas the other 3 substances did not result in any changes (which also means that none of the 4 substances led to an increased cell death). Moreover, nintedanib (1 µg/mL) induced oxidative stress in the Mel270 by approximately 1.2 to 1.5-fold compared to the untreated control, but not the OMM2.5 cells.

Conclusions

Nintedanib could suppress the growth of UM cells in a concentration-dependent manner. The metastatic UM cell line OMM2.5 was not sensitive to the pro-oxidant activity of nintedanib. This study was the first to investigate nintedanib in the context of UM. We propose further investigation of this substance to elucidate its effects on this tumor entity with the hope of identifying advantageous therapeutic options for future adjuvant tumor therapies.

Joint CB1 and NGF Receptor Activation Suppresses TRPM8 Activation in Etoposide-Resistant Retinoblastoma Cells

In childhood, retinoblastoma (RB) is the most common primary tumor in the eye. Long term therapeutic management with etoposide of this life-threatening condition may have diminishing effectiveness since RB cells can develop cytostatic resistance to this drug. To determine whether changes in receptor-mediated control of Ca2+ signaling are associated with resistance development, fluorescence calcium imaging, semi-quantitative RT-qPCR analyses, and trypan blue dye exclusion staining patterns are compared in WERI-ETOR (etoposide-insensitive) and WERI-Rb1 (etoposide-sensitive) cells. The cannabinoid receptor agonist 1 (CNR1) WIN55,212-2 (40 µM), or the transient receptor potential melastatin 8 (TRPM8) agonist icilin (40 µM) elicit similar large Ca2+ transients in both cell line types. On the other hand, NGF (100 ng/mL) induces larger rises in WERI-ETOR cells than in WERI-Rb1 cells, and its lethality is larger in WERI-Rb1 cells than in WERI-ETOR cells. NGF and WIN55,212-2 induced additive Ca2+ transients in both cell types. However, following pretreatment with both NGF and WIN55,212-2, TRPM8 gene expression declines and icilin-induced Ca2+ transients are completely blocked only in WERI-ETOR cells. Furthermore, CNR1 gene expression levels are larger in WERI-ETOR cells than those in WERI-Rb1 cells. Therefore, the development of etoposide insensitivity may be associated with rises in CNR1 gene expression, which in turn suppress TRPM8 gene expression through crosstalk.

Surgical excision of eyelid tumors and subsequent ophthalmoplastic reconstruction

In recent years new modern therapeutic concepts have been developed in the treatment of malignant eyelid tumors; however, surgical restoration remains an important component of the therapeutic options addressed, which include microsurgical tumor excision into healthy tissue and subsequent coverage of the defects. An ophthalmic surgeon experienced in oculoplastic surgery is responsible for the recognition and evaluation of the existing alterations and planning a procedure together with the patient that meets the patient's expectations. The planning of surgery must always be individualized and fit the initial findings. Depending on the defect size and localization, different coverage strategies are available to the surgeon. To ensure successful reconstruction, every surgeon should master a wide range of reconstructive techniques.

Diagnosis and treatment of malignant eyelid tumors

BACKGROUND

Malignant tumors of the eyelid are much less frequent than benign eyelid alterations. These are frequently incidental findings without symptoms which are often overlooked or misinterpreted by patients.

OBJECTIVE

This article gives an overview of clinical aspects, diagnostics and treatment of the five most common malignant eyelid tumors and exemplarily explains the essential principles of evidence-based treatment of malignant eyelid tumors.

METHODS

This narrative review was prepared based on a selective literature search. The depiction of the treatment of eyelid tumors is supported by illustrations of clinical cases.

RESULTS

The medical history and inspection provide initial indications of malignancy. Every eyelid change suspected of being malignant should be examined histologically to confirm a diagnosis. By far the most common malignant eyelid tumor in Europe is basal cell carcinoma, which metastasizes only in exceptional cases. Squamous cell carcinomas, sebaceous adenocarcinomas, melanomas and Merkel cell carcinomas occur much less frequently. In these cases, potential metastasis in particular must be considered when making the diagnosis and staging has to be initiated. Surgical excision into healthy tissue with tumor-free margins is the gold standard for malignant eyelid tumors. Non-surgical adjuvant or neoadjuvant forms of evidence-based treatment can be initiated based on the individual case to minimize the risk of recurrence and metastasis.

CONCLUSION

It is essential to recognize eyelid changes at an early stage, to classify them correctly and to initiate the appropriate treatment. The interaction between the general condition and the personal needs of a patient as well as state of the art medicine are the keys to a good personalized treatment.

Treated Cases of Retinopathy of Prematurity in Germany: 10-Year Data from the Retina.net Retinopathy of Prematurity Registry

PURPOSE

To analyze changes in demographic parameters and retreatment patterns over a 10-year period in a clinical routine setting of infants with retinopathy of prematurity (ROP) requiring treatment documented in the German Retina.net ROP registry.

DESIGN

Multicenter, noninterventional, observational registry study recruiting patients treated for ROP.

SUBJECTS

A total of 692 eyes of 353 infants treated for ROP were documented in the Retina.net ROP registry over a 10-year period between 2011 and 2020. These cases cover about 15% of all infants treated for ROP in Germany.

METHODS

The Retina.net ROP registry was established in 2012 to jointly collect information on infants treated for ROP. The database collects information on demographic parameters (gestational age [GA], birth weight, neonatal comorbidities) as well as treatment parameters (type of treatment, weight and age at treatment, and stage of ROP). A total of 19 centers contributed to the analysis. This is the 10-year analysis of data from 2011 to 2020, in which we focus on changes over time regarding the respective parameters.

MAIN OUTCOME MEASURES

Changes over time in demographic parameters and treatment patterns for ROP in Germany.

RESULTS

The overall incidence of treatment requiring ROP was 3.5% of all infants screened for ROP at participating centers. Gestational age, weight at birth, and weight at treatment remained stable over the 10-year period, whereas postmenstrual and postnatal age at treatment increased moderately but statistically significantly over the years. The most prevalent ROP severity stage at treatment was stage 3+ in zone II (76.6% of all treated eyes). Treatment patterns changed considerably from predominantly laser treatments in 2011 (75% of all treated eyes) to predominantly ranibizumab treatments in 2020 (60.9% of all treated eyes). The overall retreatment rate was 15.6%. Retreatment rates differed between initial treatment modalities (14.1% after laser coagulation, 12% after bevacizumab and 24.5% after ranibizumab). Treatment-associated systemic or ophthalmic complications were rare.

CONCLUSIONS

This data analysis represents one of the largest documented cohorts of infants treated for ROP. The data on demographic parameters and treatment patterns provide useful information for further improvement of ROP management.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Detection of Circulating Tumor Cells in Patients with Small Choroidal Melanocytic Lesions

PURPOSE

To determine the presence of circulating tumor cells (CTCs) in patients with indeterminate small choroidal melanocytic lesions (SCMLs).

DESIGN

Retrospective case series.

PARTICIPANTS

Forty-seven patients with choroidal melanocytic lesions 2.5 mm or less in tumor thickness and ≤ 10 mm in largest basal diameter (LBD).

METHODS

Blood samples were analyzed for CTCs and the presence of monosomy-3 (M3) in CTCs. Tissue biopsy was performed in the patients who were CTC-positive (pCTC).

MAIN OUTCOME MEASURES

Presence and M3 status of the CTCs with regard to the clinical characteristics and results from tissue biopsy.

RESULTS

Median thickness of all (n = 47) lesions was 1.1 mm (range: 0.2-2.5 mm), and LBD was 5.6 mm (range: 2.0-10.0 mm). Circulating tumor cells were found in 25 patients (n = 25). This group was classified as pCTC and compared with the CTC-negative (nCTC) group consisting of 22 patients (n = 22). Median tumor dimensions in the pCTC versus the nCTC group were 1.6 mm (range: 0.6-2.5 mm) versus 0.5 mm (range: 0.2-2.5 mm) for thickness and 6.6 mm (range: 4.1-10.0 mm) versus 4.0 mm (range: 2.0-8.0 mm) for LBD, respectively. Both LBD and thickness were positively associated (P < 0.001) with the presence of CTC. Compared with the nCTC group, a higher percentage of the pCTC group exhibited LBD > 5 mm (36% vs. 88%), subretinal fluid (9.1% vs. 56%), orange pigment (4.5% vs. 60%), sonographic hollowness (9.1% vs. 60%), and the presence of multiple risk factors (0% vs. 68% for ≥3 factors) with P < 0.001 for all parameters. No significant difference was detected in the clinical parameters of the patients who had disomy-3 (D3) (n = 7) versus M3 (n = 17) in their CTC. The tissue biopsy confirmed the uveal melanoma (UM) in 22 of the 25 pCTC patients (88%), whereas no conclusive diagnosis could be determined in the remaining 3 cases because of insufficient or invalid material.

CONCLUSIONS

We report compelling evidence for the potential of liquid biopsy as an additional tool to screen SCMLs for malignancy. These findings pave the way toward the implementation of liquid biopsy to detect small UM and monitor melanocytic lesions.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Trends in the Utilization and Outcomes of Brachytherapy vs. Proton Therapy in Localized Uveal Melanoma in the United States

PURPOSE/OBJECTIVE(S)

To determine the trends in the utilization of different techniques of radiation treatment in localized uveal melanoma in the United States and to determine the difference in outcome between brachytherapy (BT) and proton-beam therapy (PT).

MATERIALS/METHODS

Using the North American Association of Central Cancer Registries (NAACCR), we identified 17451 patients with localized uveal melanoma with known both surgical and method of radiation therapy between 1995-2018. Univariate and multivariable analyses were performed to identify factors and characteristics that may have a potential impact on the treatment. Net survival was calculated using Relative survival in Ederer II cumulative expected method with actuarial. Overall survival (OS) and cancer-specific survival (CSS) were estimated by Kaplan-Meier method and life-tables.

RESULTS

The registries included 28.312 patients with uveal melanoma, out of them 22,983 patients with localized disease. Patients with known both surgical and method of radiation therapy were 17451 patients. We have studied this group further. The median age of this group was 61 (IQR 51-71), males were 51.9% (N = 9063), whites were 98.1% (N = 16921), and choroidal tumors were 87.8% (N = 15330). The median tumor thickness was 3.9mm (IQR 24-70), while, the median maximum tumor diameter was 11.3mm (IQR 8.0-14.4). The median follow-up time was 5.9 years (IQR 3.1-10.3). Among all patients, 57.5% (n = 10032) received BT, and 9.8% (n = 1708) received PT. Collectively, 30.1% (n = 5247) of the patients received no radiation treatment. BT constituted 14% of treatment modalities in 1995 and steadily increased to 65% in 2017. PT utilization was minimal in 1995 (1.4%) and also increased to 14.3% in 2017. Younger age and thinner tumor thickness were independently associated with better Cancer-specific survival (CSS) and overall survival (OS). For all patients who were treated primarily with radiation treatment, the 5-year OS was 85,9% and the 10-year OS was 77.2%. There were no differences in rates of OS or CSS between patients who were treated with BT or PT.

CONCLUSION

There is a continuous increase in the utilization of both BT and PT in the treatment of localized uveal melanoma. Similar survival outcomes could be anticipated for both radiation treatment techniques.

On the Current Care Situation and Treatment of Ocular Mucous Membrane Pemphigoid in Germany

BACKGROUND

Ocular involvement in mucous membrane pemphigoid (MMP) is relatively rare, with a prevalence of 25 cases per million population, equating to approx. 2,100 patients throughout Germany. Diagnosis can be difficult - especially in cases of isolated ocular involvement - and treatment can be complex and lengthy. Immunosuppressants or immunomodulatory drugs are often used. Due to the complexity of diagnosis and treatment, MMP patients are usually referred to specialized centers. The aim of this project was to evaluate the current care situation of patients with ocular MMP in Germany.

METHODS

A paper-based survey was designed and sent to all university eye clinics and other specialized centers in Germany in April 2020. The survey asked about the existence of a specialized outpatient service, the total annual number of patients with MMP, the annual number of newly diagnosed patients, any interdisciplinary collaboration for diagnostic or therapeutic purposes, as well as the local and systemic therapy used.

RESULTS

Of a total of 44 clinics, 28 (64%) responded, reporting a total average of 27 ± 42 (0 - 200) patients and 3.6 ± 2.2 (0 - 10) new cases per year. This corresponds to a total of 741 patients. Only nine (32%) of the responding clinics offer specialized MMP clinics. 93% of the centers collaborate with the local dermatology department. 79% perform serological and histological diagnostics in-house. About half of the centers (n = 16) apply a standardized treatment regime. Systemic glucocorticoids (66.7%) are most commonly used, followed by mycophenolate mofetil and dapsone (57.1%), rituximab (33.3%), azathioprine and cyclophosphamide (28.6%), as well as methotrexate (19.0%). The least frequently used treatment is intravenous immunoglobulin (14.3%).

CONCLUSION

This survey of German ophthalmology departments obtained data from about one third of the estimated total cohort of all patients with MMP in Germany. These are presumed to be exclusively patients with at least one ocular involvement. The complex care of these patients is usually provided in collaboration with a dermatologist and with the use of systemic anti-inflammatory medication. Currently, an ophthalmological MMP register is being established to better record the epidemiology and care situation of this rare disease in Germany and to improve it in the long term.

[Digital teaching 2020: Online teaching receives a better assessment than face-to-face teaching]

BACKGROUND

Due to the corona pandemic, face-to-face teaching was no longer permitted in the summer semester 2020 and online alternatives were quickly found.

OBJECTIVE

In our article, we illustrate the switch from face-to-face to online teaching in ophthalmology at the University of Lübeck and compare online teaching with face-to-face teaching.

METHODS

The central teaching evaluation takes place every semester with a standardized questionnaire. Based on the evaluation of these questions, a direct comparison of the attendance semester of the winter semester 2019/2020 with the online semester of the summer semester 2020 was carried out.

RESULTS

The structure (p = 0.003), the organization (p = 0.001), the resources made available (p = 0.034), the attendance of the lectures (p < 0.001) and further dates (p = 0.041), the increase in interest (p = 0.039) and learning (p = 0.001) were rated better in the online semester than in the face-to-face semester. Overall, the digital summer semester 2020 (p < 0.01) received a significantly better overall grade than the face-to-face semester in winter 2019/2020.

CONCLUSION

The structure of our courses has also been proven online. The theoretical content could be excellently mediated; however, practical exercises are not possible online. For the learning of practical skills, face-to-face instruction is still necessary.

Patient-derived xenograft mouse models to investigate tropism to the central nervous system and retina of primary and secondary central nervous system lymphoma

AIMS

How and why lymphoma cells home to the central nervous system and vitreoretinal compartment in primary diffuse large B-cell lymphoma of the central nervous system remain unknown. Our aim was to create an in vivo model to study lymphoma cell tropism to the central nervous system.

METHODS

We established a patient-derived central nervous system lymphoma xenograft mouse model and characterised xenografts derived from 4 primary and 4 secondary central nervous system lymphoma patients using immunohistochemistry, flow cytometry and nucleic acid sequencing technology. In reimplantation experiments, we analysed dissemination patterns of orthotopic and heterotopic xenografts and performed RNA sequencing of different involved organs to detect differences at the transcriptome level.

RESULTS

We found that xenografted primary central nervous system lymphoma cells home to the central nervous system and eye after intrasplenic transplantation, mimicking central nervous system and primary vitreoretinal lymphoma pathology, respectively. Transcriptomic analysis revealed distinct signatures for lymphoma cells in the brain in comparison to the spleen as well as a small overlap of commonly regulated genes in both primary and secondary central nervous system lymphoma.

CONCLUSION

This in vivo tumour model preserves key features of primary and secondary central nervous system lymphoma and can be used to explore critical pathways for the central nervous system and retinal tropism with the goal to find new targets for novel therapeutic approaches.

[Surgical excision of eyelid tumors and subsequent ophthalmoplastic reconstruction]

In recent years new modern therapeutic concepts have been developed in the treatment of malignant eyelid tumors; however, surgical restoration remains an important component of the therapeutic options addressed, which include microsurgical tumor excision into healthy tissue and subsequent coverage of the defects. An ophthalmic surgeon experienced in oculoplastic surgery is responsible for the recognition and evaluation of the existing alterations and planning a procedure together with the patient that meets the patient's expectations. The planning of surgery must always be individualized and fit the initial findings. Depending on the defect size and localization, different coverage strategies are available to the surgeon. To ensure successful reconstruction, every surgeon should master a wide range of reconstructive techniques.

[Diagnosis and treatment of benign eyelid tumors]

BACKGROUND

Benign tumors of the eyelids are frequent entities. They are often cause for cosmetic concern or can lead to irritation of the ocular surface. The differentiation from premalignant or malignant eyelid tumors is particularly important. In most cases this can be done clinically; however, in some cases histological evaluation is warranted.

OBJECTIVE

The aim of this article is to characterize the most important benign tumors of the eyelid and to ascertain when a histological examination is necessary. Furthermore, fundamental treatment procedures are discussed.

METHODS

This narrative review was prepared based on a selective literature search. The characteristics of some eyelid tumors are underlined with illustrations from clinical cases.

RESULTS

Most benign eyelid tumors are treated because of cosmetic or functional concerns. Some of them, including actinic keratosis, keratoacanthoma, cutaneous horn, trichofolliculoma, resemble malignant lid tumors or precancerous lesions and are thus excised in oder to obtain a diagnosis. Dermoid cysts can cause complications and congenital melanocytic naevi can exhibit malignant transformation and may need treatment. Inflammatory tumors can be treated conservatively in most cases but might require surgery in certain cases. Systemic associations exist with some of the benign lid tumors and should not be overlooked as they can be crucial for overall patient morbidity.

CONCLUSION

Benign tumors of the eyelids are frequent and can be found at any age depending on the diagnosis. This article describes the lesions most commonly encountered in the clinical routine and helps at making a plan for further management.

Increased Angiopoietin-1 and -2 levels in human vitreous are associated with proliferative diabetic retinopathy

BACKGROUND

Diabetic retinopathy is a frequent complication of diabetes mellitus and a leading cause of blindness in adults. The objective of this study was to elucidate the diabetic retinopathy pathophysiology in more detail by comparing protein alterations in human vitreous of different diabetic retinopathy stages.

METHODS

Vitreous samples were obtained from 116 patients undergoing pars plana vitrectomy. Quantitative immunoassays were performed of angiogenic factors (VEGF-A, PIGF, Angiopoietin-1, Angiopoietin-2, Galectin-1) as well as cytokines (IL-1β, IL-8, IFN-γ, TNF-α, CCL3) in samples from control patients (patients who don't suffer from diabetes; n = 58) as well as diabetes mellitus patients without retinopathy (n = 25), non-proliferative diabetic retinopathy (n = 12), and proliferative diabetic retinopathy patients (n = 21). In addition, correlation analysis of protein levels in vitreous samples and fasting glucose values of these patients as well as correlation analyses of protein levels and VEGF-A were performed.

RESULTS

We detected up-regulated levels of VEGF-A (p = 0.001), PIGF (p<0.001), Angiopoietin-1 (p = 0.005), Angiopoietin-2 (p<0.001), IL-1β (p = 0.012), and IL-8 (p = 0.018) in proliferative diabetic retinopathy samples. Interestingly, we found a strong positive correlation between Angiopoietin-2 and VEGF-A levels as well as a positive correlation between Angiopoietin-1 and VEGF-A.

CONCLUSION

This indicated that further angiogenic factors, besides VEGF, but also pro-inflammatory cytokines are involved in disease progression and development of proliferative diabetic retinopathy. In contrast, factors other than angiogenic factors seem to play a crucial role in non-proliferative diabetic retinopathy development. A detailed breakdown of the pathophysiology contributes to future detection and treatment of the disease.

CXCR4, CXCR5 and CD44 May Be Involved in Homing of Lymphoma Cells into the Eye in a Patient Derived Xenograft Homing Mouse Model for Primary Vitreoretinal Lymphoma

Background: Primary vitreoretinal lymphoma (PVRL), a rare malignancy of the eye, is strongly related to primary central nervous system lymphoma (PCNSL). We hypothesized that lymphoma cells disseminate to the CNS and eye tissue via distinct homing receptors. The objective of this study was to test expression of CXCR4, CXCR5, CXCR7 and CD44 homing receptors on CD20 positive B-lymphoma cells on enucleated eyes using a PCNSL xenograft mouse model. Methods: We used indirect immunofluorescence double staining for CD20/CXCR4, CD20/CXCR5, CD20/CXCR7 and CD20/CD44 on enucleated eyes of a PCNSL xenograft mouse model with PVRL phenotype (PCNSL group) in comparison to a secondary CNS lymphoma xenograft mouse model (SCNSL group). Lymphoma infiltration was evaluated with an immunoreactive score (IRS). Results: 11/13 paired eyes of the PCNSL but none of the SCNSL group were infiltrated by CD20-positive cells. Particularly the choroid and to a lesser extent the retina of the PCNSL group were infiltrated by CD20+/CXCR4+, CD20+/CXCR5+, few CD20+/CD44+ but no CD20+/CXCR7+ cells. Expression of CXCR4 (p = 0.0205), CXCR5 (p = 0.0004) and CD44 (p < 0.0001) was significantly increased in the PCNSL compared to the SCNSL group. Conclusions: CD20+ PCNSL lymphoma cells infiltrating the eye co-express distinct homing receptors such as CXCR4 and CXCR5 in a PVRL homing mouse model. These receptors may be involved in PVRL homing into the eye.

[Clinical aspects and care of radiogenic treatment side effects on the eye]

Malignant tumors of the eye can be successfully treated with radiotherapy, which, however, can lead to radiogenic side effects in the surrounding healthy tissues. A  distinction can be made between two forms of irradiation, external radiotherapy (teletherapy) and brachytherapy with a radiation source close to the tumor. The radiation dose is important for the occurrence of side effects. Acute damage usually results from inflammatory processes initiated at the cellular level. In contrast, late side effects are rather due to the reaction of the tissue with repair and remodeling processes . Acute side effects often resolve completely, especially under corresponding treatment, whereas late side effects tend to be irreversible. The aim of this article is to present risk factors as well as the clinical signs of periocular and ocular radiogenic side effects for the relevant tissue structures of the eye in a narrative review to facilitate ophthalmologic follow-up and, if necessary, treatment measures for these patients during everyday practice.

Therapy Failure and Resistance Mechanism in Eyelid and Ocular Surface Tumors

Malignant tumors of the eyelids and ocular surface are common ocular malignancies. At present, surgical treatment is mostly the first choice for these types of tumors. However, postoperative tumor recurrence and metastasis are still regarded as failures in the treatment of such malignancies. Based on this, malignant tumors of the eyelid and ocular surface are sometimes accompanied by local adjuvant chemotherapy and systemic chemotherapy to treat patients with relapse, invasion of adjacent tissues, and systemic metastases. Still, drug resistance greatly affects the treatment effect. This review lists several mechanisms of recurrence and metastasis of ocular surface and eyelid tumors after surgery, as well as mechanisms that may lead to non-surgical treatment or drug resistance.

[Lymphoma of the eye and its adnexa : Modern pathological diagnostics and systemic treatment]

BACKGROUND

Malignant lymphomas of the eye and its adnexal structures account for approximately 5-15% of extranodal lymphomas. According to anatomic and biological criteria, two large groups of lymphomas in and around the eye need to be distinguished: (1) primary lymphomas of intraocular structures and (2) primary lymphomas of ocular adnexa. Furthermore, there is a large spectrum of secondary manifestations of malignant lymphomas in ocular and periocular structures.

OBJECTIVE

This article gives a summary of the classification and molecular pathology of various intraocular and periocular lymphomas as well as oncological systemic treatment with a focus on primary vitreoretinal lymphomas.

METHODS

A selective literature search was carried out in PubMed on the topic of intraocular and periocular lymphomas and own experiences are presented.

RESULTS

The treatment of primary vitreoretinal lymphomas (PVRL) is an interdisciplinary challenge and despite the apparently localized disease, systemic treatment concepts are necessary to reduce the high risk of secondary involvement of the central nervous system (CNS). Therefore, it is crucial that the substances used can penetrate the CNS, and protocols should be chosen in accordance with the treatment concepts for primary CNS lymphomas. The knowledge on the genetics and biology of ocular lymphomas generated by modern high throughput methods enable not only improved diagnostics using molecular methods but also provide rationales for targeted therapeutic approaches.

CONCLUSION

A deep understanding of the biological and molecular principles of intraocular and periocular lymphomas forms a basic prerequisite for precise diagnostics and the use of targeted systemic treatment.

[Clinical procedures for intraocular lymphomas]

BACKGROUND

The classification of intraocular lymphomas is based on their anatomical location. They are divided into uveal lymphomas with involvement of the choroid, ciliary body or iris and vitreoretinal lymphomas with isolated or combined involvement of the vitreous body and/or retina. Over the last decades it has become increasingly possible to work out the clinical and pathobiological features of the various subtypes, thereby reducing the diagnostic hurdles and creating improved treatment options.

OBJECTIVE

A summary of the various types of intraocular lymphoma in terms of clinical features, diagnostics, treatment and prognosis is given as well as recommendations for follow-up care.

METHODS

A selective literature search was carried out on the subject of intraocular lymphomas using PubMed and Google Scholar.

RESULTS

Intraocular lymphomas affect different structures, so that the symptoms can also be very different. The diagnostic spectrum ranges from typical ocular examination methods to sample biopsies with subsequent cytological, histological and molecular pathological processing. The treatment pillars available are percutaneous irradiation and intravitreal drug administration as local treatment and systemic treatment or a combination of systemic and local treatment. The prognosis depends mainly on the subtype of the lymphoma and the extent of the infestation when the diagnosis is confirmed. Even though some effective treatment options are now available, it has not yet been possible to significantly reduce the mortality rate.

CONCLUSION

Many different options are available for the diagnostics and treatment of intraocular lymphomas, which require close interdisciplinary cooperation. The further developments in the field of molecular pathology allow a faster and more accurate diagnosis and could open up new treatment options in the future.

Case Report: GNAQ- and SF3B1 Mutations in an Aggressive Case of Relapsing Uveal Ring Melanoma

The molecular mechanisms for uveal ring melanoma are still unclear until today. In this case report, we describe a patient with a malignant uveal melanoma with exudative retinal detachment that had been treated with plaque brachytherapy, resulting in successful tumor regression. After 1 year, a ring-shaped recurrence with extraocular extension appeared, and the eye required enucleation. Histological and molecular genetic analyses revealed an epithelioid-cell-type melanoma with complete circumferential involvement of the ciliary body and, so far, unreported GNAQ and SF3B1 mutations in ring melanoma. Therefore, this report gives new genetic background information on this ocular tumor usually leading to enucleation.

Interventional Radiotherapy (Brachytherapy) in Eyelid and Ocular Surface Tumors: A Review for Treatment of Naïve and Recurrent Malignancies

The goal of radiotherapy in the treatment of eyelid and ocular surface tumors is to eradicate tumor burden in a manner that maintains visual function and preserve surrounding sensitive ocular tissue. Interventional radiotherapy (IRT-brachytherapy) is a radiotherapy technique associated with a highly focal dose distribution, with the advantage of boosting limited size target volumes to very high dose while sparing normal tissue. The reduction in the ocular and adnexal complications that result from this form of therapy, has led in recent years, to an increase in the use of IRT for the treatment of eyelid and ocular surface tumors. For eyelid malignancies, IRT is used as an independent treatment in small eyelids tumors, in postoperative treatment of high-risk patients and as well as salvage therapy in local recurrences. In the treatment of conjunctival malignancies, due to the high risk of local recurrence, the use of adjuvant therapies as IRT has shown to improve outcomes. In this review, we focus on eyelid and ocular surface IRT techniques and provide an overview of indication, outcomes and toxicity of IRT for the treatment of naïve and recurrent eyelid and conjunctival tumors.

[Benign Tumors of the Eyelid]

Benign tumors of the eyelids are manifold. They can severely impair the anatomical unit of upper and lower eyelid, which basically serves to protect the eyeball. Furthermore, they can induce reduction of visual acuity or cause a subjectively more or less strong aesthetic disturbance of appearance. Patients may visit the ophthalmologist by themselves or referred by a dermatologist or a general practitioner. Therefore, knowledge of the clinical signs and symptoms of benign tumors are mandatory to discriminate against malign tumors or to identify possible associated disease. In this article, the incidence, clinic, risk factors, symptomatology, histopathologic features, and probabilities of malignant transformation and recurrence of the most common benign eyelid tumors are presented. Objective of this article is to illustrate when to do further work-up to rule out systemic disease and when to do biopsy to rule out malignancy. Finally, the publication is giving an outlook on the use of artificial intelligence to diagnose lid tumors in the future.

[Alterations of the anterior segment of the eye caused by exposure to UV radiation]

BACKGROUND

By identifying diseases of the anterior segment of the eye associated with exposure to UV light, recommendations for action can be derived.

AIM

After reading this review, the reader should be familiar with UV light-associated diseases of the anterior segment of the eye.

METHOD

Using a selective literature search, UV light-associated diseases of the anterior segment of the eye were identified and protective mechanisms are described.

RESULTS

The UV light-associated lesions of the anterior segment of the eye include basal cell and squamous cell carcinomas, malignant melanoma of the eyelids and conjunctiva, pterygium, keratoconjunctivitis photoelectrica and climatic droplet keratopathy as well as cortical cataract.

CONCLUSION

Eyeglasses for filtering UV light, sunglasses and special safety glasses, such as welding helmets and wearing headgear protect against UV light exposure to the anterior segment of the eye and the associated diseases.

Benigne Lidtumoren

Benigne Lidtumoren sind vielfältig. In diesem Beitrag werden die häufigsten benignen Augenlidtumoren hinsichtlich Inzidenz, Klinik, Risikofaktoren, Symptomatik, histopathologischen Besonderheiten und Entartungs- sowie Rezidivwahrscheinlichkeit beleuchtet. Herausgearbeitet wird, wann eine systemische Abklärung erforderlich bzw. eine Probe zum Ausschluss eines Malignoms empfohlen ist und wie die Nachsorge auch im Hinblick auf eine spätere Entartung der Wucherung erfolgen sollte.

Rare Case of Bilateral Diffuse Uveal Melanocytic Proliferation with Dermal and Mucosal Hyperpigmentations

Purpose: The demonstration of a rare case of bilateral diffuse uveal melanocytic proliferation (BDUMP) due to a lung carcinoma with unusual dermal lesions. Case description: A 76-year-old man with painless bilateral vision loss revealed leopard or giraffe spot chorioretinopathy and bilateral serous retinal detachment. Ultrasound biomicroscopy revealed uveal swelling expanding into the anterior chamber angle. Dermal and mucosal lesions were present on the lip, breast, groin, scrotum, and penis. Screening analyses revealed a non-small cell lung carcinoma. Conclusions: The diagnosis of BDUMP, a rare paraneoplastic syndrome, was made. The ophthalmological diagnosis led to screening investigations and revealed the underlying malignant disease. Uncommonly, multiple dermal and mucosal lesions could be detected and were analyzed histopathologically.

Epidermal Growth Factor Is Increased in Conjunctival Malignant Melanoma

BACKGROUND/AIM

Conjunctival malignant melanoma (CMM) is a rare, but very aggressive tumor with a high metastasis rate. Not much is known about the CMM metastasis mechanisms. So far, epidermal growth factor (EGF) and its receptor (EGF-R) as well as macrophages and matrix metalloproteinase 9 (MMP-9) have been reported to lead to metastasis by epithelial-mesenchymal-transition and tumor migration in different solid tumors. Therefore, we evaluated whether EGF and EGF-R, CD68 and MMP-9 are altered in CMM samples in comparison to conjunctival nevi and healthy conjunctiva.

PATIENTS AND METHODS

EGF, EGF-R, the macrophage marker CD68 and MMP-9 expression were analyzed in human conjunctival melanoma (CMM, n=16), human conjunctival nevi (n=13) and disease-free human conjunctiva (controls, n=14) by immunohistology. Staining of each sample was evaluated using a standardized score ranging from negative (0) to triple positive (3). The groups were then compared by ANOVA, followed by Tukey's post-hoc test.

RESULTS

A statistically significant increase of EGF was seen in CMM samples in comparison to conjunctival nevi (p=0.03). In contrast, no statistically significant differences in EGF-R expression were noted between the three groups. A statistically significant increase of CD68 was only seen in conjunctival nevi compared to controls (p=0.04). MMP-9 expression was similar in all groups.

CONCLUSION

In CMM, the study data demonstrated an up-regulation of EGF in comparison to conjunctival nevi. Hence, EGF might promote proliferation of CMM cells and induce the epithelial-mesenchymal transition. Therefore, our data suggest that an interplay between EGF and CMM might have a critical role in the developing CMM tumors and metastasis.

Islet Co-Expression of CD133 and ABCB5 in Human Retinoblastoma Specimens

BACKGROUND

The role of CD133 und ABCB5 is discussed in treatment resistance in several types of cancer. The objective of this study was to evaluate whether CD133⁺/ABCB5⁺ colocalization differs in untreated, in beam radiation treated, and in chemotherapy treated retinoblastoma specimens. Additionally, CD133, ABCB5, sphingosine kinase 1, and sphingosine kinase 2 gene expression was analyzed in WERI-RB1 (WERI RB1) and etoposide-resistant WERI RB1 subclones (WERI ETOR).

METHODS

Active human untreated retinoblastoma specimens (n = 12), active human retinoblastoma specimens pretreated with beam radiation before enucleation (n = 8), and active human retinoblastoma specimens pretreated with chemotherapy before enucleation (n = 7) were investigated for localization and expression of CD133 and ABCB5 by immunohistochemistry. Only specimens with IIRC D, but not E, were included in this study. Furthermore, WERI RB1 and WERI ETOR cell lines were analyzed for CD133, ABCB5, sphingosine kinase 1, and sphingosine kinase 2 by the real-time polymerase chain reaction (RT-PCR).

RESULTS

Immunohistochemical analysis revealed the same amount of CD133⁺/ABCB5⁺ colocalization islets in untreated and treated human retinoblastoma specimens. Quantitative RT-PCR analysis showed a statistically significant upregulation of CD133 in WERI ETOR (p = 0.002). No ABCB5 expression was detected in WERI RB1 and WERI ETOR. On the other hand, SPHK1 (p = 0.0027) and SPHK2 (p = 0.017) showed significant downregulation in WERI ETOR compared to WERI RB1.

CONCLUSIONS

CD133⁺/ABCB5⁺ co-localization islets were noted in untreated and treated human retinoblastoma specimens. Therefore, we assume that CD133⁺/ABCB5⁺ islets might play a role in retinoblastoma genesis, but not in retinoblastoma treatment resistance.

[Retinal tumors in adults - Part 1: vascular tumors of the retina]

Retinal tumors are a heterogeneous group of congenital and acquired lesions. In this review series the important retinal tumors are discussed and presented in two articles. In the first part of the article the most important vascular tumors of the retina are presented. Even with benign tumors visual symptoms, such as exudative retinal detachment occur, which often lead to irreversible visual impairments. Because visual symptoms are often a manifestation of systemic diseases, the ophthalmologist plays an important role in the accurate and early diagnosis of retinal tumors. This article reviews the most important clinical and diagnostic features of retinal vascular tumors in adults, their systemic associations and the literature on currently available treatment strategies.

Histopathological Features and Ann Arbor Stage in Periocular Lymphoma

BACKGROUND

To evaluate biodata, symptoms/signs, lymphoma type, localization, stage level, treatment choice and outcome of ocular adnexal lymphoma (OAL).

PATIENTS AND METHODS

A single-center retrospective analysis of 56 patients with OAL was performed from 1998 to 2018.

RESULTS

OAL involved the orbit in 44.6%, the conjunctiva in 32.1%, the lacrimal apparatus in 14.3% and the eyelid in 8.93%. Extranodal marginal zone B-cell lymphoma (EMZL) was found in 60.7%, follicular lymphoma (FL) in 21.4%, diffuse large B-cell lymphoma in 7.14%, mantle cell lymphoma in 5.36% and chronic lymphatic leukaemia in 5.36% patients. No relapse was seen in 76%. EMZL and FL had a significantly better overall survival compared to other lymphoma types (p=0.002). Patients with Ann Arbor stage IE had a significantly better prognosis than those with stages higher than IE (p=0.048).

CONCLUSION

Our data suggest that clinicopathological features such as Ann Arbor stage influence survival.

Influence of Retinal Microsecond Pulse Laser Treatment in Central Serous Chorioretinopathy: A Short-Term Optical Coherence Tomography Angiography Study

Background: Central serous chorioretinopathy (CSC) is a common macular condition characterized by detachment of the neuroretina and is a frequent cause of central vision loss in adults. Among the various therapeutic strategies, subthreshold microsecond pulsed laser (SML) treatment has become a useful option. Despite the suggested involvement of choroidal circulatory disturbances in CSC, the effects of this treatment on macular microperfusion have not been fully evaluated yet. Herein, we report the impact of SML on retinal and choroidal microvascular flow using non-invasive optical coherence tomography (OCT) angiography (OCTA). Methods: In this study, CSC patients with persistent subretinal fluid (SRF) with or without secondary choroidal neovascularization (CNV) were included (referred to as the pachychoroid neovasculopathy (PNV) group and the CSC group, respectively). SML was conducted using a yellow (577 nm) laser with a duty cycle of 10%, spot size of 200 µm and duration of 200 ms. Best corrected visual acuity (BCVA) as well as OCT and OCTA images were evaluated at baseline and 4 weeks after SML. OCTA parameters of interest included full retinal perfusion (FRP), choriocapillaris perfusion (CCP), Sattler’s layer perfusion (SLP), and Haller’s layer perfusion (HLP), which were evaluated longitudinally and compared to unaffected fellow eyes. Results: 27 affected eyes and 17 fellow eyes from 27 patients were included. Before treatment, central retinal thickness (CRT) and subfoveal choroidal thickness (SFCT) of affected eyes were significantly larger than in fellow eyes. Four weeks after SML, CRT decreased significantly, whereas perfusion parameters did not change. In subgroup analyses, the CSC group showed a significant decrease in SFCT, whereas the PNV group did not despite the decrease in CRT. Conclusion: Our results suggest that the SML may affect the SFCT of the CSC, but not the PNV patients at least within four weeks following treatment. This effect seems to be independent of the change in choroidal perfusion measured with OCTA.

Primary Vitreoretinal Lymphoma Therapy Monitoring: Significant Vitreous Haze Reduction After Intravitreal Rituximab

BACKGROUND/AIMS

Intravitreal rituximab is an off-label treatment option for primary vitreoretinal lymphoma (PVRL). The objective of this study was to monitor the therapeutic response and safety profile of intravitreal rituximab in a cohort of PVRL patients.

METHODS

In this retrospective, uncontrolled, open label, multicentre study, 20 eyes from 15 consecutive patients diagnosed with PRVL received at least one intravitreal injection of 1mg in 0.1ml rituximab. Biodata of the PVRL patients was recorded as well as visual acuity and vitreous haze score immediately before rituximab intravitreal injection and at follow-up examinations. Intravitreal rituximab safety data was also recorded. Additional rituximab injections were made during control visits on a pro re nata (PRN) regime using increased vitreous haze to indicate recurrence.

RESULTS

There was significant vitreous haze reduction (p=0.0002) followed by significant improvement of visual acuity (mean best visual acuity before therapy 0.57 logMAR, after therapy 0.20 logMAR (p=0.0228) during the follow-up time up to 4 years. Only mild ocular side effects were reported. Median follow-up time was 565 days (range, 7-1253 days).

CONCLUSION

Intravitreal rituximab therapy shows promising PVRL regression without any severe side effects. Although our clinical data support rituximab as intravitreal therapy in PVRL disease, further study is warranted.

Evaluating Retinal and Choroidal Perfusion Changes after Isometric and Dynamic Activity Using Optical Coherence Tomography Angiography

Optical coherence tomography angiography (OCTA) is a non-invasive tool for imaging and quantifying the retinal and choroidal perfusion state in vivo. This study aimed to evaluate the acute effects of isometric and dynamic exercise on retinal and choroidal sublayer perfusion using OCTA. A pilot study was conducted on young, healthy participants, each of whom performed a specific isometric exercise on the first day and a dynamic exercise the day after. At baseline and immediately after the exercise, heart rate (HR), mean arterial pressure (MAP), superficial capillary plexus perfusion (SCPP), deep capillary plexus perfusion (DCPP), choriocapillaris perfusion (CCP), Sattlers’s layer perfusion (SLP), and Haller’s layer perfusion (HLP) were recorded. A total of 34 eyes of 34 subjects with a mean age of 32.35 ± 7.87 years were included. HR as well as MAP increased significantly after both types of exercise. Both SCPP and DCPP did not show any significant alteration due to isometric or dynamic exercise. After performing dynamic exercise, CCP, SLP, as well as HLP significantly increased. Changes in MAP correlated significantly with changes in HLP after the dynamic activity. OCTA-based analysis in healthy adults following physical activity demonstrated a constant retinal perfusion, supporting the theory of autoregulatory mechanisms. Dynamic exercise, as opposed to isometric activity, significantly changed choroidal perfusion. OCTA imaging may represent a novel and sensitive tool to expand the diagnostic spectrum in the field of sports medicine.

[Chorioretinal atrophy in pediatric cerebral folate deficiency-a preventable disease?]

Cerebral folate deficiency (CFD) results in neurological alterations and a massive degeneration of the choroid/retina if left untreated, which limit the visual field and visual acuity. This article reports the case of a female patient with CFD, who developed autistic personal characteristics prior to reaching school age and first started to speak at the age of 3 years. At the age of 6 years she was presented because of unclear reduced visual acuity in the right eye. At that time mild bilateral peripheral chorioretinal atrophy was present, which subsequently became more pronounced. Additionally, a centrally emphasized chorioretinal atrophy further developed. Visual acuity of both eyes progressively deteriorated until stagnating at 0.1 at the age of 14 years. The causal assignment of the findings of the patient was not possible for many years. Choroideremia was excluded by molecular genetic testing (CHM gene with no mutations) and gyrate atrophy was ruled out by a normal ornithine level. The existence of a mitochondrial disease was almost completely excluded by exome sequencing. After the onset of further nonocular symptoms, e.g. neuromuscular disorders, electroencephalograph (EEG) alterations and autistic disorder, intensified laboratory diagnostics were performed in the treating pediatric hospital. Finally, an extremely low level of the folic acid metabolite 5‑methyltetrahydrofolate was detected in the cerebrospinal fluid (CSF) leading to the diagnosis of CFD. High-dose substitution treatment with folic acid was subsequently initiated. After excluding the presence of a pathogenic mutation of the FOLR1 gene for the cerebral folate receptor 1, a high titer blocking autoantibody against cerebral folate receptor 1 was detected as the cause.