Optical coherence tomography angiography (OCTA) as a new diagnostic tool in uveitis

Background: The broad spectrum of uveitis disorders requires a multimodal imaging approach in the daily practice of an ophthalmologist. As inflammatory conditions, they have in common an alteration in leukocyte migration. In this context, optical coherence tomography angiography (OCTA) might be of great value for diagnosing or following up patients with these disorders. To date, OCTA has rather been used as an additional tool besides the well-established diagnostic imaging tools, but its complementary diagnostic features become increasingly relevant, to follow disease activity and treatment response and for the understanding of pathomechanisms of various uveitis types. This review summarizes the possible applications of OCTA and its advantages and disadvantages as opposed to dye-based angiographies in uveitic diseases. Main body: Hitherto gold standards in the diagnostic workup of posterior or intermediate uveitis have been angiography on a dye-based method, which is fluorescein or indocyanine green. It gives information about the status of the blood-retinal barrier and the retinal and choroidal vasculature by visualizing diffuse leakage as a state of inflammation or complications as an ischemia or choroidal neovascularization. As noninvasive methods, fundus autofluorescence depicts the status of metabolic activity of the retinal pigment epithelium and OCT or enhanced depth imaging OCT, respectively, as a depth-resolving imaging method can supply additional information. OCTA as a non-invasive, depth-resolution imaging tool of retinal and choroidal vessels adds detailed qualitative and quantitative information of the status of retinal and choroidal vessels and bridges the gap between the mentioned conventional diagnostic tools used in uveitis. It is important, though, to be aware of its limitations, such as its susceptibility to motion artifacts, limited comparability among different devices, and restricted contribution of information regarding the grade of disease activity. Conclusion: OCTA as a non-invasive, depth-resolution imaging tool can give qualitative and quantitative information about the status of retinal and choroidal vessels, but also has certain limitations. Employing OCTA as a complementary rather than exclusive tool, it can give important additional information about the macro- and microvasculature under inflammatory circumstances. Thereby, it also contributes to the understanding of the pathophysiology of various uveitis entities

Discrepancy between prevalence and perceived effectiveness of treatment methods in myofascial pain syndrome: Results of a cross-sectional, nationwide survey

Background: Myofascial pain is a common dysfunction with a lifetime prevalence affecting up to 85% of the general population. Current guidelines for the management of myofascial pain are not available. In this study we investigated how physicians on the basis of prescription behaviour evaluate the effectiveness of treatment options in their management of myofascial pain. Methods: We conducted a cross-sectional, nationwide survey with a standardized questionnaire among 332 physicians (79.8% male, 25.6% female, 47.5 +/- 9.6 years) experienced in treating patients with myofascial pain. Recruitment of physicians took place at three German meetings of pain therapists, rheumatologists and orthopaedists, respectively. Physicians estimated the prevalence of myofascial pain amongst patients in their practices, stated what treatments they used routinely and then rated the perceived treatment effectiveness on a six-point scale (with 1 being excellent). Data are expressed as mean +/- standard deviation. Results: The estimated overall prevalence of active myofascial trigger points is 46.1 +/- 27.4%. Frequently prescribed treatments are analgesics, mainly metamizol/paracetamol (91.6%), non-steroidal anti-inflammatory drugs/coxibs (87.0%) or weak opioids (81.8%), and physical therapies, mainly manual therapy (81.1%), TENS (72.9%) or acupuncture (60.2%). Overall effectiveness ratings for analgesics (2.9 +/- 0.7) and physical therapies were moderate (2.5 +/- 0.8). Effectiveness ratings of the various treatment options between specialities were widely variant. 54.3% of all physicians characterized the available treatment options as insufficient. Conclusions: Myofascial pain was estimated a prevalent condition. Despite a variety of commonly prescribed treatments, the moderate effectiveness ratings and the frequent characterizations of the available treatments as insufficient suggest an urgent need for clinical research to establish evidence-based guidelines for the treatment of myofascial pain syndrome

Vasculitis-like hemorrhagic retinal angiopathy in Wegener’s granulomatosis

Background: Granulomatosis with polyangiitis, also known as Wegener’s granulomatosis, is a chronic systemic inflammatory disease that can also involve the eyes. We report a case of massive retinal and preretinal hemorrhages with perivascular changes as the initial signs in granulomatosis with polyangiitis (Wegener’s granulomatosis). Case presentation: A 39-year-old Caucasian male presented with blurred vision in his right eye, myalgia and arthralgia, recurrent nose bleeds and anosmia. Fundus image of his right eye showed massive retinal hemorrhages and vasculitis-like angiopathy, although no fluorescein extravasation was present in fluorescein angiography. Laboratory investigations revealed an inflammation with increased C-reactive protein, elevated erythrocyte sedimentation rate and neutrophil count. Tests for antineutrophil cytoplasmic antibodies (ANCA) were positive for c-ANCA (cytoplasmatic ANCA) and PR3-ANCA (proteinase 3-ANCA). Renal biopsy demonstrated a focal segmental necrotizing glomerulonephritis. Granulomatosis with polyangiitis (Wegener’s granulomatosis) was diagnosed and a combined systemic therapy of cyclophosphamide and corticosteroids was initiated. During 3 months of follow-up, complete resorption of retinal hemorrhages was seen and general complaints as well as visual acuity improved during therapy. Conclusion: Vasculitis-like retinal changes can occur in Wegener’s granulomatosis. Despite massive retinal and preretinal hemorrhages that cause visual impairment, immunosuppressive therapy can improve ocular symptoms

Comparative study of trabeculectomy using single sutures versus releasable sutures

BACKGROUND: The purpose of this study was to compare the outcomes of trabeculectomy using single sutures or releasable sutures. METHODS: This retrospective study analyzed the medical records of 61 patients who had undergone trabeculectomy using single sutures (n = 33, 54.1%) or releasable sutures (n = 28, 45.9%). The scleral flap was secured with a mean 3.9 (range 3-5) single sutures in 33 patients and with three releasable sutures in 28 patients. Primary outcomes were the success rate, based on intraocular pressure and medication usage, and the frequency of complications and post-surgical interventions. The criteria used to determine complete success were, first, intraocular pressure =20% intraocular pressure reduction without glaucoma medication. RESULTS: All patients had an intraocular pressure <= 21 mmHg; 87.5% in the single suture group and 92.6% in the releasable suture group had an intraocular pressure < 18 mmHg at 24 months. There was a highly significant reduction in intraocular pressure to baseline values in both groups at the last visit. Applying the first criterion, complete success was achieved in 57.6% of patients with single sutures and 71.4% with releasable sutures, and based on the second criterion, 66.7% and 71.4%, respectively. No significant difference was found between the groups with regard to intraocular pressure, or success or complication rates. CONCLUSION: The results of trabeculectomy using single sutures or releasable sutures are equivalent. Therefore, the choice of suture technique should be based on individual patient requirements and surgeon experience

LOW ENDOPHTHALMITIS RATES AFTER INTRAVITREAL ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR INJECTIONS IN AN OPERATION ROOM: A Retrospective Multicenter Study.

PURPOSE To evaluate the rate of presumed endophthalmitis (EO) after intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections in three European hospitals performed in an operation room (OR) under sterile conditions. METHODS A retrospective multicenter study between 2003 and 2016 at three European sites, City Hospital Triemli Zurich, Switzerland (CHT), Zealand University Hospital Roskilde, Denmark (ZUH) and University Clinic Bern, Switzerland (UCB). Intravitreal injection (IVI) database of each department was reviewed. All anti-vascular endothelial growth factor injections were performed using a standardized sterile technique in an operation room. Injection protocols were similar between the three sites. No preinjection antibiotics were given. Postoperative antibiotics varied among sites. RESULTS A total of 134,701 intravitreal injections were performed at the 3 sites between 2003 and 2016. Ten cases of presumed endophthalmitis were documented: 4 in 50,721 at CHT (95% CI: 0.0071-0.0087%), 2 in 44,666 at ZUH (95% CI: 0.0039-0.0051%), and 4 in 39,314 at UCB (95% CI: 0.0092-0.011%). This results in one case in 13,470 intravitreal injections and a combined incidence of 0.0074% per injection (95% CI: 0.0070-0.0078%). Positive cultures were found in 4 out of 10 presumed endophthalmitis cases. CONCLUSION The standardized sterile technique in an operation room with laminar airflow showed very low rates of endophthalmitis at three European sites