Nikolai Gross

Treatment of optic neuritis with erythropoietin (TONE): a randomised, double-blind, placebo-controlled trial—study protocol

Introduction Optic neuritis leads to degeneration of retinal ganglion cells whose axons form the optic nerve. The standard treatment is a methylprednisolone pulse therapy. This treatment slightly shortens the time of recovery but does not prevent neurodegeneration and persistent visual impairment. In a phase II trial performed in preparation of this study, we have shown that erythropoietin protects global retinal nerve fibre layer thickness (RNFLT-G) in acute optic neuritis; however, the preparatory trial was not powered to show effects on visual function. Methods and analysis Treatment of Optic Neuritis with Erythropoietin (TONE) is a national, randomised, double-blind, placebo-controlled, multicentre trial with two parallel arms. The primary objective is to determine the efficacy of erythropoietin compared to placebo given add-on to methylprednisolone as assessed by measurements of RNFLT-G and low-contrast visual acuity in the affected eye 6 months after randomisation. Inclusion criteria are a first episode of optic neuritis with decreased visual acuity to ≤0.5 (decimal system) and an onset of symptoms within 10 days prior to inclusion. The most important exclusion criteria are history of optic neuritis or multiple sclerosis or any ocular disease (affected or non-affected eye), significant hyperopia, myopia or astigmatism, elevated blood pressure, thrombotic events or malignancy. After randomisation, patients either receive 33 000 international units human recombinant erythropoietin intravenously for 3 consecutive days or placebo (0.9% saline) administered intravenously. With an estimated power of 80%, the calculated sample size is 100 patients. The trial started in September 2014 with a planned recruitment period of 30 months. Ethics and dissemination TONE has been approved by the Central Ethics Commission in Freiburg (194/14) and the German Federal Institute for Drugs and Medical Devices (61-3910-4039831). It complies with the Declaration of Helsinki, local laws and ICH-GCP. Trial registration number NCT01962571.

Orbital Reconstruction: Prefabricated Implants, Data Transfer, and Revision Surgery

External impact to the orbit may cause a blowout or zygomatico-maxillary fractures. Diagnosis and treatment of orbital wall fractures are based on both physical examination and computed tomography scan of the orbit. Injuries of the orbit often require a reconstruction of its orbital walls. Using computer-assisted techniques, anatomically preformed orbital implants, and intraoperative imaging offers precise and predictable results of orbital reconstructions. Secondary reconstruction of the orbital cavity is challenging due to fractures healed in malposition, defects, scarring, and lack of anatomic landmarks, and should be avoided by precise primary reconstruction. The development of preformed orbital implants based on topographical analysis of the orbital cavity was a milestone for the improvement of primary orbital reconstruction.

Technique and Results for the Transconjunctival Removal of Orbital Haemangiomas

BACKGROUND: The cavernous haemangioma (cavernoma) is the most common orbital tumour in adults. Various surgical approaches have been described so far. We prefer a transconjunctival approach and analyse herein how our outcomes compare with those of transcutaneous or transosseous approaches. METHODS: A retrospective series of 10 cases was analysed with regard to surgical success and complications. RESULTS: The tumour could be completely removed in all cases. In one case, preoperative diplopia disappeared after surgery. Another case suffered from postoperative diplopia, which resolved within two months. Two cases developed a long-lasting partial tonic pupil. CONCLUSION: A retrobulbar cavernoma can be safely removed via a transconjunctival approach through shrinkage by coagulation and subsequent cryoextraction.

Sirolimus-induced regression of a large orbital lymphangioma

ABSTRACT Microcystic lymphatic malformations are difficult to treat surgically, especially when located in the orbital apex. Recently, pharmacologic inhibition of the mTOR pathway by sirolimus was reported as a safe and efficacious treatment option for lymphatic malformations (also known as lymphangiomas). We report the case of a young male patient in which a unilateral, retrobulbar lymphatic malformation regressed to a large extent under treatment with 1 mg sirolimus given orally twice a day over a period of six months.

Visual field defects following different resective procedures for mesiotemporal lobe epilepsy

INTRODUCTION One of the most common side effects of mesiotemporal lobe resection in patients with medically intractable epilepsy are visual field defects (VFD). While peripheral defects usually remain unnoticed by patients, extended VFD influence daily life activities and can, in particular, affect driving regulations. This study had been designed to evaluate frequency and extent of VFD following different surgical approaches to the mesiotemporal area with respect to the ability to drive. MATERIALS AND METHODS This study comprises a consecutive series of 366 patients operated at the Epilepsy Center in Freiburg for intractable mesiotemporal lobe epilepsy from 1998 to 2016. The following procedures were performed: standard anterior temporal lobectomy (ATL: n=134; 37%), anterior temporal or keyhole resection (KH: n=53; 15%), and selective amygdalohippocampectomy via the transsylvian (tsAHE: n=145; 40%) and the subtemporal (ssAHE: n=34; 9%) approach. Frequency and extent of postoperative VFD were evaluated in relation to different surgical procedures. According to the German driving guidelines, postoperative VFD were classified as driving-relevant VFD with the involvement of absolute, homonymous central scotoma within 20° and driving-irrelevant VFD with either none or exclusively minor VFD sparing the center. RESULTS Postoperative visual field examinations were available in 276 of 366 cases. Postoperative VFD were observed in 202 of 276 patients (73%) and were found to be driving-relevant in 133 of 276 patients (48%), whereas 69 patients (25%) showed VFD irrelevant for driving. Visual field defects were significantly less likely following ssAHE compared with other temporal resections, and if present, they were less frequently driving-relevant (p<0.05), irrespective of the side of surgery. CONCLUSION Subtemporal sAHE (ssAHE) caused significantly less frequently and less severely driving-relevant VFD compared with all other approaches to the temporal lobe, irrespective of the side of surgery.

[Induced Incomitance of one Muscle Strabismus Surgery in Comparison to Unilateral Recess-Resect Procedures].

BACKGROUND Surgical correction of intermediate squint angles may be performed on one muscle alone or as a combined unilateral recess-resect procedure. No larger case series has yet systematically measured the amount of induced incomitance that could potentially lead to visual disturbances. METHODS 31 patients with strabismus and binocular vision (phoria or intermittent strabismus) were operated on one extraocular eye muscle; 30 patients underwent a unilateral recess-resect procedure. Preoperatively and three months postoperatively, we measured the latent angle of squint on a tangent screen over the horizontal 60° in 10° increments and then calculated the amount of induced incomitance. RESULTS After one muscle surgery, the induced incomitance was 1.7° over a 20° gaze range, 3.2° over a 40° gaze range and 3.8° over a 60° gaze range. For recess-resect procedures, the induced incomitance was 1.4°, 2.6° and 3.4°, respectively. A significant correlation between the surgical dose and the induced incomitance was only seen in one muscle surgery for the 40° and 60° gaze range, but not for the 20° gaze range. A subgroup analysis of patients with an identical surgical dose in one and two muscle procedures (6-8 mm) found greater induced incomitance in one muscle procedures, but only for the 40° and 60° gaze range (p = 0.02). Double vision in any gaze direction was reported by 16 % of patients after one muscle surgery and 10 % of patients after unilateral recess-resect surgery (p > 0.05). CONCLUSION One muscle surgery is a viable option in small and intermediate angles of squint. The induced incomitance is rather small and does not lead to significant visual disturbances in the central gaze range.