A Jünemann

Universitätsklinikum Erlangen, Erlangen, Bavaria, Germany

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Publications (184)303.66 Total impact

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    ABSTRACT: Endothelial dysfunction and vascular dysregulation play a role in the multifactorial pathogenesis of glaucomatous optic nerve atrophy. Dyslipidaemia as a risk factor for endothelial dysfunction is associated with glaucoma and cardiovascular morbidity and mortality. In additional to a genetic disposition, a potential mechanism for the pathogenesis of endothelial dysfunction could be an additive effect of several risk factors, like dyslipidaemia, smoking, arterial hypertension, diabetes and hyperhomocysteinaemia. This paper reviews the literature concerning the association between dyslipidaemia and glaucomatous disease and explains the possible role of dyslipidaemia for the pathogenesis and progression of glaucoma. The role of exogeneous modifiable risk factors for prevention and therapy of glaucoma and their neutralisation by changing life style like weight reduction, modifications of nutrition and physical activity, are discussed.
    Klinische Monatsblatter fur Augenheilkunde. 09/2014;
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    ABSTRACT: The aim of the study was to evaluate the relationship between the area of isopters obtained using semi-automated kinetic perimetry (SKP) and Vigabatrin dosage in epilepsy patientswith pretreatment baseline examination during 2-years of the follow-up.
    BMC Ophthalmology 04/2014; 14(1):56. · 1.44 Impact Factor
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    ABSTRACT: To examine the influence of the cold pressor test (CPT) on steady-state-pattern electroretinograms (PERG) in normal subjects and glaucoma patients. Steady state PERGs to 7.8 Hz pattern reversal stimuli were recorded in 63 subjects. Fifteen healthy control subjects, 14 patients with ocular hypertension (OHT) and 34 patients with open-angle glaucoma (20 normotensive (NTG) and 14 high tension glaucoma (HTG)) were examined. Steady State PERG amplitudes and latencies were analysed at baseline, during cold stimulus using a modified cold pressure test and during the subsequent recovery phase. Blood pressure and heart rate were simultaneously recorded in 10 normals and 11 glaucoma patients. During the three test conditions (baseline, ice-water, warm-water) glaucoma patients (NTG and HTG) showed significantly reduced PERG amplitudes in comparison to control subjects (p<0.001) and to OHT patients (p<0.004). Patients with OHT displayed lower PERG amplitudes than control subjects (n.s., with consideration of Bonferroni). Only NTG patients showed a significant effect of the CPT on PERG amplitude (significant decrease during warm-water p=0.02). Latencies shortened significantly during warm-water period after cold stimulus in control subjects (p=0.05) and in NTG patients (p=0.02) with a non-significant trend of shortened latencies in the OHT (p=0.06) and HTG groups (p=0.3). Systolic and diastolic blood pressure increased during cold water (p < 0.001) and a decreased during warming up conditions (p < 0.001). This study shows that a cold pressure test influences the PERG responses particularly in NTG.
    Investigative ophthalmology & visual science 02/2014; · 3.43 Impact Factor
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    ABSTRACT: To study the changes in astigmatism after canaloplasty and to analyze its correlation with long-term intraocular pressure (IOP) results. Twenty-six eyes of 26 consecutive patients with primary open-angle glaucoma (n=14) and pseudoexfoliative glaucoma (n=12) undergoing canaloplasty were included in this retrospective study. Canaloplasty comprised of 360-degree catheterisation of Schlemm canal by means of a flexible microcatheter with distension of the canal by 2 tensioning 10-0 polypropylene sutures. Primary outcome measures included IOP, glaucoma medication usage, astigmatism, and adverse events at 2, 4, 12, and 24 weeks postoperatively. The mean preoperative IOP was 21.1±5.8 mm Hg. The mean IOP decreased to 14.25 ±4.3 mm Hg at 6 months. Mean astigmatism preoperatively was 0.77±0.5 D, which increased to 3.3±1.7 D at 2 weeks postoperatively (P≤0.05; Wilcoxon-test). Thereafter, the astigmatism underwent a spontaneous decline, reaching 1.9±0.8 D at 4 weeks and 1.2±0.74 D at 12 weeks postoperatively. Best-corrected visual acuity did not change significantly. Six months after canaloplasty, mean astigmatism reached the preoperative range of 0.86±0.52 D. Astigmatism at 2 weeks correlated significantly and inversely with IOP at 6 months (r=0.59, P=0.005; Spearman). The change of astigmatism after canaloplasty follows a clear time course with a maximum at 2 weeks reaching preoperative values at 6 months. The amount of surgically induced astigmatism might be helpful to predict outcome of canaloplasty in terms of IOP reduction.
    Journal of glaucoma 01/2014; 23(1):e53-9. · 1.74 Impact Factor
  • Julia M Weller, Georg Michelson, Anselm G Juenemann
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    ABSTRACT: This case report depicts the clinical course of a female patient with unilateral retinitis pigmentosa (RP), who presented first in 1984 at the age of 43 years. At the beginning, there were cells in the vitreous leading to the diagnosis of uveitis with vasculitis. Within 30 years, the complete clinical manifestation of RP developed with bone spicule-shaped pigment deposits, pale optic disc, narrowed arterioles, cystoid macular oedema, posterior subcapsular cataract, concentric narrowing of the visual field and undetectable electroretinogram signal. At the age of 72 years, there are still no signs of retinal dystrophy in the other eye.
    Case Reports 01/2014; 2014.
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    ABSTRACT: Introduction. We report a case of a male patient presented with sarcoid lesions of the iris and conjunctiva, mimicking tuberculosis due to epithelioid cell granulomas with small central necrosis in conjunctival biopsy. Patient. A 25-year-old man was referred to our department for further management of an "iris tumor with iridocyclitis" in his right eye. Initial examination showed an isolated vascular tumor of the iris and ciliary body with anterior uveitis and mutton-fat keratic precipitates, suggesting the diagnosis of a granulomatous disease. Conjunctival biopsy revealed granulomatous epithelioid cell inflammation with small central necrosis without acid-fast bacilli. Extensive systemic examination, including bronchoscopy and transbronchial biopsy, provided the diagnosis of sarcoidosis stage 2 with pulmonary involvement, thus ruling out tuberculosis. Systemic and local steroid therapy was initiated, leading to complete recovery of our patient with complete disappearance of the iris lesion and improvement of the pulmonary function. Conclusion. Although noncaseating epithelioid cell granulomas are typical for sarcoidosis, small central necrosis can be found in some granulomas, leading to presumption of tuberculosis. Extensive systemic checkup in cooperation with other specialists is essential to confirm the correct diagnosis and to initiate the appropriate therapy.
    Journal of Ophthalmology 01/2014; 2014:656042. · 1.37 Impact Factor
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    ABSTRACT: Purpose: To compare the results of Flicker Defined Form (FDF)-perimetry with standard automated perimetry (SAP) and retinal nerve-fiber-layer (RNFL) thickness measurements using spectral domain OCT. Methods: 64 healthy subjects, 45 ocular hypertensive patients, and 97 'early' open-angle glaucoma (OAG) patients participated in this study. Definition of glaucoma was exclusively based on glaucomatous optic disc appearance. All subjects underwent FDF-perimetry, SAP and peripapillar measurements of the RNFL thickness. FDF-perimetry and SAP were performed at identical test locations (G1 protocol). Exclusion criteria were: subjects younger than 34 years, SAP-MD > 5 dB, eye diseases other than glaucoma, or non-reliable FDF-measurements. The correlations between the perimetric data on the one hand and RNFL thicknesses on the other hand were statistically analyzed. Results: The age corrected sensitivity values and the local results from the controls were used to determine FDF mean-defect (FDF-MD). FDF-perimetry and SAP showed high concordance in this cohort of experienced patients (MD-values: R=-0.69, P <0.001). 38 of in total 42 OAG-patients with abnormal SAP-MD also displayed abnormal FDF-MD. However, FDF-MD was abnormal in 28 out of 55 OAG-patients with normal SAP-MD. FDF-MD was significantly (R=-0.61, P <0.001) correlated with RNFL-thickness with a (non-significantly) larger correlation coefficient than conventional SAP-MD (R=-0.48, P <0.001). Conclusion: FDF-perimetry is able to uncover functional changes concurrent with the changes in RNFL thickness. FDF-perimetry may be an efficient functional test to detect early glaucomatous nerve atrophy.
    Investigative ophthalmology & visual science 12/2013; · 3.43 Impact Factor
  • A G M Jünemann, C Huchzermeyer, R Rejdak
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    ABSTRACT: The prospective multicenter randomized controlled clinical trials (RCTs) Ocular Hypertension Glaucoma Treatment Study (OHTS), Early Manifest Glaucoma Trial (EMGT), Advanced Glaucoma Intervention Study (AGIS), Collaborative Initial Glaucoma Treatment Study (CITGS) and Collaborative Normal Tension Glaucoma Study (CNGTS) are often named as landmarks for glaucoma management as the results of these studies provided the evidence for numerous therapeutic decisions in clinical practice. The studies confirmed the consensus that reduction of intraocular pressure reduces the risk of glaucoma progression covering the whole spectrum of glaucoma from ocular hypertension to advanced glaucoma. Furthermore, the identification of new risk factors allows a higher precision of assessment of the risk of progression. The RCTs achieved the main goal of high level of evidence, thus making progress in the understanding of glaucoma and its treatment and bridging consensus-based and evidence-based decisions. However, the implementation of the results into clinical practice needs adequate and accurate interpretation of the results.
    Der Ophthalmologe 12/2013; 110(12):1134-1148. · 0.53 Impact Factor
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    ABSTRACT: The purpose of this study was to analyze if anterior chamber parameters are risk factors for the development of pigment dispersion syndrome (PDS) and/or for the conversion to pigmentary glaucoma (PG). This study included a total of 63 eyes from 35 patients with PDS and PG and 65 eyes from 49 unaffected volunteers as the control group. The following parameters were measured by slit lamp optical coherence tomography (SL-OCT): anterior chamber volume (ACV) and depth (ACD), angle opening distance (AOD) and the trabecular iris space area (TISA) at 500 µm and 750 μm from the scleral spur. Comparisons between the following groups were performed: between the PDS/PG and the control group, between PDS and PG and between male and female patients. The results of ACV, ACD, AOD and TISA were significantly higher in PDS/PG patients when compared to the control group. There were no significant differences between PDS and PG. The gender-specific comparison also showed no significant differences. Significantly higher anterior chamber parameters are a possible risk factor for development of PDS; however, a higher risk of conversion to PG does not seem to correlate with increased anterior chamber parameters. The parameters of the anterior chamber are apparently not associated with the male predominance of PDS and PG.
    Der Ophthalmologe 09/2013; · 0.53 Impact Factor
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    ABSTRACT: Purpose. To compare the longitudinal loss of RNFL thickness measurements by SD-OCT in normals and glaucoma patients with or without progression concerning optic disc morphology. Methods. 62 eyes, comprising 38 glaucomatous eyes with open angle glaucoma and 24 healthy controls, were included in the study (Erlangen Glaucoma Registry, NTC00494923). All patients were investigated annually over a period of three years by Spectralis SD-OCT measuring peripapillary RNFL thickness. By masked comparative analysis of photographs the eyes were classified into non-progressive and progressive glaucoma cases. Longitudinal loss of RNFL thickness was compared to morphological changes of optic disc morphology. Results. Mixed model analysis of annual OCT scans revealed an estimated annual decrease of the RNFL thickness by 2.12 µm in glaucoma eyes with progression, whereas glaucoma eyes without progression in optic disc morphology lost 1.18 µm per year in RNFL thickness (p = 0.002). The rate of change in healthy eyes was 0.60 µm and thereby also significantly lower than in glaucoma eyes with progression (p < 0.001). The intrasession variability of three successive measurements without head repositioning was 1.5 +- 0.7 µm. The loss of mean RNFL thickness exceeded the intrasession variability in 60% of non-progressive eyes, and in 85 % of progressive eyes after three years. Conclusions. Longitudinal measurements of RNFL thickness using SD-OCT show a more pronounced reduction of RNFL thickness in patients with progression compared to patients without progression in glaucomatous optic disc changes.
    Investigative ophthalmology & visual science 04/2013; · 3.43 Impact Factor
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    ABSTRACT: Trace elements might play a role in the complex multifactorial pathogenesis of age-related macular degeneration (AMD). The aim of this study was to measure alterations of trace elements levels in aqueous humor of patients with non-exsudative (dry) AMD.For this pilot study, aqueous humor samples were collected from patients undergoing cataract surgery. 12 patients with dry AMD (age 77.9±6.62, female 8, male 4) and 11 patients without AMD (age 66.6±16.7, female 7, male 4) were included. Aqueous levels of cadmium, cobalt, copper, iron, manganese, selenium, and zinc were measured by use of Flow-Injection-Inductively-Coupled-Plasma-Mass-Spectrometry (FI-ICP-MS), quality controlled with certified standards.PATIENTS WITH AMD HAD SIGNIFICANTLY HIGHER AQUEOUS HUMOR LEVELS OF CADMIUM (MEDIAN: 0.70 µmol/L, IQR: 0.40-0.84 vs. 0.06 µmol/L; IQR: 0.01-.018; p = 0.002), cobalt (median: 3.1 µmol/L, IQR: 2.62-3.15 vs. 1.17 µmol/L; IQR: 0.95-1.27; p<0.001), iron (median: 311 µmol/L, IQR: 289-329 vs. 129 µmol/L; IQR: 111-145; p<0.001) and zinc (median: 23.1 µmol/L, IQR: 12.9-32.6 vs. 5.1 µmol/L; IQR: 4.4-9.4; p = 0.020) when compared with patients without AMD. Copper levels were significantly reduced in patients with AMD (median: 16.2 µmol/L, IQR: 11.4-31.3 vs. 49.9 µmol/L; IQR: 32.0-.142.0; p = 0.022) when compared to those without. No significant differences were observed in aqueous humor levels of manganese and selenium between patients with and without AMD. After an adjustment for multiple testing, cadmium, cobalt, copper and iron remained a significant factor in GLM models (adjusted for age and gender of the patients) for AMD.Alterations of trace element levels support the hypothesis that cadmium, cobalt, iron, and copper are involved in the pathogenesis of AMD.
    PLoS ONE 01/2013; 8(2):e56734. · 3.53 Impact Factor
  • A G M Jünemann
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    ABSTRACT: Pseudoexfoliation (PEX) glaucoma is the most frequent and most important type of secondary glaucoma, accounting for approximately 25% of open angle glaucoma worldwide and currently representing the most common identifiable cause of glaucoma overall. Due to high intraocular pressure levels, marked diurnal pressure fluctuations and spikes, and rapid optic nerve damage and visual field loss, PEX glaucoma represents a relatively severe and progressive type of glaucoma. Therefore, hard and fast lowering of intraocular pressure is necessary. Fixed combinations in medical therapy and early glaucoma surgery are recommended. When considering a surgical procedure (e.g. selective laser trabeculoplasty, bleb-dependent or bleb-independent surgery) the timing of cataract surgery plays a major role. Pathogenesis, clinical characteristics and therapeutic aspects of PEX glaucoma are described in the following article.
    Der Ophthalmologe 10/2012; 109(10):962-75. · 0.53 Impact Factor
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    ABSTRACT: There are many controversies among ophthalmologists and obstetricians regarding indications for caesarean section due to preexisting eye diseases. Many ophthalmologists still believe myopia, retinal detachment, glaucoma or diabetic retinopathy to be indications for a caesarean section. There is a discrepancy between clinical practice and evidence-based medicine, as none of the published trials have reported any retinal changes after vaginal delivery This report provides information on the influence of physiological changes on eye diseases during the final stage of the delivery. We conclude that an eye disease is not an indication for a caesarean section.
    Ginekologia polska 08/2012; 83(8):613-7. · 0.79 Impact Factor
  • A G M Jünemann, N Sterk, R Rejdak
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    ABSTRACT: Many ophthalmologists and obstetricians recommend either an assisted vaginal delivery with forceps or vacuum extraction, or a Caesarean section in cases of pre-existing eye diseases, such as myopia, retinal detachment, glaucoma or diabetic retinopathy. This is mainly based on the increase of intraocular pressure during the final stage of labor. These recommendations, however, are not evidence-based. None of the published trials have reported any retinal changes after vaginal delivery. This report provides information on the influence of physiological changes on eye diseases during the final stage of delivery. In general eye disease is not an indication for an instrumental or operative delivery provided regular eye examinations (once each trimester) have been performed.
    Der Ophthalmologe 03/2012; 109(3):229-34. · 0.53 Impact Factor
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    ABSTRACT: This paper documents a rare nonprogressive developmental disorder-bilateral circumscribed posterior keratoconus-in a 60-year-old man referred for a cataract surgery. For the first time ultrasound biomicroscopy was used to visualise the local anterior bulging of the posterior corneal surface with concomitant thinning of the stroma. The amount of localized posterior depression, corneal thickness and the refractive power of both the posterior and anterior corneal curvature were measured using slit-scanning topography analysis (Orbscan).
    Journal of Ophthalmology 01/2012; 2012:587075. · 1.37 Impact Factor
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    ABSTRACT: Vascular endothelial growth factor (VEGF) plays an important role in the pathogenesis of choroidal and retinal neovascularization. Anti-VEGF therapy changed the standard-of-care for ocular disease with neovascularisation. This article presents one promising new drug--VEGF Trap-Eye--and results of clinical trials evaluating its efficacy in the treatment of wet age-related macular degeneration, central retinal vain occlusion, diabetic macular edema and choroidal neovascularization secondary to pathologic myopia.
    Klinika oczna 01/2012; 114(4):308-10.
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    ABSTRACT: Background: Due to the slow progression of the Glaucoma disease, a large study population and long-time observations are needed to gain insights into its long-term effects and progression rates. Since modalities can export data in machine-readable formats, statistical analyses of the large number of examinations is feasible. These data have been integrated in a central patient registry, the Erlangen Glaucoma Registry (EGR). Objectives: The primary focus of the EGR system design has been its fitness for analyses. It holds almost all the available research data for registered glaucoma patients. This allows for cross-sectional and longitudinal observations and for evaluation of prognostic validity of diagnostic procedures. Methods: An adequate technology for integration of data and flexibility in data analysis is a database management system (DBMS). Here, a careful schema design is mandatory. Adding new modalities leads to schema modifications which are supported by defining a core database schema and attaching all data to this core. On that basis, a large number of modalities have been connected to the EGR. Results: The registry contains data of 1,400 patients in the main longitudinal study. It has successfully helped in scientific research, as can be seen in a large number of published papers. For example, validation of new sensory physiological methods requires patients with reliable diagnoses. The existence of a well-documented patient collective facilitated finding such patients. Conclusions: The EGR holds a unique amount of available data gathered in large longitudinal studies. It was successful in terms of medical results obtained. Developed as an evolutionary system, it can easily be extended.
    Technical reports / Dep. Informatik (ISSN 2191-5008). 01/2012; CS-2011,2.
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    ABSTRACT: There is evidence that multifocal visual evoked potentials (VEPs) can be used as an objective tool to detect visual field loss. The aim of this study was to correlate multifocal VEP amplitudes with standard perimetry data and retinal nerve fibre layer (RNFL) thickness. Multifocal VEP recordings were performed with a four-channel electrode array using 58 stimulus fields (pattern reversal dartboard). For each field, the recording from the channel with maximal signal-to-noise ratio (SNR) was retained, resulting in an SNR optimised virtual recording. Correlation with RNFL thickness, measured with spectral domain optical coherence tomography and with standard perimetry, was performed for nerve fibre bundle related areas. The mean amplitudes in nerve fibre related areas were smaller in glaucoma patients than in normal subjects. The differences between both groups were most significant in mid-peripheral areas. Amplitudes in these areas were significantly correlated with corresponding RNFL thickness (Spearman R=0.76) and with standard perimetry (R=0.71). The multifocal VEP amplitude was correlated with perimetric visual field data and the RNFL thickness of the corresponding regions. This method of SNR optimisation is useful for extracting data from recordings and may be appropriate for objective assessment of visual function at different locations. This study has been registered at http://www.clinicaltrials.gov (NCT00494923).
    The British journal of ophthalmology 11/2011; 96(4):554-9. · 2.92 Impact Factor
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    ABSTRACT: PURPOSE:: To investigate the impact of typical scan score (TSS) on discriminating glaucomatous and healthy eyes by scanning laser polarimetry and spectral domain optical coherence tomography (SD-OCT) in 32 peripapillary sectors. PATIENTS AND METHODS:: One hundred two glaucoma patients and 32 healthy controls underwent standard automated perimetry, 24-hour intraocular pressure profile, optic disc photography, GDxVCC, and SD-OCT measurements. For controls, only very typical scans (TSS=100) were accepted. Glaucoma patients were divided into 3 subgroups (very typical: TSS=100; typical: 99≥TSS≥80, atypical: TSS<80). Receiver operating characteristic curves were constructed for mean retinal nerve fiber layer values, sector data, and nerve fiber indicator (NFI). Sensitivity was estimated at ≥90% specificity to compare the discriminating ability of each imaging modality. RESULTS:: For discrimination between healthy and glaucomatous eyes with very typical scans, the NFI and inferior sector analyses 26 to 27 demonstrated the highest sensitivity at ≥90% specificity in GDxVCC and SD-OCT, respectively. For the typical and atypical groups, sensitivity at ≥90% specificity decreased for all 32 peripapillary sectors on an average by 10.9% and 17.9% for GDxVCC and by 4.9% and 0.8% for SD-OCT. For GDxVCC, diagnostic performance of peripapillary sectors decreased with lower TSS, especially in temporosuperior and inferotemporal sectors (sensitivity at ≥90% specificity decreased by 55.3% and by 37.8% in the atypical group). CONCLUSIONS:: Diagnostic accuracy is comparable for SD-OCT and GDxVCC if typical scans (TSS=100) are investigated. Decreasing TSS is associated with a decrease in diagnostic accuracy for discriminating healthy and glaucomatous eyes by scanning laser polarimetry. NFI is less influenced than the global or sector retinal nerve fiber layer thickness. The TSS score should be included in the standard printout. Diagnostic accuracy of SD-OCT is barely influenced by low TSS.
    Journal of glaucoma 10/2011; · 1.74 Impact Factor
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    ABSTRACT: Pseudoexfoliation (PEX) syndrome/glaucoma is a complex, late-onset disorder of the elastic fiber system. Strong genetic risk is conferred by the lysyl oxidase-like 1 (LOXL1) gene, but additional comodulating factors are necessary for the manifestation of the disease. The aim of this study was to analyze the effect of various PEX-associated pathogenic factors on the genotype-correlated expression of LOXL1 and elastin-related genes. Cultured human Tenon's capsule fibroblasts with high- and low-risk LOXL1 haplotypes were exposed to transforming growth factor (TGF)-β1, interleukin (IL)-6, homocysteine, oxidative stress, hypoxia, or ultraviolet (UV) radiation. Changes in the expression of LOXL1 and elastic constituents of PEX material and TGF-β1 were assessed by quantitative real-time PCR, Western blotting, immunohistochemistry, and electron microscopy. Treatment of fibroblasts with TGF-β1, oxidative stress, UV light, and hypoxia induced a significant increase in expression levels of LOXL1 and elastic proteins, whereas the effect of IL-6 was limited to induction of elastic constituents. Immunohistochemistry and electron microscopy confirmed an upregulation of LOXL1 and elastic fiber proteins and their assembly into extracellular microfibrillar networks with focal aggregation of microfibrils into PEX-like fibrils on stimulation with TGF-β1 and oxidative stress. Basal and stimulated expression of LOXL1 mRNA and protein was slightly decreased in cells carrying the high-risk compared with the low-risk haplotype of LOXL1, but the differences between groups were statistically not significant. The findings support the notion that both genetic and nongenetic fibrogenic factors, particularly TGF-β1 and oxidative stress, may cooperate in the stable accumulation of PEX aggregates.
    Investigative ophthalmology & visual science 09/2011; 52(11):8488-95. · 3.43 Impact Factor

Publication Stats

1k Citations
303.66 Total Impact Points

Institutions

  • 2000–2014
    • Universitätsklinikum Erlangen
      • Department of Ophthalmology
      Erlangen, Bavaria, Germany
  • 1991–2013
    • Friedrich-Alexander Universität Erlangen-Nürnberg
      • Department of Ophthalmology
      Erlangen, Bavaria, Germany
  • 2009–2012
    • Medical University of Lublin
      • Department of Ophthalmology
      Lublin, Lublin Voivodeship, Poland
    • Universität Ulm
      Ulm, Baden-Württemberg, Germany
  • 2005–2010
    • Universität Heidelberg
      • Faculty of Medicine Mannheim and Clinic Mannheim
      Heidelberg, Baden-Wuerttemberg, Germany
  • 2006
    • Medical University of Sofia
      • Department of Ophthalmology
      Ulpia Serdica, Sofia-Capital, Bulgaria
  • 2003
    • Freie Universität Berlin
      • Division of Medical Informatics
      Berlin, Land Berlin, Germany