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ZusammenfassungIn diesem Artikel sollen die Grundlagen zur Verwendung intraokularer Tamponaden in der Glaskörper-/Netzhautchirurgie bei Ablatio retinae und anderen Pathologien anhand zusätzlichen Videomaterials anschaulich dargestellt werden. Behandelt werden die verschiedenen Gase, Silikonöle und flüssigen Perfluorocarbone mit ihren Indikationen, ihrer Anwendung und insbesondere der intraoperativen Handhabung mit Fallstricken und Komplikationen. Charakteristische Animationen zeigen dabei nachvollziehbar die Prinzipien in der chirurgischen Handhabung. Seitens der beiden Erstautoren ist dieser Artikel ihrem Lehrer Herrn Prof. Dr. V.-P. Gabel gewidmet, der in den frühen 90er-Jahren die ersten Vitrektomiekurse für Augenärzte an der Universitäts-Augenklinik Regensburg erfolgreich im jährlichen Rhythmus etabliert hat und in denen viele heute noch netzhautchirurgisch tätige Kolleginnen und Kollegen ihre ersten Schritte in diesem Segment erlernt haben. Die weiteren Co-Autoren partizipierten unter seiner Leitung an jährlichen Vitrektomie-Wetlabs im Rahmen der Augenärztlichen Akademie Deutschlands.

Inherited retinal diseases can result from various genetic defects and are one of the leading causes for blindness in the working-age population. The present study aims to provide a comprehensive description of changes in retinal structure associated with phenotypic disease entities and underlying genetic mutations. Full macular spectral domain optical coherence tomography scans were obtained and manually segmented in 16 patients with retinitis pigmentosa, 7 patients with cone–rod dystrophy, and 7 patients with Stargardt disease, as well as 23 age- and sex-matched controls without retinal disease, to assess retinal layer thicknesses. As indicated by generalized least squares models, all IRDs were associated with retinal thinning (p < 0.001), especially of the outer nuclear layer (ONL, p < 0.001). Except for the retinal nerve fiber layer, such thinning was associated with a reduced visual acuity (p < 0.001). These advances in our understanding of ultrastructural retinal changes are important for the development of gene-, cell-, and optogenetic therapy. Longitudinal studies are warranted to describe the temporal component of those changes.

This article describes the development of decreased intraocular pressure (IOP) under general anesthesia with medetomidine, midazolam, and fentanyl in mice with normal and elevated IOP.IOP was measured using the iCare Tonolab rebound tonometer. Twelve 3-4 months-old male and female C57BL/6J mice were randomized to a control group with physiological IOP and a high IOP group with experimentally induced ocular hypertension using tarsal injections of dexamethasone-21-acetate. For anesthesia, medetomidine and midazolam were used, subgroups additionally received fentanyl. IOP was measured every 2.5 min for 30 min.Control group differed with 14.89 mmHg (SEM: 0.58) significantly (In mice, general anesthesia with medetomidine and midazolam leads to a declining IOP over time. Adding fentanyl to the anesthesia did not alter these effects. The decline is time-dependent and IOP-dependent.

Background: Patients with Sjögren’s syndrome and polyneuropathy more frequently develop cranial nerve affection when compared to patients with chronic inflammatory demyelinating polyneuropathy (CIDP). We therefore aimed to analyze trigeminal corneal nerve fibre characteristics in both patient groups. Methods: A total of 26 patients with Sjögren’s syndrome associated neuropathy and 29 patients with CIDP were recruited at our university hospital and compared to 6 healthy controls. Dry eye symptoms and signs were assessed via clinical examination and the Ocular Disease Surface Index questionnaire. Trigeminal corneal nerve fibres were analyzed via corneal confocal microscopy (CCM) as a non-invasive in vivo microscopy. Results: CCM revealed significantly reduced corneal nerve fibre density and corneal nerve fibre main branch density in the Neuro-Sjögren group when compared with healthy controls. There were no significant group differences between the Neuro-Sjögren and the CIDP group for any of the microscopic parameters. Dry eye assessment showed similarly reduced scores for both patient groups, while healthy controls showed better results for objective dry eye signs. There was no correlation between microscopic parameters of the corneal confocal microscopy and parameters of dry eye assessment. Conclusions: Our data revealed trigeminal corneal nerve affection in patients with neuropathy associated with Sjögren’s syndrome and patients with CIDP detected by CCM. No difference was found between both neuropathy groups indicating that CCM is not able to distinguish between both entities.

Ziel: In der vorliegenden Arbeit berichten wir über den Fall einer jungen Frau mit postinfektiösem Auftreten einer Myasthenia gravis nach einer COVID-19-Infektion mit leichten respiratorischen Symptomen und Anosmie/Ageusie einen Monat vor der Aufnahme in unsere neurologische Abteilung. Methoden: Die Patientendaten stammten aus den Krankenakten der Medizinischen Hochschule Hannover. Die schriftliche Einverständniserklärung der Patientin lag vor. Ergebnisse: Die 21-jährige Patientin stellte sich mit subakut aufgetretenen, vertikal versetzten Doppelbildern infolge einer rechtsseitigen partiellen Nervus-okulomotorius-Parese und Ptosis vor. Etwa vier Wochen zuvor waren leichte respiratorische Symptome, Kopf- und Gliederschmerzen ohne Fieber sowie eine Anosmie/Ageusie aufgetreten. Bereits während der etwa zehn Tage anhaltenden letztgenannten Symptome hatte die Patientin «müde Augen» und fluktuierende Doppelbilder bemerkt. Die klinische Untersuchung einschließlich eines positiven Tests mit Edrophoniumchlorid und der Nachweis erhöhter Acetylcholinrezeptor-Antikörpern deuteten auf einen ätiologischen Zusammenhang mit der okulären Manifestation einer Myasthenia gravis hin. Mit drei verschiedenen serologischen Tests (Abbott, DiaSorin, Euroimmun) wurden Antikörper (IgA/IgG) gegen SARS-CoV-2 im Serum nachgewiesen, was für dieses spezifische Coronavirus als Erreger der vorausgegangenen Infektion bei dieser Patientin spricht. Durch Gabe von intravenösen Immunglobulinen und oralem Pyridostigmin wurde das myasthene Syndrom erfolgreich behandelt. Schlussfolgerung: Dies ist der erste Fallbericht über eine postinfektiöse Myasthenia gravis als neurologische Komplikation bei einer COVID-19-Patientin.

Zusammenfassung Hintergrund Strabologische Operationen werden häufig in universitären Zentren durchgeführt. Ziel dieser Arbeit ist es, die Kosten dieser chirurgischen Leistung an einer Universitätsklinik zu ermitteln und die Kostenkompensation für den ambulanten Bereich zu überprüfen. Material und Methode Von allen Strabismusoperationen an der Medizinischen Hochschule Hannover wurden in den Jahren 2018 und 2019 relevante OP-Daten wie Alter des Patienten, Anzahl der operierten Muskeln, Schnitt-Naht-Zeit, Präsenzzeiten der Chirurgen und Anästhesisten sowie der entsprechenden Funktionsdienste auf Basis des klinikeigenen Informationssystems evaluiert. Im Rahmen einer Kostenträgerrechnung wurden dabei die Kosten für Personal, Material, Raummiete und Overhead kalkuliert. Ergebnisse Insgesamt wurden 302 Operationen (stationärer Anteil: 92,1 %) bis auf wenige Ausnahmen unter Vollnarkose durchgeführt. Das mittlere Alter der Patienten betrug 31 Jahre (Median: 26 Jahre), wobei 33 Patienten Kinder unter 6 Jahren waren. Im Mittel wurden 1,84 Muskeln pro Eingriff operiert. Die mittlere Schnitt-Naht-Zeit betrug 51,5 min, die mittlere Anästhesiezeit 85 min, die Präsenzzeit des Funktionsdienstes OP und auch die des Funktionsdienstes Anästhesie belief sich auf jeweils 104 min, die zusätzliche Aufwachraumzeit auf 66 min. Die am Gesamtprozess durchschnittlich entstandenen Personalkosten summierten sich auf 642,14 € zuzüglich durchschnittlich 109,23 € Material‑/Medikamentenkosten (Operation und Anästhesie) sowie Reinigung und Raumkosten (inklusive Infrastrukturkosten) von 178,71 €. Somit betrugen die Gesamtkosten einer durchschnittlichen strabologischen OP in unserem Kollektiv 930,08 € (Minimum: 491,01 €, Maximum: 1729,29 €). Kostenkalkulationen von Untergruppen ergaben aufgrund unterschiedlicher Behandlungszeiten (37 min für 1 Muskel bis 72 min für 3 und mehr Muskeln) respektive Anästhesiezeiten insbesondere bei Kindern 5 Jahren; Differenz 11 min [1 Muskel], 25 min [2 Muskeln] und 30 min [3 und mehr Muskeln]) deutlich höhere Kosten bei Kindernarkosen und einer höheren Anzahl operierter Muskeln. Das reine Kostenniveau einer Strabismusoperation an unserer Klinik erscheint durchschnittlich um den Faktor 2 höher als das Entgelt, welches für Strabismusoperationen über EBM (einheitlicher Bewertungsmaßstab) im ambulanten Bereich erlöst wird. Schlussfolgerungen Die rein betriebswirtschaftlich errechneten Kosten für strabologische Operationen an einer Universitätsklinik sind signifikant höher als die im ambulanten Bereich nach Paragraf 115b, Absatz 1, SGB V aktuell zu erzielenden Erlöse. Unter diesen Bedingungen können solche Operationen ambulant nicht kostendeckend erbracht werden.

Zusammenfassung Hintergrund Im Bereich des Pflegedienstes wurden und werden Mindestpersonalbemessungen gefordert und umgesetzt. Die Bundesärztekammer hat die Deutschen Fachgesellschaften im Dezember 2019 nach ihren Erfahrungen zu Personalvorgaben für Ärztinnen und Ärzte im Krankenhaus befragt. Da hierzu in der Augenheilkunde bislang keine strukturiert erhobenen Daten vorlagen, gründete die DOG im März 2020 einen Arbeitskreis zur Bearbeitung dieser Anfrage. Methode Im Rahmen mehrerer Abstimmungsrunden erstellte der „Arbeitskreis Personalvorgaben für Ärztinnen und Ärzte im Krankenhaus“ der DOG einen Fragebogen zu den bisherigen Erfahrungen in der Personalausstattung und -planung von Augenkliniken, der im Mai 2020 an die Chefärzte und Direktoren aller deutschen Universitätsaugenkliniken und Hauptabteilungen für Augenheilkunde verschickt wurde. Der Fragenbogen beinhaltete Einzelfragen mit vorgegebenen und freien Antwortmöglichkeiten zur Vorgehensweise und Ist-Situation bei der Personalausstattung sowie zum Aufgaben- und Organisationsspektrum des Ärztlichen Dienstes der Abteilungen. Ergebnisse Von 104 angeschriebenen Leitern von Hauptabteilungen antworteten 53 (51 %). Davon entfielen 25 Antworten auf universitäre Abteilungen (64 % Antwortquote), 23 auf Abteilungen von öffentlichen oder frei-gemeinnützigen Trägern (46 %) und 5 auf private Klinikträger (33 %); 49 % gaben an, dass es keine transparente Berechnungsgrundlage der Anzahl ärztlichen Stellen ihrer Klinik gibt. Nur bei 47 % der befragten Abteilungen werden die ambulanten Aufgaben, Leistungen und Erlöse im Stellenschlüssel berücksichtigt. Es zeigte sich ein statistisch signifikant höheres Verhältnis an Vollzeitkräften pro Bettenanzahl in den Universitätsaugenkliniken gegenüber den privaten und öffentlich/frei-gemeinnützig geführten Augenkliniken (p Schlussfolgerung Das Ergebnis zeigt, wie heterogen und intransparent die Personalbemessung in den deutschen Hauptabteilungen für Augenheilkunde festgelegt wird. Die universitären Abteilungen haben im Schnitt höhere Personalressourcen in Bezug auf die Bettenkapazität für die Bewältigung zusätzlicher Aufgaben in Forschung und Lehre. In der Personalberechnung werden vielfältige Aufgaben, darunter auch ambulante Aufgaben, die deutlich zum Erlös einer Augenklinik beitragen, oft nicht berücksichtigt. Eine transparente und einheitliche Berechnungsgrundlage für das ärztliche Personal der Abteilungen ist zukünftig wichtig, um eine ausreichende Personalausstattung für ein patienten- und mitarbeiterorientiertes Arbeitsumfeld zu gewährleisten.

Purpose To evaluate the relationship between macular pigment optical density (MPOD) and glaucoma. Methods Forty-three patients with an established glaucoma diagnosis (25 females, 18 males, mean age 70 (range 34-84)) and 43 healthy controls (28 females, 15 males, mean age 62 (range 30-87)) were included in this prospective diagnostic case-control study. All subjects underwent detailed eye examination including ophthalmoscopy, best-corrected visual acuity, biomicroscopy, measurement of the axial length of the eye, objective refraction, lens status, central foveal thickness on spectral-domain optical coherence tomography (SD-OCT). In all glaucoma patients, a visual field assessment and a measurement of the retinal nerve fibre layer (RNFL) on SD-OCT were done. MPOD was determined using the macula pigment module of the Spectralis HRA+OCT (Heidelberg Engineering GmbH, Heidelberg, Germany) at 0.51°, 1.02° and 1.99° retinal eccentricity using two-wavelength autofluorescence imaging. Results In the glaucoma group, the median of the visual field mean defect was 5.1 db (quartiles 3.0 and 13.5) and the mean RNFL-thickness global was 65.9 µm (SD ± 16.1). Median MPOD measured at 0.51°, 1.02° and 1.99° retinal eccentricity in the glaucoma group was 0.42 DU, 0.34 DU and 0.13 DU, in the control group 0.40 DU, 0.35 DU and 0.12 DU respectively. There was no statistically significant difference of median MPOD between glaucomatous and control eyes (p=0.510, 0.735, 0.481). No significant relation between MPOD at 1.02 retinal eccentricity and the presence of glare symptoms was found (p=0.948). However, age seems to correlate with median MPOD measured at 1.02 retinal eccentricity (p=0.017). Conclusion There was no evidence for lower MPOD levels in our glaucoma patients; lower MPOD was not related to the presence of glare symptoms. However there seems to be a positive correlation between age and MPOD at 1.02° retinal eccentricity. To further investigate the relation between glare reported by glaucoma patients and glare disability linked to lower MPOD levels, additional studies are necessary that include both detailed inquiry of the quality of glare and a glare quantification and precise analysis of MPOD levels in glaucoma patients.

Zusammenfassung Hintergrund Die Medien berichten über die erhöhte Gewaltbereitschaft von Patienten sowie Angehörigen gegenüber medizinischem Personal. Bislang wurden wenige Untersuchungen zu diesem Thema durchgeführt, entsprechend schwach ist die Datenlage. Gerade Augenärzte haben an der Spaltlampe engen Kontakt zum Patienten und sind oft mit Patienten allein. Methodik Auf Grundlage der Aggressions-Wahrnehmungsskala (POPAS Fragebogen, Oud 2000) sowie der Umfrage zu Aggressionen und Gewalt unter Allgemeinmedizinern (Vorderwülbecke et al. 2015) wurde ein Fragebogen entwickelt. Im Herbst 2018 erhielten alle Mitglieder der Deutschen Ophthalmologischen Gesellschaft (DOG) und des Berufsverbandes der Augenärzte (BVA) per Mail eine Einladung, um den Fragebogen online auszufüllen. Ergebnisse Von 9411 angeschriebenen Augenärzten nahmen insgesamt 1508 (Alter: 49 ± 12 Jahre) an der Befragung teil (16 %). 806 (53,7 %) Befragte waren weiblich. 1139 (75,5 %) Teilnehmer arbeiteten in Praxen. Insgesamt 1264 (83,3 %) der Augenärzte hatten Aggressionen/Gewalt in ihrer Tätigkeit erfahren. 986 (65 %) Befragte hatten verbale Übergriffe ohne Drohung erlebt. Von bedrohlich körperlichen Gewalterfahrungen berichteten 363 (24,1 %) Ärzte. 30 (2 %) Teilnehmer erhielten aufgrund schwerer körperlicher Gewalt eine ärztliche Behandlung. Sexuelle Einschüchterung/Belästigung bejahten 322 (21,4 %) der Befragten, von diesen waren 243 (75,5 %) weiblich. 533 (47,9 %) Ärzte empfanden, dass aggressive/gewalttätige Verhaltensweisen in den letzten 5 Jahren zugenommen haben. Schlussfolgerung Die hohe Teilnehmeranzahl weist auf die hohe Relevanz des Themas hin. Die Umfrage hat erstaunliche Ergebnisse geliefert, die weitere Diskussionen und Handlungen zur Folge haben sollten, um die Sicherheit der Mitarbeiter zu verbessern.

Even in the era of intravitreal injection therapy (intravitreal operative injection of medication, IVOM) for the treatment of macular and retinal diseases, such as age-related macular degeneration (AMD), proliferative diabetic retinopathy (DR) and diabetic macular edema (DME) as well as proliferative stages and/or macular edema due to retinal vein occlusion (RVO), conventional retinal laser treatment is still of importance. It can be focally performed on an on-label basis for DME and macular edema due to branch RVO (BRVO) and its use as panretinal treatment for proliferative stages in retinal diseases as well as for the treatment of retinal holes is undisputed. The spectrum is extended by the treatment of less common diseases, such as retinal hemangioblastoma, macroaneurysms and subhyaloid macular hemorrhage. There is cause for concern that knowledge about the correct performance of retinal laser application might be shifted into the background due to an increase of IVOM treatment, which could lead to an increase in unnecessary errors. The aim of this manuscript is to increase awareness for the correct indications and execution of retinal laser treatment based on case examples of flawed or insufficient treatment.

Autosomal recessive bestrophinopathy (ARB) has been reported as clinically heterogeneous. Eighteen patients (mean age: 22.5 years, 15 unrelated families) underwent ophthalmological examination, fundus photography, fundus autofluorescence, and optical coherence tomography (OCT). Molecular genetic testing of the BEST1 gene was conducted by the chain-terminating dideoxynucleotide Sanger methodology. Onset of symptoms (3 to 50 years of age) and best-corrected visual acuity (0.02&ndash, 1.0) were highly variable. Ophthalmoscopic and retinal imaging defined five phenotypes. Phenotype I presented with single or confluent yellow lesions at the posterior pole and midperiphery, serous retinal detachment, and intraretinal cystoid spaces. In phenotype II fleck-like lesions were smaller and extended to the far periphery. Phenotype III showed a widespread continuous lesion with sharp peripheral demarcation. Single (phenotype IV) or multifocal (phenotype V) vitelliform macular dystrophy-like lesions were observed as well. Phenotypes varied within families and in two eyes of one patient. In addition, OCT detected hyperreflective foci (13/36 eyes) and choroidal excavation (11/36). Biallelic mutations were identified in each patient, six of which have not been reported so far [c.454C&gt, T/p.(Pro152Ser), c.620T&gt, A/p.(Leu207His), c.287_298del/p.(Gln96_Asn99del), c.199_200del/p.(Leu67Valfs*164), c.524del/p.(Ser175Thrfs*19), c.590_615del/p.(Leu197Profs*26)]. BEST1-associated ARB presents with a variable age of onset and clinical findings, that can be categorized in 5 clinical phenotypes. Hyperreflective foci and choroidal excavation frequently develop as secondary manifestations.

Hintergrund Wahrend die intraoperative optische Koharenztomographie (iOCT) im Bereich der Makulachirurgie oder der lamellierenden Keratoplastiken einen sichtbaren Vorteil bringen kann, ist ihr Einsatz bei der Ablatiochirurgie bisher mit unklarem Nutzen verknupft.

Spectral domain optical coherence tomography (SD-OCT) has become a standard diagnostic tool in the surgical management of vitreomacular interface disorders. The high-resolution cross-sectional information obtained from SD-OCT is a perfect complement to vitreoretinal surgery. It provides detailed intraoperative anatomical views that are not possible with a microscope.To investigate the value of intraoperative real-time OCT with respect to improvement of surgical techniques in the management of vitreomacular disorders.A review of the current literature was conducted and an analysis of own systematically evaluated data was included to provide a comprehensive overview of potential applications for the clinical use of intraoperative real-time OCT in macular surgery.Intraoperative real-time OCT can provide detailed visualization of epiretinal membranes and help to identify whether complete membrane removal has been achieved following surgery. In addition, it can provide qualitative and quantitative information that has previously not been available and assist in surgical decision-making. Intraoperative real-time OCT allows membrane peeling to be performed in selected cases without using retinal dyes, whereas it is not ideal for accurately guiding the surgeon while performing maneuvers.Intraoperative real-time OCT provides high-resolution visualization of the effects of surgical maneuvers on the microarchitecture of the retina and surrounding tissues and will fill a gap in the understanding of the pathophysiology and prognostic factors of vitreomacular disorders; however, with currently available systems, accurate intraoperative real-time guidance of surgical maneuvers is hindered by several limiting factors.

Purpose To investigate 12-month outcomes of conversion to aflibercept in patients with neovascular age-related macular degeneration resistant to ranibizumab. Methods Twenty-two eyes of 19 consecutive patients received 3 monthly aflibercept injections followed by a pro re nata protocol. Spectral-domain optical coherence tomography (OCT) images were obtained before each injection. All 49 cross-sectional OCT B-scans obtained in each examination were investigated and the largest choroidal neovascularization (CNV) size was chosen. The same cross-sectional B-scan sections containing the maximum CNV size were used during the follow-up. Results After 12 months, best-corrected visual acuity increased from 45.68 ± 20.25 to 59.09 ± 17.50 Early Treatment Diabetic Retinopathy Study letters (p2 (p = 0.003), and macular volume improved from 9.64 ± 1.75 to 8.45 ± 0.98 mm3 (pConclusions Visual and anatomic improvement were obtained after conversion to aflibercept.

Selective retina therapy (SRT) targets the retinal pigment epithelium (RPE) with pulsed laser irradiation by inducing microbubble formation (MBF) at the intracellular melanin granula, which leads to selective cell disruption. The following wound healing process rejuvenates the chorio-retinal junction. Pulse energy thresholds for selective RPE effects vary intra- and interindividually. We present the evaluation of an algorithm that processes backscattered treatment light to detect MBF as an indicator of RPE cell damage since these RPE lesions are invisible during treatment. Eleven patients with central serous chorioretinopathy and four with diabetic macula edema were treated with a SRT system, which uses a wavelength of 527 nm, a repetition rate of 100 Hz, and a pulse duration of 1.7 μs. Fifteen laser pulses with stepwise increasing pulse energy were applied per treatment spot. Overall, 4626 pulses were used for algorithm parameter optimization and testing. Sensitivity and specificity were the metrics maximized through an automatic optimization process. Data were verified by fluorescein angiography. A sensitivity of 1 and a specificity of 0.93 were achieved. The method introduced in this paper can be used for guidance or automatization of microbubble-related treatments like SRT or selective laser trabeculoplasty.

Presentation of a patient with two foreign bodies each 21 cm long in left nasal orbit and penetrating as far as the sinciput. The patient had been knitting at the time of the accident and had probably autonomously thrust the two knitting needles into the left orbit, as assessed by questioning of other parties. The patient had a known history of paranoid schizophrenia and dementia. Central imaging revealed the position of the knitting needles with respect to the intracranial vessels to be threatening. The surgical removal of the knitting needles was carried out without any serious complications, such as intracranial hemorrhage.

With about 50-60 million cases in the US alone, dry eye disease represents a severe health care problem. Cyclosporin A (CsA) would be a potent candidate for a causal therapy. However, CsA is not sufficiently water soluble to be administrated via simple eye drops. We developed an in situ nanosuspension (INS) as a novel approach towards the administration of CsA to the cornea. It precipitates upon contact with the tear fluid and creates CsA nanoparticles that enter the cornea and release the drug by dissolution. We selected two liquid poly(ethylene glycols) (PEG) that dissolve CsA and create nanoparticles by precipitation of CsA upon water contact. Aqueous solutions of PEG and Solutol, a non-ionic surfactant, were well tolerated by primary human epithelial cells in vitro. To determine the critical water content needed for a precipitation, the solubility of CsA was investigated in quaternary systems of drug, solvent, surfactant and water. The best INS formulation showed a particle size of 505 ± 5 nm, a polydispersity index (PdI) of 0.23 ± 0.03 and a neutral zeta potential of -0.07 ± 0.05 mV. After single administration to porcine eyes in vitro, 3165 ± 597 ng(CsA)/g(cornea) were detected in corneal tissue, while the levels of Restasis a commercial formulation were, with 545 ± 137 ng(CsA)/g(cornea), significantly lower (P0.01). These results demonstrate that an INS is a promising, novel approach towards the causal treatment of inflammatory diseases at the anterior eye.

To identify differences in extracellular matrix contents between idiopathic epiretinal membranes (IEM) of cellophane macular reflex (CMRM) or preretinal macular fibrosis (PMFM) type.

BACKGROUND: Heavier than water tamponades offer the possibility to support the inferior part of the fundus after retinal detachment. The aim of this study was to evaluate the anatomic and functional outcome of complicated retinal detachment treated with vitreous surgery and heavy silicone oil (HSO) tamponade. Surgery was performed in eyes with rhegmatogenous retinal detachment (RD) predominantly in the lower hemisphere or with penetrating injury (either as primary intervention or after development of proliferative vitreoretinopathy [PVR]). MATERIALS AND METHODS: Sixty-one eyes of 61 patients with RD - mostly complicated by PVR - and a minimum follow-up of 12 months were included in this study. Vitreoretinal surgery with HSO (Oxane HD) tamponade was performed in all patients. In 52 patients, heavy silicone oil was used in the management of complicated RD. 9 patients had surgery for complicated RD after penetrating eye injury.The mean follow-up period was 30.3 +/- 10.2 months. RESULTS: The overall final anatomic success rate was 79 %. In 39 % of the cases the retina remained attached during the entire follow-up period. CONCLUSIONS: The anatomic success rate after surgery with HSO (Oxane HD) was relatively low; however, only complex cases bearing a higher risk of retinal re-detachment received HSO in this study. Oxane HD does not appear to have major advantages compared to conventional silicone oil or other new-generation heavy silicone oils in these cases.

At the 111th German Medical Assembly in May 2008 in Ulm, Germany, a public debate on rationing of health care performances was started. Since the money in the German health care system is not enough to provide every diagnostic or therapy for every patient as a coverage of the compulsory medical insurances, a lot of specific health care performances have been rationed during the last years not to be covered by the regular medical insurance any more, such as, e. g., PSA measurements in urology or IOP measurements in ophthalmology. In contrast to the health care system in Scandinavia, where rationing of health care performances is publicly documented by the government, no similar public statements exist in Germany. Due to this, it is left to physicians to explain to their patients the "hidden" rationing of public health care performances, which also leads to an increase in individual health care performances (IGeL in Germany) to be paid for privately by the patient. It is undoubtedly true that not all medically possible performances need to be paid for by the health insurance; however, an official determination of these "out of pocket" health care performances is necessary. Therefore, it was the aim herein to work out possible "stop" criteria--according to the Scandinavian system--for common eye diseases and consecutive therapies, which need not be paid for or only be paid after a delay by the health insurances.

Spectral domain optical coherence tomography (SD-OCT) in patients can deliver retinal cross-sectional images with high resolution. This may allow the evaluation of the extent of damage to the retinal pigment epithelium (RPE) and the neurosensory retina after laser treatment. This article aims to investigate the value of SD-OCT in comparing laser lesions produced by conventional laser photocoagulation and selective retina treatment (SRT).In a retrospective study, conventional retinal laser (CRL) lesions and SRT laser lesions were evaluated with SD-OCT. One hundred seventy-five CRL lesions were investigated in 10 patients with diabetic maculopathy at timepoints between 1 hr and 4 years after treatment. Ninety-one SRT lesions were examined in 9 patients with central serous retinopathy, geographic atrophy, and diabetic maculopathy at timepoints between 1 hr and 2 years. CRL lesions were applied with an ophthalmoscopically slightly grayish-white appearance (Nd:YAG laser at 532-nm wavelength; power 100-200 mW; retinal spot diameter 100 microm; pulse duration 100 ms). SRT lesions were applied with a Nd:YLF (527 nm; pulse duration 200 ns [30 pulses at 100 Hz]; energy 100-200 microJ/pulse; retinal spot diameter 200 microm) and were visible only angiographically.All CRL lesions were characterized by high reflectivity in OCT images throughout the full thickness of the neurosensory tissue 1 hr after irradiation, suggesting complete neurosensory coagulation. Strong contraction through the full thickness of the neurosensory layers was observed within 7 days after treatment. In contrast, the neural retina appeared unaffected after SRT. For both lesion types, the RPE layer appeared to be regular or thinner immediately after treatment, whereas within a period of 4 weeks, a RPE thickening indicating RPE proliferation was observable. One year and later after treatment, CRL lesions were characterized by RPE atrophy combined with significant damage of the neurosensory tissue. SRT lesions aged one year and older revealed unaffected neurosensory structures and an intact RPE layer.Spectral domain OCT can be used clinically to follow the development of laser-induced lesions over time. Postoperative RPE proliferation was observed in both CRL and SRT laser lesions. RPE atrophy appeared subsequently only in CRL lesions, whereas the neurosensory retina appeared unaffected following SRT. These results suggest the selective effect of SRT in humans without causing adverse effects to the neurosensory retina.

Background Selective retina therapy (SRT) solely affecting the RPE while sparing of the photoreceptors is usually performed with a train of repetitive laser pulses of 1.7 microseconds in duration. It was our purpose to evaluate the principle feasibility of SRT with shorter 200 nanoseconds laser pulses in patients. Methods Nineteen patients with macular disorders [diabetic maculopathy (DMP), geographic atrophy (GA), drusen maculopathy and central serous chorioretinopathy (CSR)] were treated with a prototype of a SRT laser (Nd:YLF laser; 527 nm; 1.7 microseconds and 200 nanoseconds pulse duration; 30 pulses at 100 Hz; spot size: 200 µm). Test lesions (n = 175) with increasing energy were applied at the lower arcade to determine the individual angiographic and ophthalmoscopic threshold radiant exposures (therapeutic window) before applying the central treatment lesions within these ranges additionally guided by online optoacoustic measurements. Postoperatively RPE damage was visualized and confirmed by fluorescein angiographic leakage and correlated with optoacoustic results. Additionally ED50 damage thresholds were calculated by probit analysis. Results None of the short repetitive 200 nanoseconds laser pulses led to retinal hemorrhages or retinal ruptures. Nearly all of the test- and treatment lesions could be visualized by angiography indicating desired RPE damage but were ophthalmoscopically invisible suggesting intact neurosensory retinal structures. ED50 cell damage threshold energies were significantly lower using 200 nanoseconds (99.6 µJ; n = 122) instead of 1.7 microseconds (196.3 µJ; n = 53) laser pulses. Optoacoustic and angiographic visibility correlated in 83.7% (200 nanoseconds) and 87.5% (1.7 microseconds). Conclusions Selective RPE effects can safely be achieved using shorter 200 nanoseconds laser pulses in patients without adverse effects to the neurosensory retina. The required pulse energy compared to the standard 1.7 microseconds regime was reduced by about a factor of 2 suggesting a reduced heat generation and flow into adjacent tissues during the shorter laser impact and thus possibly enhancing selectivity. Optoacoustics also seem to be a viable alternative in 200 nanoseconds treatment for a non-invasive online dosimetry control system. Lesers Surg. Med. 40:616–624, 2008. © 2008 Wiley-Liss, Inc.

The scientific background of laser photocoagulation of the ocular fundus was studied extensively by several investigators in the 1970 s and 1980 s. The basic principles were successfully resolved during that time and clinical consequences for proper application of the laser photocoagulation for various diseases were deduced. The present paper gives an overview about the physical basics of laser-tissue interactions during and after retinal laser treatment and the particular laser strategies in the treatment of different retinal diseases. Thus, it addresses the issue of the impact on tissue of laser parameters as wavelength, spot size, pulse duration and laser power. Additionally, the different biological tissue reactions after laser treatment are presented, such as, e. g., for retinopexia or macular treatments as well as for diabetic retinopathies. Specific laser strategies such as the selective laser treatment of the RPE (SRT) or the transpupillary thermotherapy (TTT) are presented and discussed.

The purpose of this study was to characterise an ex-vivo adult porcine retina-retinal pigment epithelium (RPE) perfusion organ culture model. Fresh porcine full-thickness retina-RPE-choroid tissue samples were clamped into tissue carriers and mounted in two-compartment containers. The retinal and choroidal sides were continuously perfused with culture medium. pO(2), [Na(+)], [K(+)], [Cl(-)], [glucose], [lactate], and pH were measured in the medium. Tissue samples were examined after 24h, 4, 7, and 10 days in culture. The morphology of the retina and the RPE was examined by light and electron microscopy (LM, EM). The retinal cellular integrity was further examined by immunohistochemistry (Ki 67, GFAP, rhodopsin, synaptophysin, syntaxin, NF 200, TUNEL-test). Fresh porcine full-thickness retina-RPE-choroid tissue samples and tissue samples in static organ culture served as controls. LM, EM, and immunohistochemistry showed intact retinal and RPE cytoarchitecture kept in perfusion culture. Photoreceptor outer segments showed first signs of degeneration after 24h, significant signs of apoptosis and necrosis appeared in the retina after 4 days in perfusion culture. Control tissue samples kept in static culture showed disintegration of the retinal cytoarchitecture after 4 days in culture. The data show that adult porcine retina-RPE tissue can be maintained morphologically intact in perfusion organ culture for at least 10 days. Although first signs of degeneration set in after 24h the structural preservation of the tissue in perfusion organ culture is superior to that in static culture. The perfusion culture model of the retina refines organotypic in vitro test systems and may help to reduce the number of necessary animal experiments in retina and RPE research. It offers new perspectives for the safety testing of substances designed for intraocular application.

Seit 2004 wird die Krankenhausbehandlung offener Augenverletzungen in der DRG C01Z als Fallpauschale abgerechnet. Da das Ausmas der Behandlungsmasnahmen allerdings signifikant vom sehr heterogenen Verletzungsmuster abhangt, werden in dieser DRG okonomisch sehr unterschiedliche Falle zusammengefasst. Ziel dieser Arbeit war daher die Uberprufung der Kostendeckung fur die operative Behandlung von offenen Augenverletzungen an einer Universitats-Augenklinik. Die Leistungsdaten fur die DRG C01Z wurden fur die Jahre 2005 und 2006 uber die E1-Bogen nach §21 KHEntG zusammengefasst. Die Behandlungskosten wurden uber die Berechnung der OP-Fixkosten, der variablen OP-Kosten inklusive Personal und Material und der stationaren Kosten auf eine durchschnittliche OP heruntergebrochen. Im Untersuchungszeitraum wurden 180 offene Augenverletzungen von insgesamt 4721 stationaren Operationen behandelt. In 80 Fallen wurde eine Hornhaut-/Skleranaht (+Phako/IOL; n=10); (mittlere OP-Zeit: 67,81 min) durchgefuhrt. In 100 Fallen wurde eine Pars-plana-Vitrektomie (ppV) mit entsprechenden adjuvanten Masnahmen (mittlere OP-Zeit: 124,69 min) benotigt. Der OP-Fixkostenanteil pro OP belief sich auf 130,60 EUR; die variablen Kosten inklusive Personal und Material variierten zwischen durchschnittlich 570 EUR (Hornhaut-/Skleranaht ± 250 EUR fur Phako und IOL; n=10) und 1230 EUR fur die ppV. Kostentrachtige Adjuvanzien wie die Benutzung von Cerclage, Perfluorocarbonen, Gas und Silikonol sowie die kombinierte Phako ± IOL verursachten zusatzliche Kosten zwischen 51 und 250 EUR pro Zusatz (durchschnittlich 182 EUR) wobei mindestens zwei dieser Zusatze bei 50% und mindestens ein Zusatz bei 90% der ppVs benutzt wurde. Die stationaren Kosten beliefen sich bei einer mittleren Verweildauer von ca. 8 Tagen pro Fall auf 2184 EUR (Tagessatz 273 EUR). Die durchschnittlichen Gesamtkosten eines Falles differierten masgeblich fur die reine Naht-OP (2662 EUR, mittlere Verweildauer: 7,06 Tage) und ppVs (3712 EUR; mittlere Verweildauer: 8,62 Tage). Zusatzliche nicht gedeckte Kosten entstanden bei 20 Fallzusammenfuhrungen (11,1%) fur Reoperationen wahrend des stationaren Aufenthaltes. Die C01Z wurde im Erhebungszeitraum mit durchschnittlich 3205,96 EUR bei einem Relativgewicht von 1,177 und einer Baserate von 2723,79 EUR in Bayern vergutet. Damit sind die ppVs deutlich unterbezahlt und die reine Versorgung durch Naht ist deutlich uberbezahlt. Aufgrund der Inhomogenitat befurworten wir einen Split der C01Z fur penetrierende Augenverletzungen.

Purpose: Up to date several approaches have been undertaken to achieve an ‘easy-to-handle’ animal model of choroidal neovascularizations (CNVs) in rabbits; however, so far in none of the studies could healthy retinal tissue be maintained, which is mandatory to further investigate the effects of photodynamic therapy (PDT) or anti-vascular-endothelial-growth-factor treatments. It was our aim to reevaluate and verify the method of inducing experimental CNVs in rabbits using subretinally injected linoleic acid hydroperoxide (LHP) as proposed by Tamai et al. and to use it for experimental PDT. Material and Methods: In 33 eyes of Chinchilla breed rabbits LHP of two different concentrations (25 and 100 µg/50 µl) was injected into the subretinal space via a transvitreal approach under guidance of an operation microscope. Ophthalmoscopic and angiographic examinations were performed on days 3, 7, 14 and 28 after surgery. Preliminary PDT with different experimental parameter sets was performed in 3 eyes using the new photosensitizer Tookad. Results: Using LHP in the higher concentration, an angiographically determined CNV induction was observed in 27% of all injection sites (n = 34) on days 14 and 28 revealing early well-demarcated and progressive leakage. No CNV was detected at the lower LHP concentration (60 injection sites). Subretinal CNV was verified histologically revealing vessel formation above the retinal pigment epithelium level. Herein, a significant damage to the outer retinal layers was always observed; however, the general structure of the choriocapillary layer was maintained. Tookad PDT was clinically able to completely stop leakage in 1 case and reduce leakage in 2 cases. Histologically the choriocapillary layer was occluded. Conclusion: Subretinal injection of LHP induces angiographically well-demarcated classic CNVs in rabbits; however, the CNV rate was low, and histology revealed severe damage of the outer retinal layers but not of the choriocapillary layer, which is important for studying PDT interactions. Preliminary experimental PDT could clinically stop or reduce leakage from angiographic CNV. Due to the small CNV rate and the significant collateral retinal tissue damage, this model seems to be only of partial suitability for investigating new treatment modalities in CNV.

Hintergrund Seit 2004 werden stationare Behandlungen uber Fallpauschalen nach DRGs abgerechnet. Die Entgelthohe richtet sich nach den Kostenkalkulationen der Kalkulationskrankenhauser, zu denen nur wenige Universitatskliniken gehoren. Ziel dieser Arbeit war die Uberprufung der Kostendeckung fur die operative Behandlung von netzhaut-/glaskorperchirurgischen Eingriffen (DRG C03Z und C17Z) mittels Pars-plana-Vitrektomie (ppV) an einer Universitatsaugenklinik.

Die selektive Retinatherapie (SRT) wird zurzeit als neue, schonende Laserbehandlungsmethode fur verschiedene Erkrankungen des Augenhintergrunds evaluiert, die mit einer reduzierten Funktion des retinalen Pigmentepithels (RPE) assoziiert werden. Mit der SRT wird im bestrahlten Areal lediglich das RPE behandelt, ohne die angrenzende neurosensorische Netzhaut mit den Photorezeptoren und die unter dem RPE liegende Aderhaut zu schadigen. Die Therapie fuhrt idealerweise zu einer Regeneration des RPE und einem gesteigerten Metabolismus am chorioretinalen Ubergang. Im Gegensatz zur etablierten Laserphotokoagulation, bei der die bestrahlten und umgebenden Areale der Netzhaut komplett verodet werden, bleiben bei der SRT Skotome vollstandig aus. Der Artikel gibt eine Ubersicht uber die Methodik und die Mechanismen zu selektiven RPE-Effekten und resumiert In-vitro- und vorklinische Ergebnisse zur Bandbreite der Selektivitat fur verschiedene Bestrahlungsparameter. Die Beschreibung einer optoakustischen Methode zur Online-Visualisierung der optisch nicht sichtbaren Effekte und damit zur Dosimetrie ohne angiographische Kontrolle runden die Ubersicht ab.

Hintergrund Selektive RPE-Lasertherapie ist durch repetitive Laserbestrahlung mit Mikrosekundenpulsen unter Schonung der Photorezeptorschicht moglich. Damit konnen zentrale Netzhautpathologien wie diabetische Makulopathie, weiche konfluierende Drusen im Rahmen der altersbedingten Makuladegeneration oder die Chorioretinopathia centralis serosa ohne konsekutive Laserskotome behandelt werden. Es war Ziel dieser Studie zu zeigen, ob ein selektiver RPE-Schaden auch mit einem konventionellen grunen cw-Laserstrahl erreicht werden kann, wenn dieser zur Bestrahlung uber die Netzhaut gescannt wird.

Purpose: Central serous chorioretinopathy (CSC) affects mostly young and middle-aged adults. Typically, a serous retinal detachment occurs with a focal leakage point in fluorescein angiography. Fundus autofluorescence (AF) is related to the lipofuscin within the retinal pigment epithelium (RPE). As CSC is thought to be associated with RPE disorders, AF measurements might be able to detect distinct changes within the RPE level. The purpose of this study was to compare AF patterns in acute and chronic-recurrent CSC and to evaluate the potential value of AF as a non-invasive monitoring tool. Methods: From 85 patients diagnosed with CSC (mean age 43 years), AF images were retrospectively evaluated and compared with angiographic and ophthalmoscopic findings. Fluorescein angiography and AF measurements were performed using a Heidelberg retina angiograph. Autofluorescence was excited at a wavelength of 488 nm and detected above 500 nm. Results: Acute CSC as determined by an acute decrease in visual acuity (VA) within the last 6 weeks, focal point leakage and neurosensory retinal detachment was diagnosed in 39 patients. In 36 of those patients (92%), a significantly decreased AF at the leakage point (72%) and/or decreased AF in the area of neurosensory detachment (77%) were observed. Regarding chronic-recurrent CSC as determined by a decrease in VA for longer than 6 weeks and mottled hyperfluorescent appearance in angiography, abnormalities in AF were observed in 44/46 patients (96%). In those patients, decreased or mottled AF was observed at the leakage point itself (76%), whereas significantly increased AF was seen in the area of residual neurosensory retinal detachment (85%). Conclusions: In acute CSC, decreased AF is presumably due to a blockage caused by oedema, whereas in chronic-recurrent forms, irregular and increased AF is observed, possibly reflecting reactive RPE changes secondary to RPE defects and neurosensory detachment. If these findings could be systematically underlined by prospective clinical studies, AF might be an interesting non-invasive tool for monitoring RPE changes in CSC and for performing differential diagnosis.