Search

Screening is a strategy used in a systematic approach to identify an unrecognized disease or risk factors in individuals in a population without signs or symptoms. The test characteristics (specificity and sensitivity) and the prevalence of the disease are of vital importance for the achievable quality of prediction. Multidimensional decision-making must not only consider the benefits of screening but also its potential disadvantages, such as overtreatment, diagnostics of unclear findings and the psychological impact on healthy individuals. Besides medical, ethical and test theoretical considerations, economic considerations also have to be included in decision-making on a screening program. In Germany, a nationwide screening for diabetic retinopathy and regional programs for amblyopia screening exist. Screening for glaucoma or age-related macular degeneration is currently not funded by the statutory health insurance.

Hintergrund: Ziel der Studie ist die Korrelation von funktionellen und morphologischen Aspekten vor und 12 Monate nach Makulaforamen-Chirurgie. Methoden: In dieser prospektiven, interventionellen, konsekutiven Studie wurde bei 16 Augen von 16 Patienten nach Erstdiagnose und maximaler Symptomendauer von 2 Monaten eine erfolgreiche transkonjunktivale 23-gauge-Vitrektomie mit ILM-Peeling durchgefuhrt. Praoperativ sowie 3, 6 und 12 Monate postoperativ erfolgte die Bestimmung des bestkorrigierten Visus (logMAR), eine 10° Mikroperimetrie (MP-1) sowie eine Spektral-Domain basierte optische Koharenztomografie (SD-OCT) Untersuchung. Die Photorezeptorenschicht (Inneres und Auseres Segment, IS/OS) wurde anhand der SD-OCT-Bilder gewertet und mit den Daten der Mikroperimetrieanalyse in der fovealen und parafovealen Region korreliert. Ergebnisse: Nach 3 Monaten zeigte sich bereits eine Stabilisierung des bestkorrigierten Visus mit Regeneration der IS/OS-Linie sowie eine Besserung des Fixationsverhaltens als auch der Sensitivitat im Makulabereich. Nach 12 Monaten kam es zu einer signifikanten Restitution der IS/OS-Linie. Die bestkorrigierte Sehscharfe, die mittlere Gesamtsensitivitat sowie die Fixation verbesserten sich signifikant innerhalb des 12-monatigen Beobachtungszeitraums (p

Die navigierte Lasertherapie mit dem Navilas®-System erlaubt durch die Implementierung computergestutzter Assistenzsysteme hohe Prazision und Sicherheit in der retinalen Lasertherapie. Zusatzliche bietet sie Vorteile hinsichtlich einer Standardisierung von Planung und Ausfuhrung sowie der Dokumentation und Qualitatssicherung einer Laserbehandlung. Derzeitiger Anwendungsschwerpunkt der navigierten Lasertherapie ist neben der fokalen, sektoriellen Netzhautlasertherapie nach retinalen venosen Gefasverschlussen und der panretinalen Laserkoagulation bei Patienten mit proliferativer diabetischer Retinopathie (DR) vor allem das diabetische Makulaodem (DMO). Hier konnte gezeigt werden, dass sich insbesondere durch die Kombination initialer Anti-VEGF-Therapie und nachfolgender navigierter Makulalasertherapie synergistische Effekte ergeben konnen. Es wurden signifikant langere behandlungsfreie Intervalle bei im Vergleich zur Anti-VEGF-Monotherapie gleichwertiger Visusentwicklung berichtet. Trotz vielversprechender Ergebnisse ist aufgrund der weltweit noch beschrankten Datenlage eine abschliesende Beurteilung des Stellenwerts der navigierten Lasertherapie derzeit noch nicht moglich.

Hintergrund Es erfolgte eine Evaluation der Zielgenauigkeit von navigierter Lasertherapie mit dem NAVILAS®-System bei diabetischem Makulaodem (DMO).

Einleitung Das Glaukom zahlt zu den haufigsten Ursachen irreversibler Erblindung weltweit und kann die Lebensqualitat und Funktionsfahigkeit betroffener Patienten signifikant beeintrachtigen. Mit dem englischsprachigen „Glaucoma Quality of Life-15“ (GQL-15) steht seit geraumer Zeit ein spezialisiertes Instrument zur Quantifizierung der funktionellen Beeintrachtigung von Glaukompatienten zur Verfugung. Diese Studie evaluiert eine deutschsprachige Version des GQL-15 und stellt Korrelationen zu Gesichtsfeldparametern her.

BACKGROUND: The aim of this study was to examine the changes in static analysis of the retinal vasculature during an acute rise of blood pressure in young normal subjects. MATERIAL AND METHODS: An increase of blood pressure was induced in 30 young normal subjects (age 18 – 30 years) by physiological stress. Retinal fundus photographs were taken before and immediately after the stress. The central retinal artery equivalent (CRAE), the central retinal vein equivalent (CRVE) and the arterio-venous ratio (AVR) were calculated by automated vessel analysis software (Talia Technology, Lod, Israel). The same vessel segments were measured before and after the rise of blood pressure. RESULTS: At rest, mean CRAE was 97.3 ± 9.6 micrometer, CRVE 114.5 ± 12.5 micrometer and AVR 0.85 ± 0.08. The mean systemic perfusion pressure was elevated by physiological stress from a mean of 90.7 ± 7 mmHg by 18.0 ± 7.8 mmHg. The static retinal vessel analysis showed a constriction of the arteries by a mean of –1.3 ± 3.9 microns and a venous dilatation of 0.6 ± 7.2 microns. The retinal AVR was diminished significantly (p = 0.02) by –0.015 ± 0.032. The degree of arterial constriction – but not the change of AVR – correlated significantly (r = –0.39; p = 0.048) with the degree of rise of blood pressure. CONCLUSION: Retinal autoregulation during acute increase of blood pressure in young normal subjects can be measured by static retinal vessel analysis.

Kumulative Lichtexposition wird fur die Entstehung der altersabhangigen Makuladegeneration (AMD) mitverantwortlich gemacht. Die Hemmung des „vascular endothelial growth factor A“ (VEGF) ist das wichtigste Ziel der aktuellen antiangiogenen Behandlungsstrategien bei AMD. In Fallberichten konnte die Wirksamkeit des Multikinaseinhibitors Sorafenib bei Patienten mit exsudativer AMD gezeigt werden. Diese Studie untersucht die Wirkung von Sorafenib auf die Expression der VEGF-Rezeptoren 1 und 2 (VEGFR-1/2) und die lichtinduzierte Expressionszunahme von VEGF in humanen retinalen Pigmentepithelzellen (RPE-Zellen). Der Effekt von Sorafenib auf die Expression von VEGFR-1 und -2 in primaren humanen RPE-Zellen wurde auf zellularer Ebene mittels RT-CR, Immunhistochemie und Westernblot untersucht. Zusatzlich wurden die RPE-Zellen mit rein weisem Licht bestrahlt und mit Sorafenib behandelt. Dann wurden die Vitalitat der RPE-Zellen und die Expression von VEGF auf zellularer Ebene bestimmt (Real-Time-PCR, Westernblot, Immunhistochemie, ELISA). Sorafenib reduziert die VEGFR-1/2-Expression von humanen RPE-Zellen. Die Bestrahlung der RPE-Zellen mit weisem Licht fuhrt zu einer Abnahme der Vitalitat und zur Induktion von VEGF. Diese lichtinduzierten Effekte werden signifikant reduziert, wenn Zellen mit Sorafenib (1 µg/ml) behandelt werden. Die Ergebnisse dieser Studie zeigen, dass der Multikinaseinhibitor Sorafenib vielversprechende Eigenschaften fur eine mogliche Anwendung bei exudativer AMD aufweist.

OBJECTIVE: The aim of the study was to compare the diagnostic properties of a non-mydriatic 200A‚° ultra-widefield scanning laser ophthalmoscope (SLO) with mydriatic ETDRS 7-field fundus photography for diabetic retinopathy screening. METHODS: A consecutive series of 66 eyes from 34 patients with different levels of diabetic retinopathy (DR) were examined. Grading of DR and macular edema (ME) obtained from mydriatic ETDRS 7-field fundus photography were compared with grading obtained from Optomap Panoramic 200MA SLO images. All SLOs were performed with an undilated pupil and no additional clinical information was used for evaluation of images by two independent, masked experts. RESULTS: A total of 14 eyes from ETDRS 7-field fundus photography and 11 eyes from Optomap could not be graded by at least one grader due to poor image quality, yielding 48 eyes for comparison purposes. Of the 48 ETDRS 7-field fundus photographs, 9 (11 for grader 2) eyes had no or mild DR (ETDRS levels A¢Â‰Â¤20) and 17 (23 for grader 2) eyes had no ME. Agreement of Optomap retinopathy grading with ETDRS 7-field fundus photography was good, kappa 0.70 for grader 1 and kappa 0.66 for grader 2. There was good agreement between both techniques for ME, grader 1 kappa 0.68 and grader 2 kappa 0.74. CONCLUSIONS: Grading of DR levels from Optomap Panoramic 200MA non-mydriatic images showed a good correlation with mydriatic ETDRS 7-field fundus photography. Both techniques are of sufficient quality for a valid assessment of DR. Optomap Panoramic 200MA images cover a larger retinal area and might therefore offer additional diagnostic properties.

Modeling plays an important role in value-based medicine (VBM). It allows decision support by predicting potential clinical and economic consequences, frequently combining different sources of evidence. Based on relevant publications and examples focusing on ophthalmology the key economic modeling methods are explained and definitions are given. The most frequently applied model types are decision trees, Markov models, and discrete event simulation (DES) models. Model validation includes besides verifying internal validity comparison with other models (external validity) and ideally validation of its predictive properties. The existing uncertainty with any modeling should be clearly stated. This is true for economic modeling in VBM as well as when using disease risk models to support clinical decisions. In economic modeling uni- and multivariate sensitivity analyses are usually applied; the key concepts here are tornado plots and cost-effectiveness acceptability curves. Given the existing uncertainty, modeling helps to make better informed decisions than without this additional information.

The application of value-based medicine (VBM) tenets in the area of glaucoma research requires valid and reliable data concerning the quality of life with glaucoma. A multitude of instruments for measuring quality of life of patients with glaucoma have been employed in the past. Any instrument used would need to capture peripheral vision loss and its influence on patient-reported quality of life as this is one of the hallmarks of this disease. Cost-utility analyses can then be based on the reported quality of life and the cost of glaucoma therapy. Several cost-utility analyses have been applied in the field of glaucoma screening as well as treating ocular hypertension and based on this a recommendation regarding population subgroups which can be treated cost efficiently can be made.

Ein Glaukomscreening, das derzeit nicht zum Leistungsumfang der gesetzlichen Krankenkassen gehort, kann bislang nicht diagnostizierte Glaukompatienten detektieren und einer Behandlung zufuhren, um die Sehfunktion und Lebensqualitat der Patienten zu erhalten. In dieser Arbeit soll der gesundheitsokonomische Aspekt der Kosteneffizienz eines Glaukomscreenings herausgearbeitet werden. Relevante medizinische Datenbanken (CDSR, HTA, MEDLINE, EMBASE) wurden nach den Inhalten Glaukomscreening, geeigneten Testverfahren fur ein Glaukomscreening und nach gesundheitsokonomischen Analysen fur Glaukomscreening durchsucht. Die wesentlichen Arbeiten und Ubersichten werden dargestellt und zusammen mit epidemiologischen Daten erlautert und verglichen. Ein Screening auf Glaukom erfullt wesentliche Screeningkriterien. Das derzeit beste Einzeltestverfahren fur ein Glaukomscreening ist die frequenzverdoppelte Perimetrie (FDT). Die Kosteneffizienz des Glaukomscreenings wird von folgenden Parametern bedingt: Pravalenz der Erkrankung, Spezifitat des Testverfahrens, Kosten fur Screening und Krankheit und die Beeintrachtigung der Lebensqualitat durch das Glaukom. Aktuelle Kosten-Nutzwert-Analysen kommen zum Ergebnis, dass ein flachendeckendes Screening der Gesamtbevolkerung nicht kosteneffizient ist. Ein Screening von Risikogruppen kann aber durchaus kosteneffizient sein. Nach bisheriger Datenlage ist ein flachendeckendes Screening auf Glaukom nicht kosteneffizient, obgleich fur Deutschland noch keine Analyse berechnet wurde. Gesundheitsokonomische Analysen konnen die Frage klaren, bei welchen Risikogruppen und ab welcher Schwelle Kosteneffizienz besteht. Analysen dieser Art sind wichtige Kriterien fur Entscheidungstrager im Gesundheitswesen.

Kumulative Lichtexposition wird fur die Entstehung der altersabhangige Makuladegeneration (AMD) mitverantwortlich gemacht. Um die Netzhaut vor den schadlichen Einflussen des blauen Lichts zu schutzen, werden seit geraumer Zeit Blaulicht absorbierende Intraokularlinsen (IOLs) eingesetzt. Diese Studie vergleicht mogliche zytoprotektive Effekte der Blaulicht absorbierenden SN60AT IOL (ALCON) mit der ungefarbten, UV-Licht absorbierenden SA60AT IOL (ALCON) auf das humane retinale Pigmentepithel (RPE). Kulturen primarer humaner RPE Zellen wurden mit weisem Licht bestrahlt, das entweder durch eine SN60AT IOL oder eine SA60AT IOL gefiltert wurde. Nach einer Bestrahlungszeit von 15–60 min wurden Vitalitat, Induktion von Apoptose und die Expression des „vascular endothelial growth factor A“ (VEGF-A) sowie des antiapoptotisch wirksamen Proteins XIAP auf zellularer Ebene bestimmt (RT-PCR/Western Blot/ELISA) Die ungefilterte Bestrahlung der RPE-Zellen mit weisem Licht fuhrte zu einer bestrahlungszeitabhangigen Abnahme der Vitalitat und der Expression von XIAP sowie zu einer Induktion von Apoptose und Bildung von VEGF-A. Diese phototoxische Zellschadigung wurde durch beide untersuchten IOLs signifikant reduziert. Die Zellschadigung durch Bestrahlung mit Licht nach Blaulichtfilterung mit der SN60AT IOL war signifikant geringer als mit der SA60AT IOL. Sowohl UV-filternde als auch Blaulicht absorbierende IOLs reduzieren phototoxische RPE-Schadigung. Die Blaulicht absorbierende SN60AT IOL fuhrte in unseren Versuchen zu einer zusatzlichen Reduktion der Zellschadigung. Die Ergebnisse deuten darauf hin, dass Blaulicht absorbierende IOLs auch im klinischen Gebrauch eine photoprotektive Wirksamkeit auf Netzhautebene besitzen.

OBJECTIVE: The aim of this study is to provide the best available evidence on how to disinfect contact Goldman tonometers. METHODS: A systematic review of all articles on disinfection of contact tonometers was conducted. Articles published up to July 2008 were identified in Medline, Embase and references from included articles. Two observers participated in the data retrieval and assessment of the studies identified. RESULTS: A total of 89 articles was retrieved, of which 58 could be included. Of those, 18 were clinical studies, 17 experimental microbiological studies, 8 expert assessments or guidelines and 15 reviews, surveys, descriptions of new methods. The clinical studies illustrate the importance of the problem, possible side effects of some disinfection methods but yield inconclusive results regarding efficacy. Experimental studies investigated a variety of bacterial and virological questions as well as material damage by disinfection. Both chlorine-based and hydrogen peroxide-based liquid disinfection were shown to be effective if applied for 5 min. Inconsistent results exist for alcohol wipes and UV disinfection - material damage has been described for both. The US guidelines and most expert recommendations are supported by evidence of the existing data. CONCLUSIONS: Chlorine-based and hydrogen peroxide-based liquid disinfections for 5 minutes are effective and relatively safe for disinfecting contact tonometers.

OBJECTIVE Autofluorescence of the retina allows one to quantify and follow the extent and progression of dry, age-related macular degeneration (ARMD) changes. The objective of this study was to compare different analysis methods for displaying autofluorescence images. METHODS In a consecutive series of 15 patients with mild dry AMD and 15 patients without retinal pathologies, one 30 degrees autofluorescence image was obtained with the Heidelberg retina angiograph (HRA). Evaluation was performed by observers masked to the clinical group for each of the three analysis displays: topographic map in false colours (similar to height lines in maps), 3D display of optical density and quantitative, standardised evaluation of optical density values. RESULTS For the 30 eyes included, grading of ARMD versus normal yielded a sensitivity of 83 -92 % for the topographic map, 58 - 83 % for the 3D and 75 - 83 % for quantitative optical density display. The corresponding specificity was 87 - 93 % for the topographic map, 53 - 60 % for the 3D and 67 - 80 % for the quantitative optical density display. CONCLUSIONS Analysis by topographic mapping is suitable to supply quantitative information of optical density for evaluating autofluorescence images. In spite of being illustrative, a 3D display of optical density does not offer sufficient properties for analysis.

PURPOSE: Ranibizumab (Lucentis) stabilizes or improves visual acuity in a high percentage of patients with age-related macular degeneration (AMD). As this therapy is associated with significant costs, the aim of this study was to provide a cost-utility analysis, which considers both costs and utility of a therapy with ranibizumab in an economic model. METHODS: The incremental utility for the patient was modelled based on visual acuity data of the MARINA and ANCHOR study. The utility data used assume that the better seeing eye is affected. The study groups used for comparison consisted of patients who only received best supportive care, e. g., low-vision aids. The baseline scenario of the model assumes 6 treatments per year over a 2 year time period - based on the assessment of an expert panel. Treatment costs were based on German pharmacy prices and recommendations for reimbursement of the intravitreal injections. In a univariate sensitivity analysis all important parameters were varied to assess the stability of the results. RESULTS: The baseline scenario yields for predominantly classic lesions 16 882 €/QALY (quality adjusted life year), for minimally classic CNV 24 766 €/QALY and for occult CNV 26 170 €/QALY. If a distribution of the CNV types with 18 - 25 - 57 % is assumed, the mean cost of therapy with ranibizumab amounts to 24 147 €/QALY. Sensitivity analysis showed that all reasonable variations yielded results which are considered cost-effective (≤ 50.000 US $/QALY). This is especially true for high and low patient age, for groups with low (0.05 - 0.1) and high ( > 0.4) visual acuity, for a variation of costs per treatment of ± 20 %, and a prolonged treatment duration of 3 years. CONCLUSIONS: In the investigated szenario a therapy of neovascular AMD with ranibizumab is cost-effective for all angiographic subtypes as well as in the sensitivity analysis.

Die intravitreale Anti-VEGF-Behandlung mit Bevacizumab (Avastin) stellt eine neue, viel versprechende Therapie zur Behandlung von choroidaler Neovaskularisation (CNV) bei altersabhangiger Makuladegeneration (AMD) dar. Fur diese „Off-Label“ Anwendung von Bevacizumab gibt es bisher nur wenig systematische Daten hinsichtlich der Kurzzeittoxizitat. Diese Studie untersucht die Sicherheit von Bevacizumab in vitro an Zellen des vorderen und hinteren Segments des menschlichen Auges. Humane primare retinale Pigmentepithelzellen (RPE), menschliche Astrozyten aus dem Sehnervenkopf (ONHA), menschliche Trabekelmaschenwerkzellen (TMC) und seropositive Hornhaute wurden mit Bevacizumab (25 µg/ml, 250 µg/ml und 2500 µg/ml) 48 h lang behandelt, entsprechend der 0,1×-, 1×- und 10×-Dosis, die zur intravitrealen Injektion verwendet wird. Die bevacizumabbezogene Toxizitat wurde mittels eines kolorimetrischen Tests (MTT) durch Messung der Proliferationshemmung von RPE, ONHA und TMC ausgewertet. Zusatzlich wurde die Zellentwicklungsfahigkeit durch einen Live-Dead-Fluorescence Assay quantitativ bestimmt. Die Zelldichte des kornealen Endotheliums wurde durch Phasenkontrastmikroskopie quantitativ beurteilt. Bevacizumab zeigte toxische Wirkungen auf die Proliferation und Entwicklungsfahigkeit primarer RPE-Zellen bei einer Konzentration von 2500 µg/ml. Niedrigere Konzentrationen hatten keinen Einfluss auf Proliferation und Entwicklungsfahigkeit von RPE-Zellen. Keinerlei Toxizitat bestand fur alle untersuchten Konzentrationen bei menschlichem ONHA, TMC und Hornhautendothel. In dieser Studie zeigte Bevacizumab ab einer 10fach hoheren Konzentration als die ubliche Dosierung im allgemeinen klinischen Gebrauch toxische Effekte auf primares RPE. Die Blockade von VEGF ist eine mogliche Ursache hierfur. Es zeigte sich keine Toxizitat fur niedrigere Konzentrationen und andere Zellarten des vorderen und hinteren Segments des menschlichen Auges. Folglich scheint der klinische intravitreale Gebrauch von Bevacizumab bei Konzentrationen von 1–1,25 mg sicher zu sein.

PURPOSE The purpose of this study was to investigate artifacts of OCT scans and of software analysis for retinal cross-section scans in a specialised retina clinic setting. METHODS A total of 205 vertical cross-hair OCT scans of retinal Stratus OCTs were randomly chosen from the database. All scans had been performed by one experienced technician. There were 75 (37%) normal findings, the remaining scans showed various types of retinal pathology: All scanning artifacts were analysed. Retinal thickness of all scans was measured automatically at the centre of the macula using two different software algorithms: the instrument's built-in "Stratus OCT Viewer V 4.01" and the stand-alone application "Datamedical OCTview V 3.5" (Datamedical Consulting, Hamburg). Errors of the software to correctly identify the retinal surface and the outer highly reflective layer were assigned into three categories: none, minor error (no influence on measurements) and major error. RESULTS A total of 7.3% of all OCT scans showed scanning artifacts: 5 motion artifacts, 9 scans with low signal intensity and 1 decentred scan. Scanning artifacts significantly increased the frequency of software errors (p = 0.012). The presence of retinal pathology also increased the number of errors (p = 0.004). Software analysis yielded a total of 20 major and 2 minor errors for the Stratus OCT (overall 10.7%) and 32 major and 64 minor errors for the Datamedical Viewer (p < 0.001). Measurements by Datamedical OCTview were a mean of 57 micron higher due to a different definition of the outer retinal border. Retinal pathologies significantly increased the likelihood of software errors for both algorithms (both p < 0.01), most critical were macular holes and changes in age-related macular degeneration. CONCLUSION Scanning artifacts were associated with a significantly higher frequency of software errors. As artifacts of scans and software occur frequently, the interpretation of OCT scans requires special attention to artifacts.

Purpose Cost-utility and cost-effectiveness analyses are of increasing importance to clinicians and health policy experts. This study determines the costs in Germany and other countries in relation to gain of utility for patients with bilateral poor vision owing to corneal disease undergoing penetrating keratoplasty (PK) in 1 eye. Design A cost-utility analysis was performed using retrospective clinical data and high-level evidence-based data. Participants Sixty patients (mean age, 46.3 years) with bilateral poor vision who underwent PK for corneal disease. Methods Visual acuity and utility values were obtained before and 1 year after PK and after suture removal. A 10-year graft survival rate of 80% was assumed. Expenses included costs for the corneal transplant and surgery, medication, and optical rehabilitation. A discount rate of 5% was applied for costs and quality-adjusted life years (QALYs). Cost-utility analysis encompassed a 10-year period after surgery. Main Outcome Measures The number of QALYs was calculated for the study group undergoing PK. This was divided into the cost of the procedure to get the number of euros spent per QALY gained. Results Median binocular preoperative visual acuity was −log mean angle of resolution (−logMAR) 0.91±0.53 (Snellen equivalent 20/160) yielding a utility value of 0.67. After suture removal and optical rehabilitation, binocular visual acuity increased to median −logMAR 0.36±0.36 (20/46) with a utility value of 0.79. Over the 10 years after surgery and considering graft survival and discounting, a cost utility of €9551 per QALY was gained (equivalent to US$11 557). One-way sensitivity analysis yielded a range from €7706 to €12874 per QALY, highlighting the robustness of the model. Conclusions Although an expensive procedure, PK is cost effective in patients with bilateral poor vision.

Hintergrund Die „value-based medicine“ (VBM) nimmt eine Bewertung der Aufwendungen (Kosten) fur medizinisches Handeln mit dem resultierenden Nutzen fur den Patienten vor. Das ermoglicht eine quantitative Analyse von Diagnostik- und Therapieoptionen mit zunehmender Bedeutung auch in der Augenheilkunde.

Da mit dem Anstieg der Sehscharfe sowie mit anatomisch-morphologischen Ergebnissen bildgebender Verfahren die Beeintrachtigung des Patienten nach vitreomakularer Chirurgie nur teilweise beschrieben wird, ist es Ziel dieser prospektiven Studie, die Entwicklung der visuellen Lebensqualitat nach operativer Therapie bei epiretinalen Membranen darzustellen. Bei 20 Patienten mit einseitiger epiretinaler Membran wurde praoperativ und 3 Monate nach Vitrektomie mit Peeling die bestkorrigierte Sehscharfe sowie die visuelle Lebensqualitat mit Hilfe des „Visual-Functioning-14-“ (VF-14-)Tests bestimmt. Im Beobachtungszeitraum kam es zu einem Anstieg der medianen bestkorrigierten Sehscharfe von praoperativ 0,28 auf postoperativ 0,4. Die visuelle Lebensqualitat (VF-14-Werte) stieg von 72,8±4,7 (SEM) praoperativ auf 83,3±2,9 postoperativ (p

Der RTA besitzt seit einiger Zeit ein Fotomodul und die Moglichkeit der Papillentopographie. Diese beiden relativ neuen Modi sollen auf ihre klinische Eignung untersucht werden. Dazu wurde die Kombination von Weitwinkelfundusfoto und Netzhautdickenkarte hinsichtlich eines moglichen Telescreenings bei diabetischer Retinopathie an 31 Augen untersucht. Auserdem wurden Normwerte der Papille an einem Kollektiv von je 30 Normalprobanden im „Non-mydriatic-“ denen des „Mydriatic-Modus“ gegenubergestellt, fur den auch die Reproduzierbarkeit ermittelt wurde. Die Sensitivitat des RTA betrug im Mittel 93% fur proliferative diabetische Retinopathie und 100% fur das Erkennen eines diabetischen Makulaodems, wobei die Spezifitaten je nach „Grader“ zwischen 58 und 96% schwankten. Beim Vergleich der Messwerte der Papille lagen die Werte in Miosis bei 4 der 12 Parameter signifikant unter denen in Mydriasis. Fur die vorgestellte Anwendung eines Telescreenings auf diabetische Retinopathie ist der RTA prinzipiell geeignet. Die Papillentopographie ist aufgrund ihrer guten Reproduzierbarkeit zur Glaukomdiagnostik einsetzbar.

BACKGROUND The objective of the study was to illustrate the effect of the extensive changes of the German DRG System on reimbursement of clinical ophthalmology during the years 2003, 2004 and 2005. METHODS All ophthalmologic patients treated as in-patients at the Department of Ophthalmology at the University Munich during the year 2003 served as a reference data basis. By means of appropriate software those cases were then re-grouped according to the G-DRG classification of the years 2003, 2004 and 2005. This resulted in different reimbursements caused only by system changes for an exemplary hospital of maximum medical care. In addition, the same calculations were performed for four virtual, typical clinics based on the calculation data of the "Institut fur Entgeltsysteme (InEK)". For those four clinics it was assumed that 80 % of the cases came from one of the subspecialties retina, glaucoma, cataract or strabismus surgery. RESULTS Changes in the G-DRG system caused the sample hospital of maximum care to loose 8.5 % case mix index (CMI) during the period of 2003 to 2005. For three of the four virtual, typical ophthalmological clinics the theoretic reimbursement conditions also deteriorated: retina surgery -- 10.6 %, glaucoma surgery - 15.8 % and cataract surgery -- 17.9 % CMI. Only strabismus surgery showed an increase of + 5.6 % in CMI during the period examined. CONCLUSION Over the years 2003 to 2005 the CMI clearly deteriorated for many ophthalmological subspecialties given otherwise identical conditions. To calculate the changes specifically for an individual hospital, the individual base rates have to be considered.

Eine Beurteilung der Lebensqualitat von Patienten in der Augenheilkunde ist nicht nur fur Studien und zur Beurteilung neuer Therapien wichtig, sondern gewinnt auch im klinischen Alltag zunehmend fur therapeutische Entscheidungen an Bedeutung. Es steht eine Vielzahl von Instrumenten zur Messung der krankheitsubergreifenden (globalen) Lebensqualitat zur Verfugung. Ein bekannter Fragebogen hierzu ist der Short Form 36 (SF 36). In der Augenheilkunde werden zur Bestimmung der auf den Sehvorgang bezogenen (visuellen) Lebensqualitat spezifischere Instrumente benotigt. Wir geben einen Uberblick der praktischen Bedeutung und klinischen Anwendung von Methoden zur Messung der visuellen Lebensqualitat. Einige Fragebogen sind der Visual Function 14 (VF-14) oder der National Eye Institute Visual Functioning Questionnaire (NEI-VFQ). Diese werden bislang insbesondere bei haufigen ophthalmologischen Erkrankungen wie Katarakt, altersbedingter Makuladegeneration oder Glaukom eingesetzt. Wichtige Studien hierzu wurden bei einer Literaturrecherche in der Medline-Datenbank identifiziert. Es existiert eine Reihe von Instrumenten zur Messung der visuellen Lebensqualitat in der Augenheilkunde. Hohe interne Konsistenz und Validitat konnten fur viele dieser Instrumente nachgewiesen werden. Die Evaluierung der visuellen Lebensqualitat ist ein wichtiger Parameter zur Beurteilung ophthalmologischer Erkrankungen und deren Therapie. Sie sollte von allen in Praxis und Klinik tatigen Augenarzten in alle individuellen klinischen Uberlegungen mit einbezogen werden. Zudem ist sie eine bedeutsame Ergebnisvariable in klinischen und okonomischen Studien.

Purpose A close interaction between neurosensory retina and the retinal pigmentepithelium (RPE) is a prerequisite for normal vision. Glaucomatous damage is characterized by neuroretinal degeneration. As a result, an imbalanced interaction exists. However, there is only limited evidence regarding RPE involvement in glaucoma patients’ eyes. This study investigates the correlation between retinal nerve fiber layer (RNFL) thickness and RPE alterations as detected by widefield fundus autofluorescence (FAF). Methods Peripapillary RNFL thickness was quantified by optical coherence tomography (OCT). The six corresponding retinal areas were defined by a standardized grid and FAF intensity/irregularities were assessed and correlated to RNFL measurements. Results 84 glaucomatous eyes were investigated. A correlation between RNFL thickness and standardized FAF in the corresponding topographic retina segments was observed. Correlation coefficients ranged between -0.12 to 0.35 and were statistically significant in the temporal inferior central field (r=0.35, p=0.02) and the temporal inferior peripheral field (r=0.31, p=0.04). Conclusion This study provides early evidence that in glaucoma RNFL degeneration may be accompanied by corresponding RPE alterations

Purpose Treatment accuracy and patient pain were evaluated using a novel navigating laser (NAVILAS) compared to conventional laser treatment in clinically significant macular edema (CSME). Methods Focal Navilas laser was performed in 42 patients. On color images (CI) and OCT laser spots were analyzed regarding accuracy spot placement compared to planning. Treatment pain was quantified on a visual-analogue-scale (VAS) and compared to a matched control. Up to one year clinical follow-up investigated retreatment and visual acuity compared to a control of 113 patients treated by conventional laser. Results 79% of laserspots were visible on CI, of which 96% were within 100µm from the planned target. OCT confirmed that laser effects were limited to the outer retina . The number of laser spots per patient was 115+/-97 with Navilas, (43+/-36) with conventional laser. Pain on VAS was mean 1.6 (SD 1.0), 4.4 (SD 1.8) for the control. Kaplan-Meier analysis showed separation of the retreatment curves after 4-5 months with less retreatments for Navilas. Conclusion Compared to conventional laser, significantly more laserspots were placed with Navilas, patient reported pain was significantly lower. the tendency for lower retreatment rates tend with Navilas may be important when considering possible combination laser and anti-VEGF drug therapy. Commercial interest

Background Cumulative light exposure is significantly associated with progression of age-related macular degeneration (AMD). Inhibition of vascular endothelial growth factor is the main target of current antiangiogenic treatment strategies in AMD. However, other growth factors, such as platelet-derived growth factor (PDGF) and placenta growth factor (PlGF), have a substantial impact on development of AMD. Previous reports indicate that sorafenib, an oral multikinase inhibitor, might have beneficial effects on exudative AMD. This study investigates the effects of sorafenib on lightinduced overexpression of growth factors in human retinal pigment epithelial (RPE) cells. Methods Primary human RPE cells were exposed to white light and incubated with sorafenib. Viability, expression, and secretion of VEGF-A, PDGF-BB, and PlGF and their mRNA were determined by reverse transcription-polymerase chain reactions, immunohistochemistry and enzyme-linked immunosorbent assays. Results Light exposure decreased cell viability and increased expression and secretion of VEGF-A, PDGF-BB and PlGF. These light-induced effects were significantly reduced when cells were treated with sorafenib at a dose of 1 mg/ml. Conclusion The results show that sorafenib has promising properties as a potential antiangiogenic treatment for AMD.

Purpose To investigate accuracy of a navigating laser photo-coagulator in clinically significant macular edema. Methods Focal laser in 20 patients was digitally planned on fundus images and performed with navigation using Navilas® (OD-OS GmbH, Teltow, Germany). On color images, OCT and autofluorescence we analyzed 784 laser spots (mean 39 per eye) at one week follow-up and determined accuracy of spot placement using an image flicker method. Results 76% of lesions were visible on color images, 95% were within 100 µm from the planned target. OCT confirmed that laser effects were limited to the outer retina. Conclusion Navilas® laser effects were visualized to high percentage on post-treatment images, location showed high concordance to preplanning.

Purpose The 4. generation fluorochinolon moxifloxacin covers most isolates causing endophthalmitis. It is safe and effective for systemic and topical use, however only very limited data is available on prophylactic intracameral administration to prevent endophthalmitis. This study investigates the safety of Viagamox (moxifloxacin) for intracameral application in a cell culture model Methods Endothelial toxicity of Vigamox (moxifloxacin) was evaluated in cultured human corneas. Toxic effects regarding primary human RPE, trabecular meshwork cells (TMC) and corneal endothelial cells (CEC) were evaluated after 24h and under conditions of oxidative stress. By treating cells with TNF-a, LPS and IL-6 the effects of moxifloxacin on viability under conditions of inflammation were investigated. Toxicity was evaluated by measuring the inhibition of cell proliferation (MTT). Cell viability was quantified by a microscopic live dead assay Results No corneal endothelial toxicity could be detected after 30 days treatment with 500µg/mL moxifloxacin. RPE,TMC,and CEC showed adverse effects on proliferation and viability at concentrations higher than 150µg/mL moxifloxacin only. Preincubation with TNF-a, LPS, IL-6 or H2O2 and subsequent treat with moxifloxacin concentrations up to 150µg/ml for 24h had no significant effect on proliferation and viability Conclusion Moxifloxacin concentrations up to 150µg/mL had no significant toxicity on RPE, TMC, CEC and human corneas. The MIC90 of moxifloxacin for common pathogens of endophthalmitis is known to be in the range of 0.25 - 2.5µg/mL. Therefore, intracameral use of moxifloxacin at concentrations up to 150µg/mL may be safe and effective to prevent endophthalmitis after intraocular surgery

Purpose: Primary open-angle glaucoma (POAG) is one of the leading cause for blindness. Activation of optic nerve head astrocytes (ONHA) and loss of trabecular meshwork cells (TMC) are pathognomonic for this disease. Oxidative stress (OS) and elevated levels of TGF-beta play an important role in the pathogenesis of this neurodegenerative disease. This study investigates possible anti-apoptotic and cytoprotective effects of Minocycline (M) on TMC and ONHA under OS and TGF-beta. Methods: TMC and ONHA were treated with 1μM to 150μM M. Possible toxic effects and IC50 were evaluated after 24h (MTT). To investigate possible protective effects of M on TMC and ONHA, cell proliferation and viability was examined. Expression of XIAP, Survivin as well as Bcl-2 and their mRNA was assessed by RT-PCR 24h after treatment with M alone, additional incubation with TGF-beta-2 and OS. Results: M concentrations from 1μM to 75μM showed no toxic effects on TMC and ONHA. Under conditions of OS both TMC and ONHA showed an increase in viability and ability to proliferate when treated with 20-40μM M. RT-PCR yielded an overexpression of XIAP, Survivin and Bcl-2, when TMC or ONHA cells were treated with 20-40μM M for 24 hours, under OS and when additionally incubated with TGF-beta2. Conclusions: We could show that M does not have toxic effects on TMC and ONHA cells up to 75μM. The observed increase in viability and proliferation under OS and TGF-beta2 and the overexpression of XIAP, Survivin and Bcl-2 after treatment with 20-40μM M might prevent apoptotic-cell-death in response to cellular stress and may be a protective pathway for TMC and ONHA to avoid progression of glaucomatous degeneration.

This paper discusses some of the issues associated with operating a large products pipeline system, which is typically fed from multiple, very reliable, utility owned electric systems, temporarily on distributed generation. As a result of hurricane Katrina, the heart of the pipeline system was disabled by the loss of 13 pump stations over a contiguous 200-mile stretch. This paper describes the paths taken to re-energize the pump stations using multiple 2000 kW diesel generators connected in parallel to allow a combination of 9000 horsepower to be operated. An introduction to generator "droop circuits" as it pertains to the control of the multiple generators is discussed. The logistical problems that must be overcome when as large an area was affected by a long duration power outage are discussed as well as lessons learned from the experience and recommendations for future preparedness

Purpose: To compare and correlate imaging of classic subfoveal choroidal neovascularization (CNV) with noninvasive 3-dimensional imaging by the retinal thickness analyzer (RTA) to conventional fluorescein angiography (FA). Methods: A total of 29 eyes of 29 consecutive patients with predominantly classic CNV eligible for photodynamic therapy underwent FA and RTA imaging. The FA dimensions of the CNV were measured independently by two graders. With the RTA, masked to FA the size of the CNV itself as imaged in 3-dimensional reconstruction, the size of significantly thickened retina overlying the CNV and the maximum retinal thickness were measured. Results: The mean diameter of the CNV determined from 3-dimensional RTA reconstructions showed an excellent correlation with measurements from FA (r = 0.91, p < 0.001). The area of retinal thickening was by a mean of 0.7 mm in diameter larger and correlated moderately well with the size of the CNV on FA (r = 0.65, p < 0.001). In contrast, there was no correlation between the absolute retinal thickness and the CNV size on FA. Conclusions: Noninvasive quantitative mapping of predominantly classic CNV by RTA is feasible and also allows 3-dimensional measurement of the lesion itself. The results correlate well with FA assessment but visualize different properties of the disease.

Hintergrund Mit dem Jahr 2004 begann fur alle deutschen Krankenhauser verpflichtend der schrittweise Umstieg auf ein diagnosebasiertes Fallpauschalensystem. Die Vergutung eines Patienten nach den „Diagnosis Related Groups“ (DRG) richtet sich masgeblich nach der Diagnose und Behandlung eines Patienten. Ziel dieser Untersuchung ist es, die Daten der „Erstkalkulation“ im Bereich Augenheilkunde auf ihre Homogenitat zu untersuchen.

Introduction Quality of life (QoL) plays an increasingly important role in clinical studies and for the assessment of new technologies. It is directly relevant for evidence based individual patient treatment. Therefore the current study aims to summarize the impairment of vision-related QoL in selected diseases and their treatments. Materials and methods A short review based on the methods of assessing quality of life is given. Focussing on important retinal diseases like age related macular degeneration, diabetic retinopathy and disorders of the vitreoretinal interface (macular holes, ERM) the impairment of vision-related QoL by the diseases and changes by treatment are illustrated. Implications for clinical practice are discussed and recommendations are given. Observation While in some conditions visual acuity transfers well into visual QoL, this is frequently not the case and sometimes there is only weak or no correlation. Visual QoL is a more comprehensive endpoint including many other factors that influence vision such as visual field impairment, metamorphopsia or color perception. The visual QoL is also an expression of the visual preference of the individual patient. Discussion As patient perceived quality of vision may be considered the real goal of ophthalmologic therapy, it should also be considered more systematically in daily practice. Visual quality of life has a different information value than visual acuity. Evidence based study results of large patient numbers can be applied to decide on the most suitable therapeutic regimen for the individual patient. Conclusion Visual QoL has increasing importance not only in clinical studies but also in actual therapeutic decision making for the individual patient, although on many points further research is needed.