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INTRODUCTION: The implantation of the PRESERFLO™ MicroShunt (PMS) device has been shown to significantly lower increased intraocular pressure (IOP) in patients with primary open-angle glaucoma (POAG). However, guidelines on best practice for patient selection and pre-/peri-/postoperative care management are lacking. The aim of this modified Delphi panel was to achieve expert consensus on the role of the PMS to treat patients with glaucoma in Europe. METHODS: Twelve European glaucoma surgeons experienced with the PMS procedure participated in a three-round modified Delphi panel. A targeted literature review and expert steering committee guided round 1 questionnaire development. Consensus was set at a pre-defined threshold of at least 70% of panellists selecting 'Strongly disagree'/'Disagree' or 'Strongly agree'/'Agree' for six-point Likert scale questions, or at least 70% selecting the same option for multiple-choice questions. Questions not reaching consensus were restated/revised for the next round, following guidance from free-text responses/scoping questions. RESULTS: Consensus was achieved for 60.3% (n = 38/63), 60.0% (n = 18/30), and 100.0% (n = 11/11) of Likert/multiple-choice questions in rounds 1, 2, and 3, respectively. There was agreement that the PMS procedure is effective at reducing IOP in patients with high-tension POAG (greater than 21 mmHg). Although surgical techniques may vary slightly, consensus was reached on several points, including the importance of posterior application of mitomycin C (MMC). Panellists agreed that the PMS postoperative follow-up appointment schedule is reasonably predictable and mostly characterised by fewer visits than with trabeculectomy, particularly in the early phase. Although panellists agreed that combined cataract/PMS surgery and the use of non-MMC wound-healing modulators/antifibrotics during the procedure are possible, further data are needed to determine efficacy. CONCLUSION: The expert consensus reached in this panel will help inform best practice guidelines in the treatment of patients with glaucoma in Europe. Panellists also highlighted key areas for future research to improve understanding of the PMS in the treatment algorithm of glaucoma. ispartof: OPHTHALMOLOGY AND THERAPY vol:11 issue:5 pages:1743-1766 ispartof: location:England status: published

Aims This exploratory randomized controlled trial (RCT) aimed to determine the splint-related outcomes when using the novel biodegradable wood-composite splint (Woodcast) compared to standard synthetic fibreglass (Dynacast) for the immobilization of undisplaced upper limb fractures in children. Methods An exploratory RCT was performed at a tertiary paediatric referral hospital between 1 June 2018 and 30 September 2019. The intention-to-treat population consisted of 170 patients (mean age 8.42 years (SD 3.42); Woodcast (WCG), n = 84, 57 male (67.9%); Dynacast (DNG), n = 86, 58 male (67.4%)). Patients with undisplaced upper limb fractures were randomly assigned to WCG or DNG treatment groups. Primary outcome was the stress stability of the splint material, defined as absence of any deformations or fractures within the splint during study period. Secondary outcomes included patient satisfaction and medical staff opinion. Additionally, biomechanical and chemical analysis of the splint samples was carried out. Results Of the initial 170 patients, 168 (98.8%) completed at least one follow-up, and were included for analysis of the primary endpoint. Both treatment groups were well-matched regarding to age, sex, and type and localization of the fracture. Splint breakage occurred in three patients (3.6%; 95% confidence interval (CI), 0.007% to 0.102%) in the WCG and in three children (3.5%, 95% CI 0.007% to 0.09%) in the DNG (p > 0.99). The incidence of splint-related adverse events did not differ between the WCG (n = 21; 25.0%) and DNG (n = 24; 27.9%; p = 0.720). Under experimental conditions, the maximal tensile strength of Dynacast samples was higher than those deriving from Woodcast (mean 15.37 N/mm² (SD 1.37) vs 10.75 N/mm² (SD 1.20); p = 0.002). Chemical analysis revealed detection of polyisocyanate-prepolymer in Dynacast and polyester in Woodcast samples. Conclusion Splint-related adverse events appear similar between WCG and DNG treatment groups during the treatment of undisplaced forearm fractures. Cite this article: Bone Joint J 2020;102-B(10):1405–1411.

To ascertain the types of childhood glaucoma managed at major international centers, current clinical practice, and intraocular pressure (IOP) control and visual acuity (VA) outcomes.Prospective, multicenter, consecutive case series.All children with newly diagnosed glaucoma in at least 1 eye who fulfilled the Childhood Glaucoma Research Network (CGRN) definition of childhood glaucoma were recruited over a 1-year period with the aim of 18 months follow up.Demographic, clinical, management data (including complications), and outcomes (IOP and VA) were entered in a secure online database. All cases included in the outcome analysis had a minimum of 6 months follow-up.The management of childhood glaucoma, IOP control, and VA outcomes.A total of 441 children (691 eyes) with newly diagnosed glaucoma were enrolled from 17 international centers. Approximately 60% of patients came from 2 centers in India; however, 47.5% of Indian patients had no or less than 6 months of follow-up outcome data from diagnosis. Primary congenital glaucoma (PCG) was the most common diagnosis (45.4%, n = 314 eyes). There was a statistically significant association between diagnosis and ethnicity/race (P0.001), with PCG more frequent in nonwhite patients, glaucoma associated with acquired conditions more frequent in South Asian patients, and glaucoma after cataract surgery more frequent in white patients. The initial surgical procedure of choice for eyes with PCG significantly differed by country. Angle surgery alone was first line in centers in the United States, United Kingdom, Germany, Saudi Arabia, Singapore, and Israel (Group 1), whereas combined trabeculotomy-trabeculectomy was the first-line procedure for PCG in centers in India and Ghana (Group 2). There was no significant difference in IOP control nor VA between the 2 groups.The most common diagnoses in this international study of children with newly diagnosed glaucoma in order of frequency were PCG, glaucoma after congenital idiopathic cataract surgery, and glaucoma associated with trauma. Indian children had a disproportionately high loss to follow-up rate. Despite international differences in the surgical approach to PCG, there was no statistically significant difference in IOP or VA outcomes. We hope the results of this study will inform key areas of future international, collaborative clinical research in childhood glaucoma.

Strain-hardening cement-based composites (SHCC) are characterized by numerous fine cracks being formed under tension and, consequently, by a high post-cracking deformability. The age dependence of this behavior was experimentally investigated for a cement-based mortar containing randomly distributed polyvinyl alcohol (PVA) fibers. Specimens made of this material were subjected to uniaxial tension. The age of initial loading varied from seven days to almost seven months. In addition to the stress-strain curves, the crack patterns were recorded and evaluated by optical methods. The first-cracking stress slightly increased and the strain at crack localization decreased with the material’s age at initial loading. Despite the observed age effect, the material did still exhibit strain-hardening behavior after almost seven months. No systematic influence of the age on the crack width distribution was found.

OBJECTIVE: The World Health Organization created the Severe Acute Respiratory Infection (SARI) criteria in 2011 to monitor influenza (flu)-related hospitalization. Many studies have since used the SARI case definition as inclusion criteria for surveillance studies. We sought to determine the sensitivity, specificity, positive predictive value, and negative predictive value of the SARI criteria for detecting ten different respiratory viruses in a Middle Eastern pediatric cohort. MATERIALS AND METHODS: The data for this study comes from a prospective acute respiratory surveillance study of hospitalized children

Purpose To determine feasibility, efficacy, and safety of ab externo 360-degree trabeculotomy with illuminated microcatheter for congenital glaucoma. Patients and methods The postoperative results of 36 eyes in 23 consecutive patients who underwent 360-degree trabeculotomy for primary congenital glaucoma (PCG) or secondary congenital glaucoma using an illuminated microcatheter were retrospectively analyzed. Success criteria were defined as intraocular pressure (IOP) ≤18 mm Hg without (complete success) and with medication (qualified success). Results In all previously nonoperated eyes with PCG (group 1), the Schlemm's canal was identified and circumferentially cannulated for 360-degree trabeculotomy. In group 2 comprising of operated eyes with PCG and eyes with secondary congenital glaucoma, the performance of 360-degree trabeculotomy failed in 4 eyes because of the Schlemm's canal occlusion or high tissue resistance of the trabecular meshwork. Mean preoperative IOP was 28.6±5 and 29.6±9 mm Hg with 7 of 20 eyes and 7 of 9 eyes receiving IOP-lowering medication in group 1 and group 2, respectively. Mean postoperative IOP was reduced to 13±2.7 and 20.2±7.1 mm Hg after a mean follow-up of 15.3 and 12.7 months with 4 of 20 eyes and 5 of 9 eyes receiving medication in group 1 and group 2, respectively. Four eyes underwent further surgery. Complete success was achieved in 16 and 3 eyes, whereas qualified success was achieved in 20 and 4 eyes from group 1 and group 2, respectively. In all eyes, a mild to moderate postoperative hyphema was observed. Conclusions Ab externo catheter-assisted 360-degree trabeculotomy controls IOP in a majority of patients with congenital glaucoma after a single operation. Moderate blood reflux in the anterior chamber is considered as a common postoperative finding. We did not observe hypotony or other severe complications in our series. In 1 patient, we experienced catheter misdirection in an eye that had previously undergone trabeculotomy.

Despite advances in surgical technique and postoperative care, fibrosis remains the major impediment to a marked reduction of intraocular pressure without the need of additional medication (complete success) following filtering glaucoma surgery. Several aspects specific to filtering surgery may contribute to enhanced fibrosis. Changes in conjunctival tissue structure and composition due to preceding treatments as well as alterations in interstitial fluid flow and content due to aqueous humor efflux may act as important drivers of fibrosis. In light of these pathophysiological considerations, current and possible future strategies to control fibrosis following filtering glaucoma surgery are discussed.

Im Kapitel zu neuen Formen der Fuhrung wird ein vertiefter Einblick in die Themen neuer Organisation- und Fuhrungsformen gewahrt. Aus der breiten Palette an aktuell in der Theorie und Praxis diskutierten Themen greifen die Autoren zum einen den „Holacracy-Ansatz“ als eine moderne Form Organisationen zu Fuhren auf, und beleuchten zum anderen die Idee der Fuhrung aus der eigenen Mitte, welche den Zusammenhang und Nutzen von Zen-Meditation und Leadership aufzeigt. Beide Aspekte konnen als neue und uberraschende Perspektiven auf das Fuhrungsthema verstanden werden. Personliche Erfahrungen und Berichte aus der Literatur und Praxis attestieren beiden Ansatzen sowohl fur die Fuhrungskrafte als auch fur die Organisationen Vorteile. Diese werden im vorliegenden Kapitel erlautert. Gleichzeitig sollen auch kritische Aspekte beleuchtet werden, um den Lesern einen ausgewogenen Eindruck zu vermitteln und eine Grundlage zu schaffen, um sich differenziert mit den genannten Themen auseinanderzusetzen.

Comparison of the 2-year results of phacotrabeculectomy (CET) and trabeculectomy (TE), both augmented with mitomycin C.This prospective study enclosed 246 eyes in 246 consecutive patients that had undergone trabeculectomy (n = 85) or phacotrabeculectomy (n = 161, hereof n = 10 phacoretrabeculectomy) augmented by mitomycin C. Endpoints were best corrected visual acuity (BCVA), intraocular pressure (IOP), and number of antiglaucomatous medications at baseline, 3 months, and 2 years postoperatively. Postoperative management involved local steroid application and laser suture lysis according to a standardized protocol.Both interventions reduced IOP statistically significant and stable. In the phacotrabeculectomy group BCVA improved from 0.45 ± 0.47 logMAR units preoperatively to 0.28 ± 0.54 logMAR units at 2 years (p0.001) and remained unchanged in the trabeculectomy group. After 2 years IOP reduced from 22.5 ± 7.2 mm Hg preoperatively to 11.5 ± 3.1 mm Hg in the TE group and from 20.0 ± 5.4 mm Hg to 12.5 ± 4.8 mm Hg in the CET group (both p0.05). The mean number of antiglaucomatous medications was significantly reduced from 2 ± 1 in both groups to 0.3 in the trabeculectomy group and to 0.4 in the phacotrabeculectomy group. With this standardized surgical procedure and postoperative protocol, there was no need for local postoperative antimetabolites. No Tenon's capsule cysts developed. In the subgroup of patients with phacoretrabeculectomy BCVA and IOP improvements were comparable to the phacotrabeculectomy group outcomes.Phacotrabeculectomy is comparably as effective as trabeculectomy alone in reducing IOP and the need for antiglaucomatous medication over a time interval of 2 years. We found indications that this favourable therapeutic effect is also true for patients needing phacoretrabeculectomy treatment.

Die Führungskräfte des vorgestellten Unternehmens bewegen sich in einem prozessgesteuerten Umfeld. Die unterste Führungsebene, die Teamleiter sind daher sehr stark in das Alltagsgeschäft involviert und können wenige Ressourcen für ihre Führungsaufgaben und für die Zukunftsgestaltung ihres Bereiches einsetzen. Daher möchte die Unternehmensleitung den Grad der Selbstorganisation in den Teams erhöhen. Dies soll dazu führen, dass Mitarbeitende das Alltagsgeschäft selbstorganisiert erledigen und den Führungskräften mehr Ressourcen für ihre Führungsrolle zur Verfügung stehen. Zur Umsetzung wurden zwei Referenzteams ausgewählt, die nach Prinzipien der Scrum-Methodik ihre Selbstorganisation und Agilität erhöhen sollen. Verbesserungen wurden sowohl auf qualitativen Dimensionen (Steigerung Arbeitszufriedenheit, Motivation, Freiräume der Führung) als auch auf quantitativen Dimensionen (Steigerung der Effizienz und Leistung) erwartet. Damit das gesamte Unternehmen von den Erfahrungen lernen kann, sollte der Prozess mit Elementen der Organisationsentwicklung begleitet und unterstützt werden. Der gesamte Prozess wird in diesem Kapitel vorgestellt.

Purpose To compare the outcomes of canaloplasty and trabeculectomy in open-angle glaucoma. Methods This prospective, randomized clinical trial included 62 patients who randomly received trabeculectomy (n = 32) or canaloplasty (n = 30) and were followed up prospectively for 2 years. Primary endpoint was complete (without medication) and qualified success (with or without medication) defined as an intraocular pressure (IOP) of ≤18 mmHg (definition 1) or IOP ≤21 mmHg and ≥20% IOP reduction (definition 2), IOP ≥5 mmHg, no vision loss and no further glaucoma surgery. Secondary endpoints were the absolute IOP reduction, visual acuity, medication, complications and second surgeries. Results Surgical treatment significantly reduced IOP in both groups (p

Die Trabekulektomie bewirkt eine ausgezeichnete Senkung des Augeninnendrucks (IOD) und stellt bislang die Referenztechnik in der Glaukomchirurgie dar. Die Kanaloplastik ist ein nicht penetrierendes Verfahren, das mithilfe der Einfuhrung eines Fadens in den Schlemm-Kanal der Aufspannung des Trabekelmaschenwerks dient und somit den naturlichen Kammerwasserabfluss wiederherstellt. Diese Ubersichtsarbeit beschreibt den Vergleich von Trabekulektomie und Kanaloplastik mit und ohne Kataraktoperation. Es erfolgt eine Beschreibung und Diskussion von Original- und Ubersichtsarbeiten sowie Fallberichten aus der Literatur. Die Trabekulektomie erreicht eine hohere Drucksenkung ohne zusatzliche Glaukommedikation, jedoch treten haufiger schwere visusbedrohende Komplikationen auf. Die Kanaloplastik zeigt interessanterweise in Kombination mit einer Kataraktoperation eine starkere Drucksenkung. Dagegen hat die alleinige Trabekulektomie einen besseren drucksenkenden Effekt als die Phakotrabekulektomie, da es aufgrund einer vermehrten Entzundungsreaktion zu einem Versagen des Filterkissens kommen kann. Die Kanaloplastik kann eine Erganzung zur Trabekulektomie darstellen, wenn ein hoherer Ziel-IOD und drucksenkende Augentropfen toleriert werden, da die Inzidenz von Komplikationen gering und die postoperative Nachsorge weniger aufwendig ist. Fur Patienten in einem fruhen Stadium der Erkrankung sowie Hochrisikopatienten fur ein Versagen der Filteroperation kann die Kanaloplastik insbesondere in Kombination mit einer Kataraktoperation, die einen additiven drucksenkenden Effekt hat, als Option gesehen werden.

Einleitung: Die Trabekulektomie (TET) stellt bisher den Goldstandard in der operativen Therapie des Glaukoms dar. Sie bewirkt eine effiziente Augeninnendrucksenkung, kann jedoch mit zahlreichen intra- und postoperativen Komplikationen verbunden sein. Bei der Kanaloplastik (KP) handelt es sich um ein nicht penetrierendes Verfahren, das auf eine Wiederherstellung der naturlichen Abflusswege ohne subkonjunktivale Fistulation zielt. Ziel: Ziel dieser Studie ist es, die beiden Verfahren bez. der intraokularen Drucksenkung (IOD), dem Erreichen von definierten Zieldruckkriterien, der postoperativ drucksenkenden Medikamente, des Visusverlaufs und der Komplikations- bzw. Interventionsrate zu vergleichen. Patienten und Methoden: Bei 22 Augen wurde eine TET und bei 22 Augen eine KP durchgefuhrt. In dieser retrospektiven Analyse wurden die Tensiowerte, die antiglaukomatose Therapie und der Visus praoperativ, nach 6 Monaten, 12 Monaten und im Rahmen der letzten Kontrolluntersuchung postoperativ erhoben. Postoperativ wurden die Komplikationen und Interventionen nach den jeweiligen Eingriffen erfasst. Ergebnisse: Der mittlere IOD wurde in der TET-Gruppe statistisch signifikant von einer praoperativen Ausgangsdrucklage von 23,91 ± 10,68 mmHg auf postoperative 10,82 ± 3,67 mmHg gesenkt. Der mittlere IOD in der KP-Gruppe wurde ebenfalls statistisch signifikant von praoperativen 23,68 ± 7,57 mmHg auf postoperative 14,50 ± 3,80 mmHg gesenkt. Die Komplikationen und notwendigen postoperativen Interventionen waren in beiden Gruppen nicht statistisch signifikant unterschiedlich. Ein Complete Success (Drucksenkung von unter 21 mmHg mit gleichzeitiger 20 %iger Drucksenkung vom Ausgangswert ohne jegliche lokale Therapie) nach der gesamten Beobachtungszeit wurde in der TET-Gruppe von 18 Patienten (81,8 %) und in der KP-Gruppe von 11 Patienten (50,0 %) (p = 0,026) erzielt. Schlussfolgerung: Die Resultate dieser Studie zeigen, dass sowohl die KP als auch die TET sichere und wirkungsvolle operative Methoden zur Behandlung des Offenwinkelglaukoms darstellen. In beiden Gruppen konnte der praoperative IOD sowie die applizierten lokalen antiglaukomatosen Medikamente durch den jeweiligen Eingriff statistisch signifikant reduziert werden. Eine langfristig tiefere Senkung des IOD ohne zusatzliche antiglaukomatose Medikation wird mittels einer TET erreicht, die jedoch in der fruhen postoperativen Phase mit einer leicht erhohten (nicht statistisch signifikant) Komplikationsrate einhergeht.

Pelvic ring stability is maintained passively by both the osseous and the ligamentous apparatus. Therapeutic approaches focus mainly on fracture patterns, so ligaments are often neglected. When they rupture along with the bone after pelvic ring fractures, disrupting stability, ligaments need to be considered during reconstruction and rehabilitation. Our aim was to determine the influence of ligaments on open-book injury using two experimental models with body donors. Mechanisms of bone avulsion related to open-book injury were investigated. Open-book injuries were induced in human pelves and subsequently investigated by anatomical dissection and endoscopy. The findings were compared to CT and MRI scans of open-book injuries. Relevant structures were further analyzed using plastinated cross-sections of the posterior pelvic ring. A fragment of the distal sacrum was observed, related to open-book injury. Two ligaments were found to be responsible for this avulsion phenomenon: the caudal portion of the anterior sacroiliac ligament and another ligament running along the ventral surface of the third sacral vertebra. The sacral fragment remained attached to the coxal bone by this second ligament after open-book injury. These results were validated using plastination and the structures were identified. Pelvic ligaments are probably involved in sacral avulsion caused by lateral traction. Therefore, ligaments should to be taken into account in diagnosis of open-book injury and subsequent therapy. Clin. Anat. 27:770–777, 2014. © 2013 Wiley Periodicals, Inc.

To compare 2 different application methods of mitomycin C (MMC) in patients undergoing trabeculectomy. This retrospective trial compared outcomes of 191 eyes that underwent trabeculectomy with small-area (96 eyes; 50.3%) and large-area (95 eyes; 49.7%) MMC application. Main outcome measures were changes in intraocular pressure (IOP), required glaucoma medications, the frequency of complications, and postsurgical interventions. Within both treatment groups, a highly significant IOP reduction was seen during follow-up (p0.0001). Statistical analyses revealed a significant difference in IOP between both groups. Patients treated with a larger size of surface area had a higher IOP reduction within the first postoperative year. Choroidal detachment, shallow anterior chamber, and bleb leak were seen more often in the large-area group with more aggressive MMC use. In contrast, complications associated with bleb failure such as bleb scarring were higher in the small-area group. Success rate was higher in the large-area MMC application group after 12 months. Large-area treatment seems to be a more efficient application method of MMC during trabeculectomy.

PURPOSE To report successful laser treatment of an iris varix. METHODS A 66-year-old man presented with an incidental finding of a cystic lesion within the iris stroma in his right eye. He developed a blood-filled and partly thrombosed tumor of the iris stroma and complained about blurred vision due to spontaneous hyphema during follow-up. RESULTS Ultrasound biomicroscopy showed a prominent and liquid-filled lesion within the iris stroma. Iris fluorescein angiography revealed a thrombosed iris tumor without intrinsic vascularization or feeding vessels. Therefore, diagnosis of an iris varix was made clinically. Recurrent bleeding occurred during follow-up and led to decreased visual acuity. Combined argon and diode laser photocoagulation was successful in terminating rebleeding and resulted in a scarred iris varix. CONCLUSIONS Symptomatic iris varices can be treated safely by combined argon and diode laser photocoagulation, facilitating a less invasive approach than surgical excision.

Von der nicht penetrierenden Glaukomchirurgie (NPGS) profitieren vor allem Patienten mit einem erhohten Komplikationsrisiko (hohe Myopie, Aphakie, fortgeschrittener Gesichtsfeldschaden). Patienten mit einer Engwinkelkomponente (fur die NPGS sollte mindestens der Skleralsporn sichtbar sein), Neovaskularisationsglaukom oder traumatischem Sekundarglaukom sind nicht fur die NPGS geeignet. Die tiefe Sklerektomie zielt hauptsachlich auf eine externe subkonjunktivale Drainage und kann durch den Einsatz von Mitomycin C und intraskleralen Implantaten zur Trabekulektomie vergleichbare IOD-Werte und Erfolgsraten erzielen. Die Viskokanalostomie und als deren Weiterentwicklung die Kanaloplastik zielen auf eine IOD-Regulation ohne Sickerkissen. Die Viskokanalostomie ist zwar sehr komplikationsarm, fuhrt aber nicht zu einer intensiven IOD-Senkung. Deutlich gunstigere Ergebnisse zeigt die Kanaloplastik. Ihre Druckwerte erreichen vor allem in der Kombination mit der Phakoemulsifikation die IOD-Senkung der kombinierten Phakotrabekulektomie und weisen eine nachhaltigere Erfolgsrate auf als die alleinige Kanaloplastik.

Purpose: The aim of this study was to compare diurnal and nocturnal intraocular pressure (IOP) fluctuations before and after trabeculectomy, and to evaluate the potential of trabeculectomy to even out IOP peaks. Materials and Methods: Retrospectively, 35 diurnal and nocturnal IOP curves of patients (35 eyes) who underwent trabeculectomy were analyzed. Diurnal and nocturnal IOP profiles were recorded from 06:00 to 23:59 and 00:00 to 06:00, respectively. Follow-up was at least 300 days. Two criteria for success were defined: (1) IOP ≤21 mm Hg and at least a 20% IOP reduction from baseline; (2) Results: The preoperative maximum diurnal and nocturnal IOP (IOPmax) were 26.5 ± 5.9 and 23.4 ± 5.2 mm Hg, respectively. The postoperative diurnal and nocturnal IOPmax were 16 ± 4.4 and 16 ± 5.4 mm Hg, respectively. Pre- to postoperative IOP reductions were statistically different (day 40% and night 32%; p < 0.001). Diurnal fluctuation was reduced significantly from 12.1 ± 4.2 mm Hg preoperatively to 5.6 ± 2.2 mm Hg postoperatively (reduction of 54%), and nocturnal fluctuation from 7.1 ± 4.5 to 3.9 ± 4.1 mm Hg (reduction of 46%, statistically insignificant due to large SD), respectively. Success criteria 1 and 2 were achieved in 71 and 54% of patients at daytime and in 63 and 57% at nighttime (no statistically significant difference detectable). Follow-up was 2.1 ± 1.7 years. Conclusions: Trabeculectomy achieves a leveling of IOPmax in the diurnal-nocturnal comparison. The preoperative fluctuations could be nearly bisected. Relating to the success criteria, the statistical analysis did not reveal a difference in the diurnal-nocturnal comparison.

PURPOSE We performed a comparative study using Goldmann applanation tonometry (GAT) and dynamic contour tonometry (DCT) to measure intraocular pressure (IOP) in eyes with keratoconus. METHODS IOP was measured in 114 eyes of 75 patients with keratoconus (51 men and 24 women; mean age, 36.1 ± 11.2 years) using GAT and DCT in randomized order. Central corneal thickness (CCT), minimal corneal thickness (MCT), and corneal topography were recorded using the Pentacam. Four groups according to Amsler's keratoconus classification were composed and analyzed for significant differences of CCT, MCT, GAT, and DCT results. RESULTS Mean CCT in the 114 keratoconus eyes was 481.1 ± 46.2 μm (range, 334-601 μm). Mean MCT was 453.3 ± 56.3 μm (range, 239-573 μm). Mean IOP measured using GAT was 13.1 ± 2.9 mm Hg, whereas mean IOP measured using DCT was 14.8 ± 2.6 mm Hg. Neither the results for GAT nor those for DCT showed a significant correlation with CCT (Pearson correlation: P < 0.05). Multifactorial analysis revealed that CCT and MCT, but not GAT and DCT, results were significantly different in corneas of varying curvatures. CONCLUSIONS This study shows that DCT measures IOP higher than GAT in eyes with keratoconus. In keratoconus, both methods seem to be independent of CCT and therefore are equally, but not interchangeably, applicable when monitoring IOP. Further analysis revealed that CCT and MCT are significantly different in corneas of varying Amsler grade.

Technical characteristics and a long-term therapeutic strategy due to a long life expectancy play a key role in pediatric glaucoma surgery. The well-established angle surgery (goniotomy and trabeculotomy) achieves successful results in primary childhood glaucoma. Trabeculectomy seems to have been displaced as a secondary approach by glaucoma drainage devices (GDD) in primary childhood glaucoma due to inferior results, especially for children under 3 years of age. Even for secondary childhood glaucoma the results of GDD are encouraging, especially for therapy refractory aphakic glaucoma. In the first 2 years after GDD surgery success rates are about 80% for pediatric glaucoma and the results appear to be independent of the type of glaucoma and implant used. The complications of GDD are balanced to the faster intraocular pressure (IOP) control during the phase of visual acuity development. Cyclodestructive procedures may be applied as a secondary adjuvant approach but they increase the risk of conjunctival scarring and hypotony for subsequent procedures.

Background Instability of pelvic ring fractures is also caused by ligament disruption. Classifications are based on the major forces leading to fracture. Data from injury mechanisms as well as clinical and radiological criteria are used to determine the degree of instability. The major aim of all kinds of stabilisation is the anatomic reconstruction of the bony pelvic ring. The injured ligamentous apparatus is still ignored. Some clinical trials assume that soft-tissue injuries may be the reason for the poor patient outcome in "open book" pelvic ring fractures. The aim of the study was to develop a realistic finite element (FE) computer model to simulate "open book" fractures and predict injury-associated instabilities for osteosynthesis planning. PATIENTS/MATERIAL: We developed a realistic FE computer model of the pelvic ring based on CT data. With anatomic studies a computer model of the ligamentous apparatus was created and inserted into the pelvic ring to complete the bone-ligament complex. Numerical simulations were performed to identify the influence of single pelvic ligaments on the shifting at the intact anterior and posterior pelvic ring. Additionally, a biomechanical validated virtual crack simulation with anterior-posterior compression forces was undertaken to predict complex instabilities in "open book" pelvic ring fractures. Results The pelvic ligaments have local and general stabilising functions. The sacrospinous and sacrotuberous ligaments are providing the vertical load transfer, whereas the ligaments of the iliosacral joint and the iliolumbal ligament are necessary for the horizontal load transfer. In "open book" fractures ligaments are ruptured stepwise from anterior to posterior. If the intraosseous and posterior ligaments of the iliosacral joint are intact, only single rotational instability along the ipsilateral iliosacral joint occurs. If the ligaments at the posterior pelvic ring are ruptured too, a second axis across both iliosacral joints was measured. In this particular case additional stabilisation of the posterior pelvic ring should be performed. Conclusion With numerical simulations, prediction of injury-associated instabilities is possible. Because of incomplete radiological data the implementation of patient-specific FE pelvic computer models into the clinical routine is still not realistic.

PURPOSE: The success of trabeculectomy in glaucoma not sufficiently controlled by maximal medical therapy substantially depends on postoperative scarring of the filtering bleb. This process of scarring can be inhibited by antimetabolites like mitomycin C (MMC) and 5-fluorouracil (5-FU). The aim of this study is the evaluation of incidence and long-term outcome of corneal surface defects and intraocular pressure following MMC- or 5FU-trabeculectomy using different doses of postoperative 5FU. METHODS: A retrospective, non-randomised comparative study of 381 patients undergoing trabeculectomy with intraoperative application of either 5FU (group A, n = 169) or MMC (group B, n = 212) was performed. Based on the Wuerzburg bleb classification score (WBCS) for postoperative wound healing evaluation, 30 of these operations of group A (group B: n = 26) did not receive 5 FU postoperatively (controls), 67 (93) received up to 7 postoperative injections of 5 mg 5 FU (normal dosage group), and 72 (93) received more than 7 injections (high dosage group). Surface epithelial defects were routinely assessed by slit-lamp microscopy and fluorescein staining. Intraocular pressure (IOP) was measured by Goldmann applanation tonometry. RESULTS: In the normal dosage group the mean total dose of 5 FU was 25.8 ± 9.1 mg in group A (group B: 28.4 ± 7.5 mg) and in the high dosage group 54.2 ± 10.9 mg 5 FU (51.7 ± 11.8 mg), respectively. Increased doses of postoperative 5 FU induced more frequent corneal erosions in both groups. Corneal erosions were seen in controls in 16.7 % (26.9 %), in the normal dosage group in 55.2 % (47.3 %) and in the high dosage group in 77.8 % (59.1 %) in group A and group B, respectively. The incidence of a corneal erosion between group A and group B did not differ significantly (p = 0.074). The mean reduction of intraocular pressure in mmHg did not show a significant difference 12 months after trabeculectomy between controls and postoperative 5-FU operations. CONCLUSION: In eyes with beginning scarring of the filtering bleb after trabeculectomy the subconjunctival injection of 5-FU allows a similar reduction of intraocular pressure as in eyes without scarring. Corneal epitheliopathy following trabeculectomy and postoperative 5 FU is dose-dependent with higher doses leading to a higher incidence of corneal erosions. As serious corneal long-term complications are rare, risk-benefit analysis justifies the application of 5-FU after filtrating glaucoma surgery.

Background: The Wuerzburg bleb classification score (WBCS) aims at an objective and standardized assessment of the developing filtering bleb after trabeculectomy, in order to detect and treat bleb scarring at the earliest possible stage of development. The purpose of this retrospective study was to evaluate the prognostic value of the early postoperative WBCS for the long-term outcome of trabeculectomy. Methods: The WBCS is a grading system for clinical bleb morphology. It evaluates the following parameters: vascularization, corkscrew vessels, encapsulation and microcysts. The WBCS of 113 eyes of 113 consecutive patients after trabeculectomy was determined 1 day, 1 and 2 weeks, 3, 6 and 12 months after surgery. Complete success was defined as an intra-ocular pressure (IOP) 20% pressure reduction without glaucoma medication after 1 year. Results: A complete success rate of 73.9% and a qualified success rate of 82.4% were achieved 1 year after surgery. The average total bleb score during follow-up in the success group was always higher than in the failure group, but there was no statistically significant difference at any time. The bleb average score for eyes with an IOP of ≤12 mm Hg after 2 weeks was significantly higher (p = 0.005) than for eyes with an IOP ≧13 mm Hg at the end of follow-up. Conclusion: Patients with a higher early WBCS postoperatively had a significantly lower IOP 1 year after surgery. However, the study could not reveal a certain prognostic value of the early total bleb score using the WBCS for the long-term complete success of trabeculectomy.

Glaukom und Hornhauterkrankungen sind haufig miteinander assoziiert und beeinflussen sich wechselseitig in Diagnostik, Therapie und Verlauf. Vor Keratoplastik liegt bei ca. 15% der Augen ein Glaukom vor. In etwa 15% der Falle wird ein Glaukom nach Keratoplastik erstdiagnostiziert. Diagnostisch erschwerend wirken sich Hornhauttrubungen, Oberflachenirregularitaten aber auch ein Stromasubstanzverlust oder -odem aus. Neben der palpatorischen Druckschatzung kann in diesen Fallen die intrakamerale Nadeldruckmessung oder zur Bewertung eines Visuspotenzials ein Blitz-visuell-evoziertes Potenzial helfen.

In der Therapie komplexer Glaukome werden verschiedene Ausgangssituationen betrachtet: vorbestehendes Glaukom, Glaukominduktion nach vitreoretinaler Chirurgie und antiglaukomatose Eingriffe. Bei vorbestehendem Glaukom und Zustand nach fistulierender Operation wird zur Erhaltung des Sickerkissens ein vitreoretinaler Zugang mit moglichst bindehautschonender Technik, wie pneumatische Retinopexie und „small-gauge“-Vitrektomie, angewendet. Nach vitreoretinaler Chirurgie steigt haufig der intraokulare Druck (IOD). Sekundarglaukome konnen nach Buckelchirurgie und Vitrektomien mit oder ohne Gas- bzw. Silikonoltamponade sowie nach Steroidgaben auftreten. Winkelblockglaukome nach Buckelchirurgie entwickeln sich infolge von Stauung und anteriorer Rotation des Ziliarkorpers. Intravitreale Gastamponaden mit expansionsfahigen oder auch gesattigten Gasen konnen ein Winkelblockglaukom mit oder ohne Pupillarblock verursachen und die okulare Perfusion kritisch einschranken. Postoperative Kontrollen, sofortiges Handeln und ein Flugverbot verhindern Dauerschaden. Die meisten Sekundarglaukome konnen lokal medikamentos und durch adaquate postoperative Lagerung beherrscht werden. Neben passagerer systemischer Gabe von Antiglaukomatosa oder Laserung ist bei massiver Schwellungsreaktion oder Uberfullung eine direkte Intervention wie partielle Gas- oder Silikonolentfernung erforderlich. Eine prophylaktische inferiore periphere Iridektomie verhindert in aphaken Augen bei intraokularer Tamponade einen Pupillarblock. Bei Einsatz von schwerem Silikonol wird diese superior angelegt. Bei Verschluss derselben ist eine Nd:YAG-Laserung meist tensioregulierend. Die durch Emulsifikation des Silikonols bedingte Uberfrachtung kann durch Trabekelwerkaspiration und Lavage verbessert werden. Bei therapierefraktarem Glaukom haben sich die Zyklophotokoagulation, ggf. repetitiv, und Drainageimplantate zur langfristigen IOD-Regulierung bewahrt. Haufig sind die Ursachen des Sekundarglaukoms multifaktoriell und erfordern eine genaue Beobachtung fur eine situative und erfolgreiche Therapie.

The coincidence of cataract and glaucoma is increasing due to population development. Trabeculectomy is still the most commonly used procedure in combined glaucoma-cataract surgery. However, a two-step approach, starting with cataract surgery should be preferred to minimize the risk of secondary filtering bleb scarring. Postoperative fibrin exudation and the complication rate are more pronounced after combined trabeculectomy compared to combined trabeculotomy and non-penetrating glaucoma surgery. Canaloplasty is a new innovative non-penetrating glaucoma procedure. The results after canaloplasty show an even lower intraocular pressure (IOP) after combined procedures compared to canaloplasty alone. Long-term results have to confirm a sustained decrease of IOP. Surgery of the chamber angle combined with cataract surgery has hardly any complications and preserves the conjunctiva. It also allows medication to be saved and more invasive surgery to be postponed.

Conjunctival scarring remains the major problem in filtering glaucoma surgery. Antimetabolites afford a reduction of scar formation, but considerable side effects limit their application. Here, we review the mechanisms and peculiarities of wound healing following glaucoma surgery and report on new developments in the field of wound healing modulation. The growth factor TGF-beta has a central role in wound healing and scarring. Therefore, novel concepts of wound healing modulation comprise scavenging of TGF-beta and specific inhibition of disinct downstream intracellular signalling pathways. Several compounds have entered preclinical evaluation and offer new potential to modulate scarring in future combination therapies.

Background: To evaluate the influence of early conjunctival suture removal following trabeculectomy on postoperative outcome. Methods: In a prospective randomized clinical trial 73 eyes of 69 consecutive patients eligible for primary trabeculectomy were included in the study. Eyes were randomly assigned to a control or intervention group. Trabeculectomy was performed with a fornix-based conjunctival flap and a conjunctival running mattress-suture. In the intervention group, the conjunctival suture was removed 4 weeks postoperatively, in the control group the suture remained in place. Both groups were followed for up to 12 months and best corrected visual acuity (BCVA), refraction, corneal topography, intraocular pressure (IOP), anterior segment and fundus were assessed preoperatively and within a week, 1, 3, 6 and 12 months after surgery. Statistical analysis was performed using SPSS for Windows (t test for independent samples). Results: Trabeculectomy induced similar astigmatism in both groups. Compared to the control group, suture removal seemed to improve BCVA at 6 and 12 months. This was associated with a significantly lower IOP at 6 and 12 months and a significantly higher complete success rate at 12 months (94 vs. 65%, p < 0.001). Astigmatism was not significantly altered by suture removal. Conclusion: Conjunctival suture material appears to hamper trabeculectomy success and postoperative visual acuity. This is independent of postoperative astigmatism. Early removal of conjunctival sutures is advisable.

Goldstandard in der Diagnostik des intraokularen Drucks (IOD) ist bislang die Goldmann-Applanationstonometrie (GAT), die jedoch abhangig von Hornhautdicke und -kurvatur ist. Bei Patienten mit Keratokonus, die eine anormale Hornhautgeometrie und -dicke aufweisen, ist die Druckmessung mittels GAT oft schwierig und wenig reproduzierbar. Ziel unserer Untersuchung war es, die dynamische Konturtonometrie (DCT), ein digitales Verfahren, das an die normale Hornhautgeometrie angepasst ist, mit der GAT im Hinblick auf ihre Abhangigkeit von der zentralen Hornhautdicke (CCT) bei Keratokonus zu vergleichen. Der IOD wurde bei 54 Patienten (38 Manner und 16 Frauen, mittleres Alter 36±9,9 Jahre) in randomisierter Reihenfolge mit dem GAT und dem DCT erhoben. Alle Patienten hatten einen topographisch gesicherten Keratokonus. Zusatzlich wurde die zentrale Hornhautdicke mittels Pentacam bestimmt. Zur statistischen Auswertung wurde die Pearson-Korrelation berechnet und ein Bland-Altman-Diagramm erstellt. Die mittlere zentrale Hornhautdicke betrug 486,2±45,5 μm. Bei Verwendung der DCT betrug der IOD im Mittel 14,9±2,6 mmHg und bei der GAT 13,3±2,9 mmHg. Damit lag die DCT mit im Mittel 1,6±2,4 mmHg signifikant hoher (p≤0,05). Sowohl die Messungen des IOD mit GAT (r=−0,03; p>0,05) als auch die Messwerte mit DCT (r=0,08; p>0,05) zeigten keine signifikante Abhangigkeit von der CCT. Am Beispiel des Keratokonus bestatigt sich, dass die mittels GAT gemessenen IOD-Werte niedriger sind als bei Verwendung der DCT. Da beide Verfahren unabhangig von der Hornhautdicke messen, eignen sie sich gleichermasen zur Verlaufskontrolle des intraokularen Drucks bei Augen mit Keratokonus, bei denen es zu einer progredienten Hornhautverdunnung kommen kann.

Background Malignant melanoma of the conjunctiva is a rare tumour. Early disease stages may be difficult to distinguish from benign lesions such as pigmented nevi or primary acquired melanosis. We describe the therapeutic procedure and histological findings in two patients and review the epidemiology and pathogenesis of malignant conjunctival melanoma. Two female patients (84 and 85 years old, respectively) presented with a pigmented tumor close to the limbus with surrounding conjunctival pigmentation and involvement of the cornea. Results Following complete excision of the tumour, conjunctival malignant melanoma arising from primary acquired melanosis was diagnosed histologically. Subsequent treatment with mitomycin C eye drops was initiated. There was no recurrence of the tumor within the follow-up period (24 and 6 months). Discussion Patients with primary acquired melanosis need to be reviewed on a regular basis to detect malignant transformation at an early stage.

Purpose: Deep sclerectomy is a non-penetrating filtering procedure that is not generally accepted, as tissue dissection is difficult and varying success rates have been reported. The purpose of the present study was to compare the use of CO2, excimer and erbium:YAG lasers in dissection of the deep corneoscleral lamella. Methods: In enucleated porcine eyes a superficial lamellar scleral flap of 5 × 5 mm was surgically dissected. The deep lamella was removed using a pulsed erbium:YAG, a CO2 or an excimer laser (10 eyes/group). All eyes were analysed histologically and 3 in each group by scanning electron microscopy (SEM). Results: It is feasible to ablate the deep corneoscleral lamella with the CO2, excimer and erbium:YAG lasers without perforating the anterior chamber. The following histology and SEM showed a smoother surface after dissection with the CO2 and excimer lasers compared to the erbium:YAG laser. There was no thermal damage after excimer laser treatment, compared to a damage zone of 10–30 µm using the erbium laser and one of 70–100 µm with the CO2 laser. Conclusions: Excimer,erbium:YAG and CO2 lasers allow the microsurgical dissection of the deep lamella. The excimer and CO2 lasers achieve a more regular and smoother tissue surface. The excimer laser has the advantage to dissect without thermal tissue damage.

Juliane Matlach,1,* Matthias Hipp,1,* Martin Wagner,2,3 Peter U Heuschmann,2,3 Thomas Klink,1 Franz Grehn11Department of Ophthalmology, 2Institute of Clinical Epidemiology and Biometry, 3Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany*These authors contributed equally to this workPurpose: The objective of the study reported here was to evaluate the outcome of a modified filtering trabeculotomy (FTO) without iridectomy in open-angle glaucoma compared with that of conventional trabeculectomy (trab).Patients and methods: Thirty eyes of 30 patients who underwent modified FTO were prospectively followed for 1 year and were compared with 87 conventional trab patients (87 eyes), matched for age and preoperative intraocular pressure (IOP). The FTO procedure consisted of a deep sclerectomy and trabeculotomy preserving the trabeculo-Descemet membrane, without iridectomy. Main outcome measures were complete success (IOP /=30% IOP reduction, without medication), IOP, visual acuity, medication, complications, and subsequent surgeries.Results: In the conventional trab group, the median preoperative IOP was 23.0 mmHg (interquartile range 20.0–27.0) with 3.0 (2.0–3.0) medications, compared with 23.0 mmHg (20.0–27.0) and 3.0 (2.8–4.0) in the modified FTO group. Median postoperative IOP at 12 months was 12.0 mmHg (10.0–13.0) in the conventional trab and 11.0 mmHg (8.0–14.0) in the modified FTO group (P=0.3). The complete success rate at 1 year was 83.1% and 79.3% in the conventional trab group and modified FTO group, respectively (P=0.8). The complications hypotony (20.7%, 24.1%), choroidal detachment (2.3%, 10.3%), and bleb scarring (17.2%, 13.8%), were present in the conventional trab group and modified FTO group, respectively.Conclusion: The outcomes of reduced IOP and medications in the FTO group were not different to those in the conventional trab group over 1 year, but some complications were more often seen with the modified FTO technique. The new filtration trabeculotomy, however, has the advantage of avoiding iridectomy, thus reducing the risk of cataract formation, and may result in the development of more favorable blebs by controlling the flow over two resistance levels.Keywords: glaucoma surgery, open-angle glaucoma, outflow resistance, iridectomy, trabeculectomy

Purpose To evaluate quality of life (QoL) with a new questionnaire after canaloplasty (CP) and trabeculectomy (TE). Patients and methods We assessed outcomes of surgery, rate of revision surgeries, patients’ mood, and influence of postoperative care on QoL, surgery interference with daily activities, and postsurgical complaints. Patients completed the QoL questionnaire 24 months after surgery. Results Patients who underwent CP (n=175) were compared to TE patients (n=152). In the CP group, 57% of patients expressed high satisfaction, while 41% of patients in the TE group said they were highly satisfied. The satisfaction difference was statistically significant (P=0.034). Significantly fewer second surgeries were needed after CP (8% CP versus 35% TE, P

Die Sickerkissenvernarbung ist die Hauptkomplikation nach filtrierender Glaukomchirurgie. Die postoperative Nachsorge entscheidet daher uber Erfolg oder Misserfolg der Operation. Bereits vor der Operation kann durch eine antiinflammatorische Vorbehandlung und Absetzen oder zumindest Reduktion der Lokalmedikation ein gunstiger Effekt auf die Vernarbungsreaktion der Bindehaut erzielt werden. Mit konventioneller Nachsorge nach Trabekulektomie lasst sich nur bei etwa 40% der Patienten langfristig der Zieldruckbereich ohne Medikation erreichen. Durch das Konzept der intensivierten postoperativen Nachsorge kann die Erfolgsrate in 5 Jahren um etwa 25% gesteigert werden. Kern des Konzepts ist eine den Stadien der Wundheilung des Sickerkissens angepasste wundmodulierende Therapie. Die genaue Beachtung der Sickerkissenmorphologie ist Grundlage fur den Einsatz von topischen Steroiden und 5-Fluorouracil. Eine ausfuhrliche Aufklarung des Patienten und engmaschige Kontrollen sind Teil des Behandlungskonzepts. Um Nebenwirkungen der Antimetabolitentherapie zu vermeiden und die Erfolgsrate der filtrierenden Glaukomchirurgie weiter zu steigern, sind ein tieferes Verstandnis der Wundheilungsstadien und eine spezifische vernarbungshemmende Therapie notwendig.

PURPOSE This is a case report of intracorneal hematoma after canaloplasty and clear cornea phacoemulsification. METHODS A 75-year-old woman presented with primary open angle glaucoma and visually significant cataract. Canaloplasty and clear corneal phacoemulsification were performed. Postoperatively she had an intracorneal hematoma, which was removed through a clear corneal tunnel. RESULTS Preoperative best-corrected visual acuity (BCVA) was 20/40 in the right eye and mean intraocular pressure (IOP) was 20 mmHg. Uneventful canaloplasty, clear corneal phacoemulsification, and implantation of a posterior chamber intraocular lens were performed. One day after the operation, BCVA was 20/400 in the right eye. The IOP was 8 mmHg. Anterior segment examination revealed a nasally located intrastromal hematoma between corneal stroma and Descemet membrane. The intracorneal hematoma was removed through a clear corneal tunnel. Six months postoperatively, BCVA was 20/25 in the right eye. The IOP with one medication was 17 mmHg. CONCLUSIONS This operation was a minimally invasive technique to remove intrastromal hematocornea after viscocanaloplasty.

Background: Treatment of choice for symptomatic carotid–cavernous and cavernous–dural fistulas is neuroradiologic intervention via the femoral artery. Owing to the location of the fistula and/or to anatomic variations, a direct surgical approach via the superior ophthalmic vein may be necessary for embolization. Methods: Three patients presented with exophthalmos, episcleral venous congestion, chemosis, restricted eye movement, and secondary glaucoma. One patient had visual impairment and scotoma due to compression of the optic nerve by the fistula. The tentative diagnosis of an arteriovenous fistula was confirmed in two cases by color Doppler imaging and in all three cases with cerebral arterial angiography (two carotid–cavernous fistulas, one cavernous–dural fistula). After an unsuccessful transarterial attempt, embolization via the superior ophthalmic vein was chosen. Results: In all three patients the preparation of the superior ophthalmic vein was performed without any complications. In two cases the fistula could be embolized completely with platinum coils. In one patient the placement of the microcatheter was impossible, because of an abnormal vascular pattern. Later on the fistula was successfully embolized by an approach via the femoral vein. All three patients had complete resolution of symptoms. There were no recurrences. Conclusion: Embolization of carotid–cavernous and cavernous–dural fistulas by a surgical approach via the superior ophthalmic vein represents safe and effective treatment when standard transarterial access is impossible. The cooperation of an orbital surgeon and an invasive neuroradiologist can be of benefit for this rare group of patients.

Um die Vermietbarkeit von Geschosswohnungen zu verbessern, werden zunehmend Balkone an Wohnhauser angebaut. Fenster werden dabei zu Balkonturen umgestaltet. Der oberste Balkon soll dabei stets ein Dach erhalten. Das Dach besteht aus Plattenmaterial Hohlkammerpolykarbonat 16 mm, aufgelegt auf Vierkantprofilen. Ein statischer Nachweis fur die Auflagerung und Befestigung der Hohlkammerplatten in den Vierkantprofilen, im Gegensatz zu dem Plattenmaterial selbst, kann nicht gefuhrt werden. Da seitens des Balkonherstellers gewunscht wird, die Balkone deutschlandweit aufstellen zu konnen, muss die zulassige Belastung des Balkondaches experimentell ermittelt werden. Abgeleitet aus der Bruchlast im Belastungsversuch werden mit einem Sicherheitsfaktor von γ = 2,0 sowohl die zulassige Schnee- als auch die Windlast errechnet.

Background Autoenucleation is a severe, rare form of self-mutilation. The majority of cases have been reported in the 15- to 60-year age group, usually in psychiatric patients with a history of depression or schizophrenia, sometimes caused by drug abuse. Case report We report a case of left-sided autoenucleation in an 84-year-old dementia patient suffering from reactive depression. Medical reports mentioned a suicide attempt 2 weeks prior to the incident, whereupon the patient was admitted to the locked ward of a psychiatric hospital. During one night of inpatient stay, the patient manually autoenucleated his left eye. Inspection of the enucleated organ revealed a completely intact globe with an attached optic nerve 5.5 cm in length. The orbit was filled with a massive haematoma. A contrast-enhanced computed tomography (CT) scan showed an orbital haematoma, absence of the left globe and optic nerve and a chiasmatic lesion, accompanied by an intracranial bleeding into the subarachnoid space. Primary wound closure was performed without complications. Visual acuity of the right eye could not be tested due to the patient's lack of cooperation. Conclusion To the best of our knowledge, this is the only reported case of an elderly patient with primary dementia who performed autoenucleation. Other aspects, such as patient history, suicide attempt, manual eye extraction and chiasma lesion are similar to cases reported earlier. The identification and evaluation of intracranial bleedings and chiasmatic lesions that can be associated with autoenucleation requires a contrast-enhanced CT, especially if a long optic nerve fragment is attached to the enucleated globe.

Purpose Scarring after glaucoma filtering surgery remains the most frequent cause for bleb failure. The aim of this study was to assess if the postoperative injection of bevacizumab reduces the number of postoperative subconjunctival 5-fluorouracil (5-FU) injections. Further, the effect of bevacizumab as an adjunct to 5-FU on the intraocular pressure (IOP) outcome, bleb morphology, postoperative medications, and complications was evaluated. Methods Glaucoma patients (N = 61) who underwent trabeculectomy with mitomycin C were analyzed retrospectively (follow-up period of 25 ± 19 months). Surgery was performed exclusively by one experienced glaucoma specialist using a standardized technique. Patients in group 1 received subconjunctival applications of 5-FU postoperatively. Patients in group 2 received 5-FU and subconjunctival injection of bevacizumab. Results Group 1 had 6.4 ± 3.3 (0–15) (mean ± standard deviation and range, respectively) 5-FU injections. Group 2 had 4.0 ± 2.8 (0–12) (mean ± standard deviation and range, respectively) 5-FU injections. The added injection of bevacizumab significantly reduced the mean number of 5-FU injections by 2.4 ± 3.08 (P ≤ 0.005). There was no significantly lower IOP in group 2 when compared to group 1. A significant reduction in vascularization and in cork screw vessels could be found in both groups (P < 0.0001, 7 days to last 5-FU), yet there was no difference between the two groups at the last follow-up. Postoperative complications were significantly higher for both groups when more 5-FU injections were applied. (P = 0.008). No significant difference in best corrected visual acuity (P = 0.852) and visual field testing (P = 0.610) between preoperative to last follow-up could be found between the two groups. Conclusion The postoperative injection of bevacizumab reduced the number of subconjunctival 5-FU injections significantly by 2.4 injections. A significant difference in postoperative IOP reduction, bleb morphology, and postoperative medication was not detected.

Pelvic ring stability is maintained passively by both the osseous and the ligamentous apparatus. Therapeutic approaches focus mainly on fracture patterns, so ligaments are often neglected. When they rupture along with the bone after pelvic ring fractures, disrupting stability, ligaments need to be considered during reconstruction and rehabilitation. Our aim was to determine the influence of ligaments on open-book injury using two experimental models with body donors. Mechanisms of bone avulsion related to open-book injury were investigated. Open-book injuries were induced in human pelves and subsequently investigated by anatomical dissection and endoscopy. The findings were compared to CT and MRI scans of open-book injuries. Relevant structures were further analyzed using plastinated cross-sections of the posterior pelvic ring. A fragment of the distal sacrum was observed, related to open-book injury. Two ligaments were found to be responsible for this avulsion phenomenon: the caudal portion of the anterior sacroiliac ligament and another ligament running along the ventral surface of the third sacral vertebra. The sacral fragment remained attached to the coxal bone by this second ligament after open-book injury. These results were validated using plastination and the structures were identified. Pelvic ligaments are probably involved in sacral avulsion caused by lateral traction. Therefore, ligaments should to be taken into account in diagnosis of open-book injury and subsequent therapy.