[Quality of Glaucoma Care in the Greater Hamburg Area]. / Erfassung der Versorgungsqualität von Glaukompatienten im Großraum Hamburg.

Background There is insufficient data on the quality of health services and health-related quality of life of patients with glaucoma. The purpose of this study was to investigate the extent to which the health services for glaucoma patients in the Greater Hamburg area conform to the guidelines set by the German Ophthalmological Society (DOG). Materials and Methods 196 glaucoma patients were offered an interview-administered questionnaire during their inpatient diurnal IOP measurement. The quality of glaucoma care and examinations recommended by the DOG were analysed. The results of the questionnaire were correlated with glaucoma severity, according to the stage of visual field defects. The correlation to the type of glaucoma was also analysed. Results The frequency of visits to the ophthalmologist was 5.1 per year. Most patients reported quarterly medical consultations. The majority of patients reported short waiting periods, because appointments were made in advance. In 92 % of cases, an intraocular pressure measurement was performed with each medical consultation. Half of the patients stated that their intraocular pressure had been measured at different times of the day. The visual field was tested a mean of 0.9 times per year at the ophthalmology clinic, but 1.4 times per year in the outpatient area. Further measures for glaucoma diagnostic testing were carried out 0.8 times per year at the ophthalmology clinic, and 0.4 times per year in the outpatient area. For the majority of patients, there were no additional costs for outpatient glaucoma diagnostic testing. Only 4 % of patients had to pay more than 100 € per year for these services. Conclusions For the majority of glaucoma patients in the Greater Hamburg area, the glaucoma health services conform to the guidelines set by the German Ophthalmological Society. Intraocular pressure measurements were performed on almost all patients at the regular check-ups and visual fields were examined as recommended. However, for about one-fifth of the patients, regular procedures for optic nerve analysis do not take place. The date of the next appointment was arranged immediately, allowing close follow-up, with little or no additional costs for the majority of patients.

[The Limits of Selective Laser Trabeculoplasty in Glaucoma Therapy]. / Die Grenzen der selektiven Lasertrabekuloplastik zur Behandlung des Glaukoms.

Introduction: The aim of this study was to evaluate the efficacy of selective laser trabeculoplasty (SLT) in the University Eye Hospital Hamburg Eppendorf. Material and Methods: We conducted a retrospective analysis of 113 eyes of 113 consecutively treated patients who underwent SLT treatment between 03/2011 and 01/2014 and had a follow-up of at least 4 months. Results: Intraocular pressure was reduced by 1.08 mmHg (7 % reduction) on average. In 43.7 % of the treated eyes, additional medical or surgical glaucoma treatment was necessary within 12 months. Conclusion: SLT is not effective as monotherapy in pre-treated eyes with low target pressure.

[Intraoperative Measurement of Refraction with a Hand-Held Autorefractometer]. / Intraoperative Refraktionsmessung mit einem handgehaltenen Autorefraktometer.

PURPOSE: The aim of this study was to evaluate an intraoperative measurement of objective refraction with a hand-held retinomax instrument. METHODS: At the end of cataract surgery objective refraction in a lying position was measured with a retinomax instrument. On the first postoperative day the same measurement was performed with a retinomax and a standard autorefractometer. To evaluate the differences between measurements, the spherical equivalent (SE) and Jackson's cross cylinder at 0° (J0) and 45° (J45) was used. RESULTS: 103 eyes were included. 95 of them had normal cataract surgery. Differences between retinomax at the operative day and the standard autorefractometer were 0.68 ± 2.58 D in SE, 0.05 ± 1.4D in J0 and 0.05 ± 1.4D in J45. There were no statistically significant differences between the groups. CONCLUSION: Intraoperative measurement of the refraction with a retinomax can predict the postoperative refraction. Nevertheless, in a few patients great differences may occur.

[Diverse effectiveness of the trabectome for different types of glaucoma]. / Unterschiedliche Effekte der Trabektomoperation auf unterschiedliche Glaukomformen.

PURPOSE: Ab interno trabeculotomy using the trabectome device is a intraocular pressure (IOP) decreasing operation by ablation of the trabecular meshwork and the inner wall of Schlemm's channel. This prospective study analyses the effectiveness of the trabectome operation in 122 patients. PATIENTS AND METHODS: The operation was conducted when topical medication was maxed out with the intraocular pressure (IOP) remaining above the desired target range. In addition to the evaluation of the whole study group further analysis concerned the effectiveness of the trabectome in different subclassifications of glaucoma. In some cases the procedure was combined with cataract surgery and subsequently the results were compared to the plain trabectome OP. The results were split into two groups: "complete success" (without postoperative medication) and "qualified success" (with medication). The evaluation was processed for the IOP levels ≤ 21 mmHg, ≤ 18 mmHg, ≤ 15 mmHg und ≤ 12 mmHg. Follow-up dates were 6 and 12 months after surgery. RESULTS: Baseline IOP was 20.15 ± 7.1 mmHg. After 6 months the average IOP of all patients was 16.53 ± 5.89 mmHg, after 12 months the IOP amounted to 15.6 ± 4.45 mmHg. At both follow-ups approximately 90 % of the "complete success" group exhibited an IOP ≤ 18 mmHg. Also at both follow-ups 75 % of the "qualified success" group achieved a range ≤ 18 mmHg - whereas 50 % gained an IOP ≤ 15 mmHg. In secondary glaucoma an IOP decrease of 36 % was achieved. In open-angle glaucomas and those with dysgenetic altered angles the operation evoked a pressure loss of ca. 20 %. The trabectome-only group as well as the group of combined surgery exhibited a significant lowering of IOP. This was accomplished by a significant reduction of eye drops. After surgery nearly half of all patients required none or 1 eye drop at most. CONCLUSION: The trabectome offers a safe and significant lowering of IOP for around 36 % and seems to be very effective in secondary glaucomas. In dysgenetic alterations and open-angle glaucoma a moderate lowering of IOP (ca. 20 %) may be expected. The amount of eye drops can be reduced for about 42 %. After surgery every second patient requires at most 1 eye drop. The technique can be combined with cataract surgery and permits a penetrating operation at a later date.

[Long-term follow-up after deep sclerectomy]. / Langzeitverlauf nach tiefer Sklerektomie.

BACKGROUND: The aim of this study was to evaluate the long-term outcome of deep sclerectomy (DS) with a follow-up of up to 8 years. PATIENTS AND METHODS: All patients who underwent a deep sclerectomy between February 2004 and October 2005 and who attended a follow-up visit between August 2009 and October 2011 were included in this study. RESULTS: This study evaluated 74 eyes of 65 patients with a mean postoperative follow-up of 76.28 ± 10.6 (53.65-92.02) months. Preoperative IOP was 18.37 ± 6.36 mmHg, postoperative IOP at the last follow-up was 12.85 ± 3.5 mmHg, corresponding a 30 % reduction. The number of IOP-lowering eye drops was reduced from 2.36 ± 1.24 to 1.66 ± 1.21 after more than 6 years (p < 0.05). The visual fields showed a mean deviation of - 9.16 ± 8.48 dB initially and - 9.43 ± 8.07 dB at the last follow-up (p > 0.05). Complete success (IOP ≤ 15 mmHg without eye drops or additional surgery) was achieved in 5 % of patients. Qualified success (IOP ≤ 15 mmHg with eye drops or additional surgery) was achieved in 81 %. 53 % (n = 39) underwent cyclophotocoagulation and 20 % (n = 15) needed revision surgery during the follow-up period. CONCLUSION: DS is an effective long-term IOP-lowering procedure leading to visual field stabilisation.

[The relevance of diabetes for patients with glaucoma]. / Die Bedeutung des Diabetes mellitus für das Glaukom.

Although there are some hints for a correlation between diabetes and primary open angle glaucoma (POAG), it remains unclear in which way diabetes influences eye pressure (IOP) and glaucoma. Despite this, the main reason for neovascular glaucoma in diabetes is proven to be retinal ischaemia due to diabetic vessel damage. Primary open angle glaucoma is more frequent than neovascular glaucoma, but neovascular glaucoma is very aggressive and difficult to treat. The mainstay of the treatment is panretinal photo- or cryocoagulation. The next treatment options are cryodestructive procedures followed by filtering surgeries. In most cases a combination of treatments is necessary. In end-stage neovascular glaucoma sometimes enucleation is the only possible therapy when the IOP cannot be controlled or phthisis bulbi occurs.

[Post-surgical treatment after non-penetrating glaucoma surgery: the goniopuncture]. / Nachbehandlung nach nicht penetrierender Glaukomchirurgie: die Goniopunktion.

Non-penetrating glaucoma surgery was primarily developed as an alternative to the widely applied trabeculectomy. Since the anterior chamber in non-penetrating surgery is not directly opened, common postoperative complications such as hypotony are rare. The most frequently applied technique in this group is the deep sclerectomy. After having prepared a superficial scleral flap a deeper scleral flap is performed and excised unroofing Schlemm's canal. The trabecular meshwork is then peeled leaving a residual trabeculodescemet membrane. As a consequence aqueous humour diffuses via the trabeculodescemet membrane under the scleral flap and subsequently under the conjunctiva. One of the reasons for a postoperatively high IOP is seen in the resistance of the residual trabculodescemet membrane. A solution to this problem lies in its puncture, the so-called goniopuncture. Goniopunctures are done in approximately 50 % of cases after deep sclerectomy and are also applied in cases of canaloplasty and viscocanaloplasty. Usually a 1064 nm Nd : YAG laser is used. A potential risk of iris incarceration is described. Two studies have shown that an equally IOP lowering effect can be achieved by treating the trabeculodescemet membrane with a frequency-doubled 532 nm Nd : YAG laser (SLT). No complications were detected in those cases. In conclusion, goniopuncture should be considered as the first line treatment for postoperative IOP increase in cases of non-penetrating glaucoma surgery. It should therefore be preferred to a (re)start of topical treatment.

[Effect of combined cataract surgery and canaloplasty on postoperative intraocular pressure (IOP)]. / Einfluss einer Kataraktoperation auf die drucksenkende Wirkung einer Kanaloplastik.

BACKGROUND: The aim of this study was to evaluate the intraocular pressure (IOP)-lowering effect of cataract surgery combined with canaloplasty compared to canaloplasty alone. METHODS: A total of 43 patients underwent canaloplasty without cataract surgery (group K) and 20 patients underwent canaloplasty with cataract surgery (group K+P). The IOP-lowering effect was measured 4-6 weeks, 3, 6 and 12 months postoperatively. RESULTS: The mean presurgical IOP was 18.26 ± 6.07 mmHg in group K and 16.95 ± 3.46 mmHg in group K+P. In group K the mean IOP was 13.08 ± 5.67 mmHg (28% reduction) 4-6 weeks postoperatively, 13.25 ± 4.51 mmHg (27%) 3 months postoperatively, 12.4 ± 3.25 mmHg (32%) 6 months postoperatively and 12.5 ± 2.45 mmHg (32%) 12 months postoperatively. The mean IOP in group K+P was 11.41 ± 4.87 mmHg (33%) 4-6 weeks postoperatively, 10.4 ± 4.88 mmHg (39%) 3 months postoperatively, 11.0 ± 2.89 mmHg (35%) 6 months postoperatively and 13.0 ± 1.94 mmHg (23%) 12 months postoperatively (no statistical significant difference between the two groups). CONCLUSIONS: Combined cataract-canaloplasty surgery has no significant additional IOP-lowering effect compared to canaloplasty alone.

[Macular hole surgery with air tamponade. Does air suffice for short-term tamponade?]. / Makulalochchirurgie mit Lufttamponade: Ist Luft als kurzzeitige Tamponade ausreichend?

BACKGROUND AND PURPOSE: We used a specially designed optical coherence tomography (OCT) device to investigate the dynamics of early macular hole closure after vitrectomy with air tamponade and to determine the closure rate and the briefest possible prone positioning. METHODS: A total of 112 patients with macular holes were examined using a modified spectral-domain OCT on days 1, 2 and 3 after vitrectomy with air tamponade. As soon as closure was complete (group one) or partial (hole closed at inner retinal layers but outer retinal layers still detached from pigment epithelial layer, group two), prone positioning was ended. If neither partial nor complete closure was observed by the third day, renewed vitrectomy was performed on postoperative days 4-8. RESULTS: Macular hole closure was achieved in 88 of the 112 eyes (79%). In 35 of the 88 eyes partial closure was noted on the first postoperative day. In 20 of the 24 eyes requiring renewed surgery the hole was finally closed. After a median follow-up of 144 days the macular hole was completely closed in all layers in 108 patients (96%). Mean visual acuity at final follow-up was 0.37 logMAR in group one, 0.29 logMAR in group two and 0.51 logMAR in patients whose holes closed after renewed surgery. Once closed, none of the macular holes reopened. CONCLUSIONS: The 79% initial closure rate in the present study is about 10% lower than that reported in other studies employing long-acting gas tamponades. However, renewed surgery with air tamponade achieved a closure rate of 96%. Early partial closure is sufficient for subsequent complete closure, requires no further tamponade or prolonged prone positioning, and has no negative effect on the functional results. Short-term prone positioning is sufficient for most patients.