Incidence and long-term outcome of laser pointer maculopathy in children.

PURPOSE: Single center study to evaluate the incidence and long-term outcome of laser pointer maculopathy (LPM). METHODS: Medical records of 909,150 patients visiting our institution between 2007 and 2020 were screened in our electronic patient record system using the keywords "laserpointer," "laser pointer," and "solar." RESULTS: Eight patients (6/2 male/female, 11 eyes) with a history of LPM were identified by fundoscopy and optical coherence tomography (OCT), all of whom were children (6/2 male/female). Mean age at injury was 12.1 years (range 6-16). Five children (62.5%) were injured between 2019 and 2020, three (37.5%) between 2007 and 2018. Median best-corrected visual acuity (BCVA) of affected eyes at first presentation was 20/25 (range 20/50-20/16). Follow-up examination was performed in seven children (10 eyes) with a median follow-up period of 18 months (range 0.5-96). BCVA improved in 4 children (5 eyes; BCVA at follow-up 20/22.5, range 20/40-20/16). Three of these four children were treated with oral steroids. OCT revealed acute signs such as intraretinal fluid to resolve quickly, while outer retinal disruption persisted until the last follow-up in eight of eleven eyes. These lesions resembled lesions of patients with solar retinopathy of which seven cases (11 eyes) were identified between 2007 and 2020. CONCLUSION: Readily available consumer laser pointers can damage the retina and the underlying retinal pigment epithelium, possibly leading to long-lasting visual impairments. The number of laser pointer injuries has increased over the last years. Therefore, access to laser pointers for children should be strictly controlled.

Individualized Treatment for Glaucoma Patients with Diabetes mellitus. / Individuelle Behandlung bei Glaukompatienten mit einem Diabetes mellitus.

Glaucoma and diabetes mellitus are two common chronic diseases in Europe and worldwide which require intensive therapy. Various pathophysiological mechanisms have been discussed which favour the development of glaucoma, especially in the presence of diabetes mellitus. Medicinal and surgical adjustment of intraocular pressure is associated with some limitations in patients with diabetes mellitus, for example, filtering interventions show lower success rates than in non-diabetic glaucoma patients. Besides pure ophthalmological endocrinological therapy, the psychological burden of two chronic diseases should also be considered and included in the individual therapy plan.

Glaucoma Treatment in German Hospitals in 2019. / Glaukombehandlung in deutschen Krankenhäusern 2019.

BACKGROUND: Surgical procedures in ophthalmology are subject to fluctuations in their application and are dependent on new developments, availability, and success rates. In the field of glaucoma surgery in particular, numerous new procedures have been introduced over the last few years. So far, hardly any analyses have been done on the current application of these newer procedures. In this paper, we present the extent to which different glaucoma surgery procedures were used in German hospitals in 2019. METHODS: The quality reports of German hospitals from 2019 were evaluated regarding all glaucoma-specific procedure codes. In particular, laser procedures, "classic" glaucoma procedures, and "modern" procedures such as MIGS (minimally invasive glaucoma surgery) are compared below. RESULTS: In 2019, 49,031 glaucoma procedures were performed in German hospitals. Numerically, cyclodestructive procedures were used most frequently. MIGS accounted for approximately 10% of procedures according to the available data. Among filtering procedures, about 40% were implant-assisted. DISCUSSION AND CONCLUSION: On the one hand, the data analyzed show a mixed expansion of the spectrum with newer procedures such as the MIGS and implants; on the other hand, classic procedures such as cyclodestruction are still used. It can be assumed that further shifts in surgical methods will be seen in the coming years.

Trends in Surgical Glaucoma Treatment in Germany Between 2006 and 2018.

BACKGROUND/AIMS: Surgical procedures in ophthalmology underlie variations over different time periods and are strongly dependent on the technical process and the invention of innovative surgical techniques. Especially, in glaucoma surgery a lot of surgical devices and techniques have been introduced during the last years. Until now, the use of these newer techniques has not been shown on a robust data basis. We herein present the numbers of different types of glaucoma surgeries performed at German hospitals between 2006 and 2018. METHODS AND DESIGN: The quality reports of hospitals in Germany from 2006 to 2018 were analyzed concerning all procedural codes for glaucoma surgery and intervention. Especially, the change in usage of "classical" and "modern" surgical techniques (MIGS: "minimally invasive glaucoma surgery") or devices was compared. RESULTS: The number of glaucoma procedures performed increased by 75% from 27,811 in 2006 to 48,794 in 2018. Absolute numbers of trabeculectomies, goniotomies, ab externo trabeculotomies and to a certain level cyclodestructive procedures decreased during the examined years while use of MIGS has increased in absolute and relative numbers since 2012. From 2015 a strong increase in the usage of XEN implants could be seen. Drainage implants (such as Baerveldt/Ahmed) showed stable absolute numbers over the time period covered. Absolute numbers of laser trabeculoplasty peaked in 2014 and decreased afterwards. Iridotomies and iridectomies increased by 120%/248% over the whole period. CONCLUSION: Our data show a trend towards the modern surgical options and especially MIGS during the recent years. Classical procedures showed a decrease in total numbers emphasized from 2013. These numbers confirm the assumption that modern glaucoma surgery is becoming more and more popular and established in German hospitals.

[Corneal Biomechanics and Measurement of Intraocular Pressure Measurement in Pathological Corneas]. / Biomechanik und Augeninnendruck bei Hornhauterkrankungen.

Measuring the intraocular pressure in eyes with corneal diseases or after corneal interventions often results in false values due to abnormal corneal biomechanics. Many different approaches are used to compensate for these abnormal corneal biomechanic properties, with varying measuring methods. There are differences when these alternative measuring methods are compared to the gold standard, applanation tonometry according to Goldmann. These differences vary between the methods and with different corneal changes. There is no clear recommendation on a precise method that is suitable for every pathological cornea. Therefore it is important to know the different variations and to include them in the analysis of every patient's intraocular pressure analysis.

Intraocular pressure measurement with Corvis ST in comparison with applanation tonometry and Tomey non-contact tonometry.

PURPOSE: Intraocular pressure (IOP) measurement can be performed with different methods. Newer methods have to be compared to the standard method, the Goldmann applanation tonometry (GAT). We herein compare two air-puff tonometers, the non-contact tonometer (Tomey NCT) and the Corvis ST (CST) with GAT in eyes with a broad spectrum of IOP. METHODS: Two hundred and forty-nine eyes of 249 patients (with diagnosis of either glaucoma or ocular hypertension) were included in this monocenter prospective cohort study. Each eye underwent IOP measurements via GAT, NCT and CST. Bland-Altman plots were calculated to compare the different methods in the three groups. Paired t tests were used for statistical comparison between the three measurement methods. The difference between the different methods was tested on correlation against central corneal thickness (CCT). RESULTS: Mean IOP in GAT was 17.6 mmHg (standard deviation (SD) 5.9), 16.3 mmHg (SD 5.6) in NCT and 18.0 mmHg (SD 5.5) in CST. Comparisons between GAT and CST vs. NCT showed significant differences (p < 0.001), while GAT vs. CST showed no significant difference (p = 0.1162). Mean CCT was 538.7 µm (SD 35.1). CONCLUSIONS: Mean values of GAT and CST show comparable results. However, both GAT and CST differ significantly from NCT. NCT shows lower IOP values compared to both other methods.

Long-term follow-up after scleral lens fixation in patients with Marfan syndrome.

BACKGROUND: The dislocation of the crystalline lens is a common finding in patients with Marfan syndrome (MFS). Scleral intraocular lens (IOL) fixation is an accepted treatment method of this complication. To now, no long-term data on scleral IOL fixation in MFS exist. METHODS: We present a retrospective study of 27 eyes of 17 MFS patients that underwent scleral lens fixation at our clinic between 1999 and 2012. These patients are compared to an age- and surgeon-matched group of 31 eyes of 27 patients who underwent the same procedure for reasons other than MFS. RESULTS: The median age in the MFS group was 35.4 years versus 35.6 years in the non-MFS group. The median follow-up was 4 years for MFS and 3 years for non-MFS. In the MFS group, significantly more IOL-dislocations occurred than compared to the non-MFS group (30% vs. 6.5%, p = 0.02). Retinal detachment occurred in four MFS-eyes compared to three eyes in the non-MFS group. Biometry prediction error was 1.11 diopters (D) for MFS and 1.33 D for non-MFS (p = 0.11). Median BCVA (best-corrected visual acuity, logMAR) was 0.1 in the MFS group versus 0.3 in non-MFS patients. CONCLUSION: Scleral lens fixation in MFS patients achieves satisfying visual and refractive outcomes. Our data shows a significantly higher rate of IOL dislocations in patients with MFS. We therefore recommend addressing this complication preoperatively.

[Critical Incident Reporting System in Risk Management at the Eye Center in Freiburg]. / Das Critical Incident Reporting System im Risikomanagement der Klinik für Augenheilkunde in Freiburg.

Background With the help of reporting systems, errors that occur in medical settings can be documented and can lead to an improved workflow. We, herein, present data from our reporting system that we have used since 2012. Materials and Methods All reports since 2012 were evaluated and analyzed regarding the annual rate of reportings, who reported and what reasons were suspected to be causative for the reported errors. Results Over the last five years a mean of 33 reports were given annually. While mostly doctors reported in the first year, the following years showed almost balanced reports from medical assistant staff and doctors. Not all of these reports resulted in actions. The most often stated reason for errors or critical situations was miscommunication between the staff. Conclusion Our data show that a constant number of reports can be obtained over at least five years from doctors as well as medical assistant staff. The main reason for critical situations seems to be miscommunication. With the increased experience with reporting systems, such as CIRS, we can expect more comparative data.

[Measurement of Quality with Routine Data]. / Qualitätsmessung aus Routinedaten.

There is a growing interest in quality measurement in the healthcare sector. Hospitals in Germany are obligated to participate in measures for external quality assurance and they must establish an internal quality management system. In addition to the legal requirements, measurement of quality is also possible with routine data. Suitable sources are the ICD system or unstandardized information from treatment documentation. The selection of suitable quality indicators is necessary to interpret the data. Complications or achievement of surgical objectives can be suitable quality indicators. Analysis of procedures or the assessment of waiting time are also possible indicators. Our first data concerning waiting time show that with increasing use of an electronic patient guidance system, the waiting time decreased in our outpatient department. Assessment of quality indicators from routine data enables a continuous measurement of quality over a long period. Measures to increase quality can easily be checked. Routine data also provide the possibility to participate in a public reporting of quality indicators.

Corneal K-Values as a Diagnostic Screening Tool for Marfan Syndrome.

PURPOSE: Marfan syndrome (MFS) is diagnosed based on Ghent nosology, including major and minor criteria such as increased axial length (AXL) and flattened corneal curvature (higher K-values) or myopia of more than -3 diopters (D) in its latest revision. Because corneal flattening may, in part, be caused by AXL increase, it may be helpful to consider K-values separately. We present statistical evaluation of using corneal K-values for identifying MFS. METHODS: A retrospective study of K-values of 74 right eyes of 74 patients with MFS, who were compared with an age- and AXL-matched group of 74 right eyes of 74 patients without MFS. After multivariate analysis, receiver operating characteristic curves were calculated. RESULTS: Mean age was 44.1 years versus 44.9 years (P = 0.834). Mean AXL was 25.22 mm versus 25.47 mm (P = 0.661). K-values showed significant differences: mean Kmax was 8.25 mm (40.91 D) versus 7.9 mm (42.72 D) (P < 0.001) and mean Kmin was 8.22 mm (41.06 D) versus 7.69 mm (43.89 D) (P < 0.001). The area under the curve in receiver operating characteristic analysis was 0.82 for Kmax and 0.78 for Kmin; the best cutoff was seen at a Kmax of at least 8.16 mm (41.36 D; sensitivity 73% and specificity 81%). CONCLUSIONS: Although both K-values differ significantly, Kmax is the better marker to identify MFS. A Kmax of more than 8.16 mm (41.36 D) seems to be a reasonable cutoff (specificity of 81% and sensitivity of 73%). Because this biometric value is easily obtained and standardized, we see it as a good supporting screening tool for MFS suspects.

Test-retest reliability of scotopic full-field electroretinograms in rabbits.

PURPOSE: To explore test-retest reliability of standard scotopic full-field ERG measurements in New Zealand White rabbits. The ERG is widely used for testing of retinal integrity after any ocular treatment. We here present detailed stimulus-response dependencies for single healthy and untreated animals, concentrating on test-retest reproducibility. MATERIALS AND METHODS: Five New Zealand White rabbits (aged 8-10 weeks, weight about 2.0-2.5 kg) underwent binocular ERG measurements after intramuscular anesthesia and pharmaceutical pupillary dilatation at a baseline day and 10 days later. Eleven scotopic flash strengths (0.0001-10 cd s/m2) were presented. Variability was quantified via the 95% limits of agreement (LOA). RESULTS: The a-waves displayed the typical monotonic sigmoid amplitude increase with flash strength, and the b-waves peaked at 0.01 cd s/m2, followed by a marked dip at 0.1-0.3 cd s/m2. LOA of both waves went through a maximum in the dip region. LOA divided by mean amplitudes (relative LOA) was fairly flat over flash strength, around 20% beyond the dip. Intraindividual interocular variability was markedly lower, around 10%. CONCLUSIONS: Scotopic ERG responses in rabbits display a region of high variability at 0.1-0.3 cd s/m2; beyond that region the amplitude-LOA is 20%, the interocular LOA being half that value. The use of intraindividual control eyes for testing any toxicity of ocular agents thus appears markedly more sensitive. As a rule of thumb, we found the relative 95% LOA as 33% between individuals, 20% across sessions and 10% between eyes.

Ab Interno Trabeculectomy With the Trabectome as a Valuable Therapeutic Option for Failed Filtering Blebs.

PURPOSE: Uncontrolled intraocular pressure (IOP) after glaucoma filtration surgery is a challenging problem in the management of glaucoma patients. The Trabectome is a device for selective electroablation of the trabecular meshwork through a clear cornea incision without affecting the conjunctiva. Minimally invasive glaucoma surgery using the Trabectome is safe and effective as primary glaucoma surgery. Here we investigate the results of ab interno trabeculectomy with the Trabectome for IOP control in patients with a failed filtering bleb. METHODS: A total of 60 eyes of 60 consecutive patients with primary open-angle glaucoma (POAG) or pseudoexfoliative glaucoma (PXG) were enrolled in this single center observational study. Trabectome surgery was performed alone or in combination with phacoemulsification by 2 experienced surgeons. IOP readings and number of IOP lowering medication as primary outcome parameters were taken by an independent examiner. Intraoperative and postoperative medication were recorded systematically. RESULTS: Mean IOP before surgery was 24.5±3.5 mm Hg and decreased to 15.7±3.4 (-36%) after mean follow-up of 415 days. The number of necessary IOP lowering medication dropped from 2.1±1.3 to 1.8±1.2 (14% reduction from baseline). A total of 25% (n=15) of cases reported here needed additional surgery after 517 days (range: 6 to 1563 d). No major complications were observed. After mean follow-up, we found a qualified success rate for PXG of 87% and 50% for POAG as revealed by the Kaplan-Meier analysis according to the definitions for success in advanced glaucoma cases according to the World Glaucoma Association (40% reduction from baseline IOP and maximum IOP of 15 mm Hg). DISCUSSION: Trabectome surgery for uncontrolled IOP after trabeculectomy is safe and effective especially in PXG patients. Given the demanding subgroup of patients studied here, it is not surprising that success rates are lower compared with previous studies investigating the Trabectome for primary glaucoma surgery. The number of necessary IOP lowering medication drops at first, but seems to reach preoperative values after 20 months of follow-up. Trabectome surgery should be considered as a valuable escape procedure for patients with failed filtering blebs and uncontrolled IOP.

Refractive and visual outcomes after combined cataract and trabectome surgery: a report on the possible influences of combining cataract and trabectome surgery on refractive and visual outcomes.

PURPOSE: To compare combined trabectome-cataract surgery with cataract-alone surgery regarding their refractive and visual outcomes and complications. METHODS: In 137 eyes that underwent combined trabectome-cataract surgery, the postoperative refraction error and best visual acuity after at least 2 months postoperatively were compared to those of an in-house control group of 1,704 eyes that underwent outpatient cataract surgery. RESULTS: Combined trabectome-cataract surgery showed no significant differences regarding the biometry prediction error (BPE, mean 0.53 D vs. 0.48 D, p = 0.24) or visual outcome (BCVA, 0.81 vs. 0.78, p = 0.06). The rate of postoperative cystoid macular edema was slightly higher in the combined surgery group (2.2 % vs. 1.9 %). CONCLUSIONS: Refractive and visual outcomes were similar in both groups. Despite the slightly higher rate of postoperative macula edema, we were able to observe that the combination of these two procedures is a feasible method in glaucoma and cataract surgeries.