[Current situation of allocation of academic medical personnel in ophthalmology departments in Germany]. / Zum Status der Personalplanung für den ärztlichen Dienst in ophthalmologischen Hauptabteilungen in Deutschland.

BACKGROUND: At present minimum nursing staff numbers have been defined and are being implemented. In December 2019 the German Medical Association asked the German professional associations about their general experience with planning of medical personnel in hospital departments. As no structured data were available on this subject, the German Ophthalmological Society (DOG) founded a working group in March 2020 to answer this request. METHOD: In the course of several consensus meetings, the working group on personnel planning for physicians in hospitals of the DOG prepared a questionnaire on previous experiences in personnel planning of eye hospitals, which was sent to the heads of all university eye hospitals and departments of ophthalmology in Germany. The questionnaire consisted of individual items with fixed choices and free answers regarding the procedure and current situation of staffing as well as the range of tasks and organization of the medical service. RESULTS: Out of 104 departments 53 (51%) responded, of which 25 were from university departments (64% response), 23 from departments of other public or non-profit ownership (46%) and 5 from departments with private hospital ownership (33%). Of these 49% stated that there was no transparent basis for calculation of the number of medical positions in their hospital. Of the surveyed departments, outpatient tasks, services and revenues were considered in the calculations in only 47%. There was a statistically significant higher ratio of full-time personnel to the numbers of beds in university departments compared to private and publicly owned non-profit institutions (p < 0.001, t­test). All departments have to cope with multiple additional tasks in addition to clinical patient care, which are taken into account only to a limited extent in the staffing. Approximately 70% of the departments provide a 24 h/7 day (24/7) medical on-call service on site, 91% have a 24/7 surgery on-call service and 34% have a cooperation with emergency services run by the Association of Statutory Health Insurance Physicians. CONCLUSION: The results show how heterogeneously and nontransparent German departments of ophthalmology are staffed in terms of medical doctors. On average, university departments have higher personnel resources per hospital bed to cope with additional tasks in research and teaching. Outpatient tasks, which contribute significantly to the revenues of an eye department, and multiple other tasks are often not taken into account in the personnel calculation. A transparent and uniform basis for calculation of the medical staff of the departments is desirable in order to achieve a sufficient personnel staffing for a patient and employee-oriented working environment.

[Macular changes in optic disc pits-Optic disc pit maculopathy (ODP-M) : Pathophysiology and possibilities of surgical treatment]. / Makulaveränderungen bei Grubenpapille ­ "Optic disc pit maculopathy" (ODP-M) : Pathophysiologie und Möglichkeiten der chirurgischen Therapie.

An optic disc pit is a rare congenital abnormality of the optic nerve, which in most cases presents as a unilateral finding. Clinically, a greyish oval excavation is seen, most commonly on the temporal side of the optic nerve disc. The optic disc pit alone normally does not lead to substantial symptoms or functional limitations; however, when a maculopathy with intraretinal and/or subretinal fluid and additional other morphological changes in the macula occur, this leads to a decrease in visual acuity. With spectral domain optical coherence tomography (SDOCT) it is possible to identify the various forms of expression, which show different natural courses. Especially the presence of subretinal fluid and defects in the outer retinal layers have a poor prognosis and have the highest risk for further deterioration. Spontaneous resolution can occur but is rare. Observation is recommended in the first step. In cases of progression or pronounced deterioration, surgical intervention is indicated. Many different techniques have been proposed but there is no gold standard at the moment. Most of the surgical approaches comprise pars plana vitrectomy with peeling of the internal limiting membrane (ILM) and gas endotamponade. Newer methods, such as the ILM flap technique also show good results. Generally, it is important to know that postoperative healing and resorption of the fluid often take a long time period of up to 1 year or even longer.

Comparison of the horizontal diameter to a modeled area of traction in eyes with vitreomacular traction: is the diameter close enough to the truth?

PURPOSE: In daily practice, vitreomacular traction (VMT) is described by the horizontal diameter of its attachment site implying a regular round shape of VMT. We investigated the deviation from this circular area of vitreous traction in patients with VMT. METHODS: A retrospective analysis of optical coherence tomography (OCT) scans was performed. The area of vitreomacular attachment was determined using six radial OCT scans (Ameasured). The assumed circular area of traction was calculated based on measuring the maximal horizontal diameter for comparison (Acircular). RESULTS: Thirty-seven eyes of 37 patients with pure VMT were included. Patients' mean age was 72.8 ± 8.2 years. Mean horizontal VMT diameter was 400.8 ± 230.5 µm (median 361 µm; range 44-991 µm). While there was no difference between mean areas of traction for Acircular and Ameasured (P = 0.93), the individual difference (|Acircular - Ameasured|) was 0.042 (± 0.044) mm2 in mean or relative 73.0% (± 135.8%). A difference of ≥ 30% of Ameasured to Acircular was found in 16 eyes (43.2%) and ≥ 100% in 7 eyes (18.9%), respectively. CONCLUSION: Vitreous attachment sites possess an irregular non-circular shape in a significant number of eyes with VMT. Consequently, the area of traction appears inaccurately described by its horizontal VMT diameter alone. As the area of traction is important for therapeutic recommendation, our results emphasize the need for a more precise description of the area of traction in eyes with VMT.

[Differential diagnosis and therapy of pigment epithelial detachment]. / Differenzialdiagnose und Therapie von Pigmentepithelabhebungen.

Retinal pigment epithelial detachment (PED) can occur associated with multiple ocular and infrequently also primarily non-ocular pathologies. They can be sub-divided into drusenoid, serous, serous-vascularized and fibrovascular PED. Most commonly PED is found in age-related macular degeneration. The knowledge of possible differential diagnoses is important for the prognosis and helps in the choice of therapy and in the individual counseling of patients.

[Reliability and safety of intravitreal Ozurdex injections. The ZERO study]. / Zuverlässigkeit und Sicherheit von intravitrealen Ozurdex-Injektionen. Die ZERO-Studie.

BACKGROUND: Since July 2010 Ozurdex® is approved in Germany for treatment of macular edema from retinal vein occlusion (RVO). The objective of this observational study was a systemic summary and analysis of clinical experience regarding complications and side effects of intravitreal administration of dexamethasone. PATIENTS AND METHODS: In a retrospective, multicenter study conducted at 10 centers, 342 eyes with RVO were treated with intravitreal dexamethasone (Ozurdex®, Allergan). After treatment the patients were followed-up over a period of 8 months and intraoperative, perioperative and postoperative complications, such as elevated intraocular pressure and dislocation of implants were systematically recorded. RESULTS: No infections, endophthalmitis, perioperative hypotension, intraoperative lens injuries or retinal detachment occurred. Elevated intraocular pressure was the most common complication accounting for nearly 20 %. In 9 % of patients the intraocular pressure increased by more than 10 mmHg compared to baseline and in 6 patients to > 35 mmHg. In cases of known glaucoma intraocular pressure elevation was not significantly more frequent compared to non-glaucoma patients. In four cases a progression of lens opacity led to phacoemulsification and two implant dislocations in the anterior chamber required surgical repositioning in the vitreous cavity. In two cases a postinterventional macular hole was observed. CONCLUSIONS: In the clinical routine Ozurdex treatment has proven to be a therapy method with minimal side effects. In Ozurdex administration intraocular pressure elevation was observed as the most common side effect; however, this generally did not require surgical intervention. Caution is advised in patients with an anterior chamber lens and iridectomy. Macular holes as a rare complication might result from vitreous traction during the administration process. In summary, even in the clinical routine application of Ozurdex the complication rate was not higher than in registration studies.

[Differences in the treatment of exudative age-related macular degeneration in Germany and Great Britain]. / Unterschiede in der Therapie der exsudativen altersabhängigen Makuladegeneration in Deutschland und Großbritannien.

The treatment of age-related macular degeneration with anti-VEGF medications has resulted not only in significant improvements in eye treatment but also in rising costs of ophthalmological therapy. This new treatment has been rapidly introduced into daily practice in Germany with its social security healthcare system and also in Great Britain with its National Health Service. In both countries the most prevalent treatment scheme currently includes three baseline injections of ranibizumab followed by additional injections depending on persisting disease activity.

[Therapy for peripapillary located and large choroidal haemangioma with PDT 'paint-brush technique']. / Behandlung peripapillärer und grosser Aderhauthämangiome mittels PDT-"Paint-Brush-Technik"

BACKGROUND: Today photodynamic therapy (PDT) with Verteporfin is the standard treatment option for symptomatic choroidal haemangiomas. Nevertheless, peripapillary or large haemangiomas pose a therapeutic dilemma, since severe adverse events have been demonstrated in cases where the optic disc was included in the treatment spot. In addition due to the size and the shape of the laser spot, peripapillary and large haemangiomas can only be undertreated or overtreated (with overlapping multiple spots). With the presented new "paint-brush technique" it is possible to treat peripapillary and large choroidal haemangiomas completely without danger for the optic disc and without overtreatment. MATERIAL AND METHODS: With the new technique the application of the laser spot is performed in a "paint-brush fashion" by moving he spot with constant speed excentrically around the lesion's centre over the entire tumour surface. This allows under visual control a complete and confluent PDT of the whole tumour surface without overlapping and/or missing areas or treating the optic disc. In total, 13 eyes of 13 patients (6 with peripapillary and 7 with large choroidal haemangiomas) have been treated. The mean follow-up time was 25.6, respectively, 14.5 months. RESULTS: The PDT with the "paint-brush technique" allows an effective treatment of the leakage in both groups. The mean increase of visual acuity was 1, respectively, 1.4 ETDRS lines 3 months after therapy, which could be maintained over the whole follow-up period. At the last examination visual acuity was unchanged or better in 12 / 13 (92 %) of eyes. After 3 months the tumour height was significantly (p = 0.031 and 0.018) reduced to 1.7 mm (52 %), respectively, 1.3 mm (30 %), which was stable during the whole follow-up. No significant side effects could be detected. CONCLUSION: The use of the PDT "paint-brush technique" allows complete treatment of choroidal haemangiomas under visual control. Sensitive structures like the optic disc could be excluded from treatment without double- or undertreatment. The functional and anatomic results are good. The technique is a safe and effective amendment in the treatment of symptomatic choroidal haemangiomas.

[Surgical treatment modalities in uveal melanomas]. / Chirurgische Behandlungsmöglichkeiten beim Aderhautmelanom.

The treatment of large uveal melanomas poses a therapeutic challenge, due to the expected treatment-related side-effects. After sole radiotherapy the majority of patients are faced with radiogenic complications secondary to the large amount of tumour necrosis. Alternative treatment modalities addressing this issue are transscleral resection in arterial hypotension in anteriorly located tumours and endoresection via pars plana vitrectomy in posteriorly located tumours. A surgical resection treatment was applied in 292 patients with large uveal melanomas. In 150 patients the tumour was treated by transscleral resection and postoperative adjuvant (106)ruthenium brachytherapy and 142 patients were treated by primary proton beam irradiation and secondary endoresection. The mean follow-up time was 3.8 and 2.5 years, respectively. Local tumour control was achieved in 76 % and 98 %, respectively. The 5-year metastatic rates were 28 % and 21 % and eye retention was achieved in 82 % and 97 %, respectively. Surgical resection of uveal melanomas with adjuvant radiotherapy is the treatment of choice in cases of large tumours, avoiding enucleation in the vast majority of cases in the long term, without increasing the incidence of tumour-related risks.

[Different indications of photodynamic therapy in ophthalmology]. / Verschiedene Indikationen der photodynamischen Therapie in der Augenheilkunde.

BACKGROUND: Photodynamic therapy (PDT) in eye disease was approved 10 years ago for age-related macular degeneration (AMD). Thereafter it was approved for choroidal neovascularisation (CNV) in pathological myopia. The treatment regimen is based on two prospective, multicentre trials (TAP and VIP studies). MATERIAL AND METHODS: In the meantime PDT has been successfully used also in several other ocular diseases. PDT is minimally invasive and has an excellent side effect profile. Different diseases and their treatment with PDT are discussed. RESULTS: The treatments of idiopathic CNV, secondary CNV in inflammatory diseases of the retina and choroid, choroidal haemangioma, vasoproliferative tumours, malignant melanoma of the choroid, and central serous chorioretinopathy with PDT are described. In most patients the disease progression can be stopped and in some the PDT treatment results in visual improvement. The prognosis is better in patients with early disease detection and small lesions. CONCLUSION: Several retinal and choroidal diseases can be treated successfully with PDT. Except for AMD and pathological myopia, PDT is an off label treatment.

[ITAP - 6-month results of a prospective, randomised phase 3 study for evaluation of the combination therapy of PDT and intravitreal triamcinolone in exudative AMD]. / ITAP - 6-Monats-Ergebnisse einer prospektiven und randomisierten Phase-3-Studie zur Evaluation der Kombinationstherapie aus PDT und intravitrealem Triamcinolon bei der exsudativen AMD.

BACKGROUND: Combination therapy of photodynamic therapy (PDT) with intravitreal triamcinolone (IVTA) for choroidal neovascularisation (CNV) in age-related macular degeneration is thought to improve the prognosis. It is therefore widely used, although results are mostly based upon non-randomised and retrospective studies. Here we present the 6-month results of our prospective, randomised, multicentre ITAP trial (Intravitreal Triamcinolone and PDT) for the evaluation of the combination therapy as compared to PDT alone. PATIENTS: This prospective, randomised, multicentre phase III trial was performed for the evaluation of the efficacy and safety of combination therapy (PDT and IVTA) as compared to PDT alone. Three randomised therapy groups (A: PDT alone, B: IVTA on the same day 1 hour after PDT C: IVTA 1 week before PDT) were monitored over 1 year. The patients included had wet AMD with predominantly classic CNV, minimal classic CNV smaller than 4 papillary diameters or occult CNV with recent disease progression. Re-treatment was performed when persistent leakage of the CNV was visible at follow-up. Primary outcome criteria were the comparison between combination therapy and PDT monotherapy concerning visual acuity, and, second, the comparison between the two groups of combination therapy. RESULTS: 92 patients were included in the study. Before treatment, mean best corrected ETDRS letter score was 52, 53 and 51 in groups A, B and C, respectively. At the 6 months follow-up, mean best corrected letter score was 40, 47 and 47, respectively, with only group A loosing more than 10 letters. This change, however, was not statistically significant between the groups. Mean retinal thickness as measured with optical coherence tomography decreased in all groups, and reached statistical significance in both combination groups. Re-treatment rates did not differ significantly between the three groups at 6 months follow-up, nor was there a significant cataract progression requiring operation. CONCLUSION: At 6 months there was no significant difference between mono- and combination therapy groups concerning visual acuity.

[Recurrence rate following adjuvant strontium-90 brachytherapy after excision of conjunctival melanoma]. / Rezidivhäufigkeit nach Exzision von Bindehautmelanomen und adjuvanter Strontium-90-Kontaktbestrahlung.

BACKGROUND: Because of the high local recurrence rates after excision of conjunctival melanomas, adjuvant local chemotherapy or irradiation is recommended. Strontium-90 brachytherapy is one radiotherapeutic option due to its low penetration depth. METHODS: 15 patients with conjunctival melanoma were treated with adjuvant strontium-90 brachytherapy after tumour excision. The treatment was fractionated into 9 irradiation sessions with 6 Gy each. The mean follow-up was 35 months (12-60 months). RESULTS: Seven patients (46%) had no recurrence during the follow-up. Three patients (20%) had a recurrence in the treated or adjacent area. Eight patients (53%) developed new tumours in non-treated areas. CONCLUSIONS: Strontium-90 brachytherapy is a useful adjuvant in the treatment of conjunctival melanomas. Regular ophthalmoscopic controls are necessary because of the high rate of new tumours in non-irradiated areas, especially in cases with primary acquired melanosis.

[Tamoxifen retinopathy: a case series of clinical and functional data]. / Tamoxifen-Retinopathie: Eine Fallserie von klinischen und funktionelle Daten.

BACKGROUND: Tamoxifen is used in the treatment of selected patients with breast carcinoma. Rarely, it has been shown to cause ocular toxic effects including crystalline retinopathy. METHODS: Retrospective analysis of clinical and functional (visual acuity, visual field, colour vision) data of a case series of eight female patients under tamoxifen therapy with electrophysiological examination. RESULTS: Seven of eight patients complained of visual disturbances. In one case, examination showed crystalline deposits in the cornea and macular area. Three patients revealed changes in full-field and multifocal electroretinogram, and two had a pathological multifocal electroretinogram only. In six cases we applied a desaturated panel D-15 colour vision test; five of these showed some disorders. CONCLUSIONS: Most tamoxifen patients who complained of visual disturbances showed electrophysiological changes, particularly in the multifocal electroretinogram and often without a certain morphological correlate. We recommend electrophysiological examination for patients with unclear visual deterioration who are receiving tamoxifen therapy.

[Photodynamic therapy with verteporfin for recurrent choroidal neovascularisation (CNV) following prior argon laser coagulation]. / Photodynamische Therapie mit Verteporfin bei Rezidiven choroidaler Neovaskularisationen (CNV) nach primärer Argonlaserkoagulation.

BACKGROUND: Photodynamic therapy (PDT) with verteporfin has been successfully introduced to treat choroidal neovascularisations (CNV) that have more than 50% classic CNV components due to exudative age-dependent macular degeneration (AMD) and other diagnoses. However, what is still unclear is if patients with recurrent subfoveal CNV who have had prior laser coagulation can also profit from PDT for CNV. METHODS: The course of visual acuity (ETDRS) and the fluorescein angiographic findings were retrospectively analysed after standard PDT of recurrent subfoveal CNV after prior argon laser coagulation of an extrafoveal or juxtafoveal CNV in AMD or other diagnoses. RESULTS: A total of 20 consecutive eyes from 19 AMD patients were evaluated. After 12 months in 14 of the 20 eyes (70%) deterioration in visual acuity of 3 or more ETDRS lines could be avoided and likewise in 7 of 16 eyes (44%) after 24 months. After the 1st year, 5 of the 7 eyes (71%) with recurrent subfoveal CNV after laser coagulation of a myopic, postinflammatory or idiopathic CNV had deterioration of visual acuity of less than three lines or an improvement in visual acuity. CONCLUSIONS: Despite the low number of patients examined, we could see an indication for PDT in recurrent subfoveal CNV after prior argon laser coagulation of extrafoveal or juxtafoveal CNV. When the patient presented with a CNV cause other than AMD, a better prognosis for visual acuity was achieved.

[Photodynamic therapy with verteporfin for uveal melanoma]. / Photodynamische Therapie mit Verteporfin beim Aderhautmelanom Eine klinisch-histopathologische Pilotstudie.

BACKGROUND: The aim of this study was to evaluate whether photodynamic therapy (PDT) with verteporfin is able to induce tumor cell necrosis in human uveal melanomas. METHODS: On four eyes with an uveal melanoma, PDT with verteporfin was performed on the tumor 2-3 days before planned enucleation. The eyes were evaluated histologically. RESULTS: In two melanomas with only mild pigmentation some effects after PDT were detected on tumor tissue in a depth up to 2.5 mm at light doses > or =100 J/cm(2). Histologically, vascular occlusion and thrombosis in tumor vessels were observed. In the heavily pigmented melanoma no tumor necrosis was induced with the above-mentioned parameters. CONCLUSION: Depending on treatment parameters and tumor pigmentation, PDT with verteporfin is able to induce tumor necrosis in human uveal melanomas. Based on these results it is possible that PDT can become an adjuvant treatment method for uveal melanoma.

[Photodynamic treatment with verteporfin for patients with idiopathic choroidal neovascularization. Two-year results]. / Photodynamische Therapie mit Verteporfin bei Patienten mit idiopathischer chorioidaler Neovaskularisation. 2-Jahres-Ergebnisse.

BACKGROUND: The aim of this study was the evaluation of safety and effectiveness of photodynamic therapy (PDT) as a treatment option for idiopathic choroidal neovascularization (CNV). METHODS: We performed a retrospective analysis of 11 eyes of 9 patients who were treated with standard PDT. The follow-up period was at least 1 year and included regular standardized ETDRS visual acuity measurement and fluorescein angiography. RESULTS: Eight sub- and three juxtafoveal CNV were treated. The mean follow-up was 23.2 months (12-41 months), the mean change in visual acuity was +2.1 lines (+3 for juxtafoveal and +1.9 for subfoveal localization), and a mean of 1.9 (1-3) treatments were performed. Visual acuity improved > or =2 lines in 6 of 11 eyes (54.5%) and 5 eyes (45.5%) remained stable (+/-1 lines). Alterations of the retinal pigmented epithelium (RPE) with window defects in fluorescein angiography occurred in 7 of 11 eyes (63.6%) but did not alter visual acuity. In 4 of 11 cases (36.4%), we saw recurrences after initially successful therapy, which were retreated successfully with PDT. CONCLUSION: Stabilization or even an improvement of visual acuity in idiopathic CNV is possible with PDT treatment. Side effects such as RPE changes and recurrences are possible, but do not seem to influence visual acuity.

[Tissue typing in perforating corneal transplantation]. / Gewebetypisierung bei der perforierenden Keratoplastik.

The demand for matched corneal grafts has risen rapidly over the last years. One reason for this is the change in the judgement of the value of tissue and especially HLA typing for prevention of an immune reaction in perforating corneal transplantation. Besides HLA or major antigens, there are other immunologically relevant tissue surface molecules such as the non-MHC antigens of which blood groups and minor antigens are the most important. With regard to effective cost-benefit and waiting time-benefit analyses, differentiated matching strategies are needed to assure optimized utilization and allocation of the still unsatisfactory number of available corneal grafts. With special matching strategies, such as the calculation of the individual waiting time, the consideration of split, non-MHC and HLA antigens, additional HLA loci as well as so-called "permissible" and "taboo" mismatches, much more has to be taken into account in the future than just the numerical correspondence of HLA antigens. This will make it possible to turn from a pure numerical approach to a functional matching strategy. This review summarizes the discussion and different matching strategies, possibilities and limitations of HLA and tissue typing in perforating corneal transplantation.