[Discolouration of Upper Lid Skin - Prurigo nodularis]. / Hautverfärbung am Oberlid ­ Prurigo nodularis.

An abnormal change in skin colour is designated as discolouration of the skin. A 73-year-old male patient with circumscribed discolouration of the upper lid margin near the lacrimal pathway is presented. Slit lamp biomicroscopy showed no other signs of pathomorphological change. An excisional biopsy was performed. The whole abnormal area was removed. The oculoplastic procedure was the surest way to establish a definite diagnosis of Prurigo nodularis.

[Ophthalmic Plastic Surgery of Exposure Keratopathy in the Intensive Care Unit]. / Okuloplastische Chirurgie bei Expositionskeratopathie auf der Intensivstation.

Critically ill patients in the intensive care unit (ICU) may develop eye problems, due to impaired ocular protective mechanisms or direct involvement of the eye in severe systemic diseases. If eye infections or ocular surface disorders are not identified in time, endophthalmitis or corneal ulcer may develop and can cause permanent functional injuries of the eye. A retrospective analysis was performed and a total of 283 complete intensive care courses of treatment were evaluated, taking into account ophthalmic medical consultations for frequent cardinal symptoms. The most common cardinal symptoms were lagophthalmus (exposure keratopathy), chemosis, redness and periorbital haematoma. The following predisposing risk factors for the onset of ocular complications during intensive care treatment were detected: chemosis (p < 0.001), redness (p = 0.007), lagophthalmus (p = 0.001), ventilation (p < 0.001), use of muscle relaxants (p < 0.001), cardiovascular (p < 0.001), and neurological diseases (p < 0.001). In 71.7 % of ICU patients, additional treatment was prescribed during the eye consultation. This includes special eye care treatment (6.0 %) and/or drug therapy (64.0 %), as well as oculoplastic surgery in 4,3 % of critically ill patients. The most common oculoplastic-surgical procedure in the ICU was lid adhesion to achieve adequate protection of the corneal surface in patients with severe exposure keratopathy. Oculoplastic surgery is the method of choice for protecting the cornea in critically ill patients, when conservative options such as hypoallergenic adhesive tape or a moisture chamber are not sufficient to protect the ocular surface. The main challenges are to pay attention to the indication and performance in due time, and to avoid permanent loss of function through transparency reduction or irregular astigmatism in post-recovery patients.

Trends of barriers to eye care among adults with diagnosed diabetes in Germany, 1997-2012.

BACKGROUND AND AIMS: To study trends of barriers to receiving recommended eye care among subjects with diabetes aged 20-81 years in northeast Germany. METHODS AND RESULTS: We analyzed population-based data from two repeated cross-sectional surveys conducted in 1997-2001 and 2008-2012 (Ns of 4308 and 4402). Andersen's Behavioral Model of Health Services Utilization was used to identify individual-level demographic, financial and health-related barriers to annual eye-care utilization in subjects with a self-reported physician's diabetes and to examine population trends in these barriers. The prevalence of diabetes increased from 6.5% to 11.4%. The prevalence of annual eye-care utilization among persons with diabetes decreased from 69.4% to 56.0% (adjusted relative risk = 0.77, p < 0.001). The decline of eye care utilization over the past decade in eye-care use was more pronounced in groups at risk for diabetes-related complications (i.e., lower socio-economic status, >5 years since diagnosis of diabetes, poor glycemic control, obesity, smoking, lack of physical activity, co-existing diseases). We identified relevant predictors of missed annual eye-care use among diabetics. CONCLUSION: The increase of diabetes prevalence and downward trend of eye-care visits at the recommended level call for development, implementation and evaluation of continued efforts to improve access to eye specialists, particularly among those with poor diabetic control, co-existing diabetic complications, and comorbidities.

[Post-surgical management of split-thickness skin grafts in oculoplastic surgery]. / Operatives Management und Nachsorge freier Spalthauttransplantate in der okuloplastischen Chirurgie.

Malignant skin tumours in periocular regions often demand ophthalmo-surgical measures. Split-thickness skin grafts still represent an important treatment alternative when plastic-reconstructive covering through local tissue of the facial area is impossible. Essential technical steps to gain viable split-thickness skin grafts are introduced. Current standards in the after-treatment of split-thickness skin grafts at the receiving location as well as in the after-care of the donor area are presented from interdisciplinary points of view referring to the latest publications. Hydrocolloidal dressings are recommended for the after-treatment of removal areas such as the inside of the forearm since they improve post-surgical management for the ophthalmologist significantly and help in abbreviating healing duration. Pain sensation of the patient as well as the rate of infection are minimal. Throughout the early stages, split-thickness skin grafts at reception areas often demand an intensified local massage treatment with hydrocortisone 2.5 % ophthalmic cream. During the later stages follow-up measures should be stopped neither too soon nor abruptly. Ointments with polysiloxane and silicon dioxide preserve skin suppleness and prevent the occurrence of shrinkage as well as hypertrophic scars.

[Topical chemotherapy for conjunctival tumours - the medical and legal bearings of the case]. / Lokale Chemotherapie von Tumoren der Bindehaut - interdisziplinär medizinische und administrative Aspekte.

The treatment management of malignant tumours is characterised and limited by specific features of the topographical structure of the eye. The anatomic characteristics of the conjunctival sac, the movable tissue structures and the need to take care of corneal transparency and conjunctival stability are the main concerns of the experts. Clinical studies have revealed adjuvant chemotherapy to have a positive effect as a therapeutic treatment for neoplasia of the conjunctiva and cornea. Although mitomycin and interferon are widely used, there are no phase III studies on local adjuvant chemotherapy (interferon, mitomycin, 5-fluorouracil) that evaluate the proof of effectiveness, potential adverse effects or interactions with other drugs. For this reason, the currently available studies fail to comply with the jurisdiction of the German Federal Social Court. Hence, the Medical Service of the Health Insurance Funds (MDK) regionally does not accept the medical preconditions for reimbursement of the costs in adjuvant local chemotherapy. A doctor's unquestioned acceptance of such an MDK decision could have legal consequences. An off-label use is acceptable by law if there is no alternative treatment available with a higher evidence level that conforms to the medical standard. It is therefore recommendable for the Joint Federal Committee commissions the experts in ophthalmology and oncology on off-label use, to review the scientific evidence regarding adjuvant therapy of malignant tumours of the ocular surface. Only in this way can regional disparities in patient care, and intrusions on the doctor-patient relationship, be avoided.

[Surgical treatment of upper lid entropion -- selected aspects]. / Zur operativen Therapie des Oberlidentropiums - ausgewählte Aspekte.

The upper lid entropion is a rare eyelid malposition in which the external lid margin turns inward against the ocular surface. It may be classified as congenital (tarsal malformation, hypoplasia of tarsus, eyelid hyperlaxity) but is more commonly an acquired condition (traumatic, immunopathological, inflammation, involutional forms). Surgery is the treatment of choice for correction of upper lid entropion. Appropriate surgical techniques are available for the respective conditions. This article gives an overview of the most commonly used treatment strategies including non-surgical and surgical procedures. Transcutaneous and intermarginal access routes have proven to be safe methods for minimal or moderate upper lid entropion. Combined surgical procedures (e.g., rotation of tarsoconjunctiva, posterior lamellar graft, everting sutures and autologous cultivated oral mucosal epithelial transplantation and so on) should be applied as treatment strategies for severe upper lid entropion with cicatricial changes in the tarsoconjunctival layer, shortage of posterior lamella and severe ocular surface disease.

[Fitness to drive with glaucoma]. / Verkehrstauglichkeit beim Glaukom.

Glaucoma is one of the eye diseases that are particularly relevant to driving in old age. The ophthalmologist often has to take on the task of traffic medical consultation or medical appraisal. It is essential to distinguish between fitness to drive and driving ability or driving safety and driving capability. The medical examination of fitness to drive can only be carried out over long intervals and basically requires an ophthalmological examination in compliance with all the requirements of the driving license ordinance. This is not a healthcare task. In the case of clarification of the fitness to drive in people with known glaucoma on behalf of the test persons themselves or a driving license authority, visual field testing must be performed using manual kinetic perimetry according to Goldmann, especially for all borderline case decisions by traffic experts. The ophthalmologist faces the particular difficulty of maintaining a balance between the legal duty of care and patient-centered care in order not to strain the patient-physician relationship.

[Patient education before ocular surgery]. / Patientenaufklärung vor Augenoperationen.

Particular importance and diligence must be attached to patient information prior to ocular surgery. A surgical intervention performed without error according to the state of the art in medicine remains exempt from punishment according to § 228 German Criminal Code (StGB) only if effective consent to the treatment is given and only then is there no liability if a risk inherent to the intervention materializes. The patient's consent is only effective if the patient has been properly informed beforehand. In medical malpractice proceedings, a breach of the duty to inform is regularly alleged. From the outset, the physician bears the burden of proof that he has obtained consent in accordance with Section 630d of the German Civil Code (BGB) and provided information in accordance with the requirements of Section 630e of the BGB. The provisions of the Patients' Rights Act also contain formulations that regularly lead to a very detailed individual review of possible errors of disclosure in medical liability proceedings. Apart from the indispensable requirement of an oral clarification discussion by a physician qualified to do so, who informs about "all essential circumstances" of the planned eye operation, the adherence to formal requirements for the clarification discussion and a written documentation with the individual discussion contents are of decisive importance in a lawsuit in order to reduce possible liability risks from the outset. On the one hand, case law sets high requirements for information and on the other hand, every ophthalmologist should also be aware that this effectively counteracts a depersonalization of the physician-patient relationship.

[Periocular surgery and the impact of split-thickness skin grafts]. / Spalthauttransplantate in der periokulären Chirurgie.

Oculoplastic surgery has to consider the specific characteristics of the periocular region and possible resulting functional consequences. Motility of eyelids, limited skin thickness with excellent wound healing conditions, lacrimal duct system and eyelid ligaments are important criteria for the individual choice of the surgical procedure. The use of split-thickness skin grafts represents an established method to repair periocular defects. Important medical conditions for split-thickness transplantation are colour of the skin, skin structure, photodamage of the skin, hair growth and other degenerative disorders. The recipient area should be treated as carefully as possible with diathermia until the bare area is completely dry. It is important that the size of the graft is slightly larger than the area to be covered because of postoperative shrinking. Small grafts tend to result in contraction which may lead to a defective position of the eyelids. For postoperative wound maintenance, gauze containing vaseline and wool wax can be used. This helps to keep the graft smooth and to prevent its detachment upon changes of dressing. Frequency and scope of complications are similar to flap surgery if adequate individual indications for split-thickness skin grafts are considered. Early onset complications are wound dehiscence, bleeding, formation of seroma, dislocation or loss of grafted skin. The postoperative maintenance of the donor site can be managed successfully with hydrocolloid dressing. Split-thickness skin grafts represent a good reconstruction technique if other tissue (full-thickness skin) from the periocular region is not available or whenever other surgical methods appear to be less promising or inapplicable. If available, ipsi- or contralateral full-thickness skin grafts are preferred because of the same skin type.

[Conjunctival tumours in elderly patients]. / Tumoren der Bindehaut im Alter.

The conjunctiva as a mucous membrane provides a protective barrier to the eye. It represents a small segment of the skin - the largest organ of the body, which has a size of about 1.7 square metres. For this reason conjunctival ageing is affected by equivalent processes as skin ageing. Common causes for these ageing processes are biological and genetic effects as well as environmental conditions and exposure to light. The resulting dysfunction in conjunctival homoeostasis and protective function represent common factors which contribute to increased incidences of tumours and malignant transformations in elderly patients. At the time of tumour manifestation the patient's age is an important parameter for differential diagnosis and regimen strategy. All therapeutic options (surgical incision or excision, cryotherapy, chemo- or radiotherapy, exenteratio orbitae etc.) have to be determined individually depending on clinically relevant findings and previous anamnesis. Due to the patient's age geriatric aspects have to be considered in therapeutic management (tissue fragility, wound healing, multimorbidity, decreased adherence).

[On the topical tolerance of aminoglycoside antibiotics--a prospective comparative cytomorphological study]. / Zur Evaluierung der lokalen Verträglichkeit von Antibiotika an der Augenoberfläche am praktischen Beispiel eines Aminoglykosides.

BACKGROUND: The local application of drugs is an efficient method for treating diseases of the external eye. However, some active substances can also cause a chronic toxic reaction at the ocular surface. No results from clinical experiments on the local tolerance of kanamycin which would meet the requirements of evidence-based medicine are as yet available. METHODS: Thus, the cytomorphological processes of the treatment with kanamycin were examined in a prospective randomised placebo-controlled double blind cross-over study. The effect of the topical application (5 times a day for 7 days) of Kanamycin POS® eye ointment on the conjunctival epithelial barrier was studied in comparison with an eye ointment base (placebo) in 25 healthy subjects. To detect cytopathological microchanges of the epithelium, we carried out a standardised impression cytology (primary compatibility parameter). Biomicroscopy, Schirmer II test and non-invasive measurement of the break-up-time (tearscope) were also examined. The subjective compatibility parameters (itching, tearing, foreign body sensation, burning sensation, mucus) were measured on a 0 - 10 visual analogue scale. RESULTS: The cytological findings of 23 subjects were included in the final evaluation of the study. The impression cytology did not reveal a different effect of kanamycin ophthalmic ointment on the conjunctival ocular surface in comparison with the placebo. Only in one subject was a marked shift found in the nuclear-cytoplasmic ratio after application of verum. No signs of increased apoptosis ("snake-like chromatin") were found at the conjunctival epithelial barrier. The mean goblet cell count was 109 goblet cells per mm (2). No significant reduction of the goblet cell density was found in any treatment group. Among the subjective compatibility parameters, only the mean for itching constantly remained above the placebo group after application of kanamycin. Statistically significant differences were not found by the Wilcoxon test. CONCLUSIONS: In contrast to the clinical experience with the systematic application of kanamycin, the standardised evaluation of this study confirmed the very good topical tolerability of the tested kanamycin eye ointment. In view of the continuing clinically relevant aspect of the availability of a wide spectrum of antibiotics to avoid the development of resistance while at the same time keeping within what is reasonable economically, Kanamycin POS® for topical application supplements the options of ophthalmological antibacterial chemotherapy.

[New concept of computer-based documentation of retinal findings in retinopathy of prematurity]. / Neues Konzept einer computergestützten Dokumentation von Netzhautbefunden bei Frühgeborenenretinopathie.

BACKGROUND: Pathological findings and clinical course of retinopathy of prematurity (ROP) are often documented with hand drawings. The use of software-based standardised symbols for ROP staging leads to improved documentation quality. METHODS: We developed graphical symbols for all ROP stages as well as plus disease. All of the symbols were integrated into a java-based application as a particular ROP category of a complete symbol library for retinal changes. The symbols can be placed on a schematic retina with a mouse click. Using anchors each symbol can be individually adapted to the specific finding (size, position, shape). RESULTS: The use of standardised symbols in a software package allows the computer-aided manufacturing of graphically high-quality documentation in affordable time. The distinct assignment of all symbols to the ROP stages prevents misinterpretation and sketchy, illegible hand drawings. CONCLUSIONS: The digital documentation of pathological changes of ROP provides an easy, economic and standardised method to record retinal findings.

[Diurnal variation of ocular pressure in open-angle glaucoma with telemonitoring]. / Tagesschwankungen des okulären Perfusionsdrucks im Telemonitoring bei primärem Offenwinkelglaukom.

BACKGROUND: The aim of this study was to study and analyse distribution, range and intraday variation of ocular perfusion pressure (OPP) in patients with primary open-angle glaucoma (POAG) in the framework of telemedical home-monitoring. METHODS: In the project Teletonometry Mecklenburg-Vorpommern (TTMV) patients were equipped with a home-monitoring system for self-measurement of intraocular pressure and blood pressure. All measurements were transmitted via telephone modem to an electronic patient record that automatically calculated OPP. We present the temporal characteristics of OPP in 70 patients with POAG. After the measurement of blood pressure and intraocular pressure was performed, the individual ocular perfusion pressure was calculated by the formula: (OPP=[2/3 x (2/3 x DBP + 1/3 x SBP)]-IOP). RESULTS: In 3282 OPP measurements the percentage of values less than 50 mmHg was: left eye 2273/69.2%--right eye 2362/71.9 % and less than 40 mmHg: left eye 687/20.9 %--right eye 794/24.2%. 50/51 (left eye/right eye) patients had an individual OPP average of less than 50 mmHg and 10/10 (left eye/right eye) patients less than 40 mmHg. The diurnal OPP trend showed 4 phases (7-12, 12-18, 18-22, 22-7 hour). In the intervals from 22-7 hour and 7-12 hour ocular perfusion pressure values were low. Between 7-12 hour ocular perfusion pressure was significantly depressed as in the other phases (p<0.05). CONCLUSIONS: Ocular perfusion pressure of glaucoma patients calculated using intraocular pressure (self-tonometry) and blood pressure demonstrates a feasible method to evaluate individual diurnal OPP fluctuations. However, this OPP could be described a bit more precisely as the really topical ocular perfusion. Many physiological conditions may not be included, e. g., autonomic circulation. Simultaneous measurement of blood pressure and intraocular pressure enable the detection and analysis of side effects and interactions between glaucoma and hypertension therapy. In clinical practice OPP telemonitoring presents a new way to examine ocular blood circulation in routine glaucoma work-up. The diurnal OPP variations were associated with the fluctuations of systemic blood pressure for the most of part.

[Fluctuation of intraocular pressure in 24-hour telemonitoring compared to tonometry during normal office hours]. / Fluktuationen des intraokularen Augendrucks - ein intraindividueller Vergleich zwischen 24-Stunden-Teletonometrie-Monitoring und ambulanter Augendruckmessung.

BACKGROUND: Elevated intraocular pressure (IOP) is a clinically relevant factor in glaucoma progression. As a dynamic parameter the IOP depends on various internal and exogenic influencing factors. Therefore, we analysed intraindividual IOD variations between ambulant care and 24-h home-monitoring using self-tonometry. PATIENTS AND METHODS: This study is based on paper-based glaucoma cards of 25 patients with primary open angle glaucoma. Additionally, all patients participated in a telemedical home-monitoring study with self-measurements of IOP and blood pressure stored in an electronic patient record. The glaucoma cards contained a total number of 409 IOP values with documentation periods from 0.5 to 10 years. In the teletonometry project all 25 patients were observed for 6 months with 1490 recorded IOP values. Statistical analysis was performed with SPSS software. RESULTS: Average IOP values for all 25 glaucoma patients were 16.3 +/- 2.9 mmHg for both eyes in glaucoma card documentation, whereas the electronic patient records showed IOP averages of 18.9 +/- 4.7 mmHg for right eyes and 18.2 +/- 4.4 mmHg for left eyes. Corresponding to the practice opening hours the glaucoma cards contained no IOP records from 12:00 pm to 01:30 pm as well as between 06:00 pm and 07:15 am. In these time periods 17 % of all IOP values recorded in 24-hour teletonometry were higher than 20 mmHg. However, statistical analysis and clinical evaluation of device parameters and measurement characteristics revealed sporadic measuring errors. CONCLUSIONS: The additional involvement of self-tonometry in telemedical 24-h home-monitoring is a feasible method to record and detect intraday IOP fluctuations. Compared to single IOP measurements documented in common paper-based glaucoma cards, the 24-h electronic patient record showed more frequent circadian IOP variations. As a result, self-tonometry and home-monitoring can be a useful link to fill the gap between singular ambulant IOP measurement and hospitalisation with 24-hour IOP profiles.

[Home-monitoring in ophthalmology--prerequisites for an improvement in quality of life: conclusions from the management research study Teletonometry Mecklenburg-Vorpommern]. / Homemonitoring in der Augenheilkunde--unter welchen Voraussetzungen für mehr Lebensqualität: Schlussfolgerungen aus der Versorgungsforschungsstudie Teletonometrie Mecklenburg-Vorpommern.

Home-monitoring represents an innovative and growing health service area in which suitable conditions have to be created for the attending doctor and also for the patient. For this it is necessary to offer the technical supply and also to establish simultaneously organisational structures in the cooperation between the doctor and the patient based on prevalent experiences of general ambulant care. The medical care as a whole can be optimised to be more patient-orientated by integrating assistant medical staff and by establishing modern IT communication channels. The evolving home-monitoring in consideration of the doctor-patient experiences can contribute to an improvement in the patient's quality of life.

[Fitness to drive and chronic eye diseases]. / Fahrtauglichkeit und chronische Augenerkrankungen.

For the participation of people with chronic eye problems in social life, the preservation of mobility is an important prerequisite. In the case of chronic illnesses they should also be given the opportunity, in accordance with the Patients Rights Act, to be able to make decisions in good time and independently on the further course of action to be taken in the event of a loss of mobility as a result of the inability to drive. In the case of a chronic progressive loss of visual acuity or loss of field of vision, the ophthalmologist should therefore initiate information and education of the patient at an early stage with respect to a possible impending inability to drive. The place, date and duration of the consultation must be documented. At the patient's request, a written evaluation report must be prepared by the examining ophthalmologist. In the daily medical routine of the clinic and practice, a distinction should be made between the medical consultation of a chronically ill eye patient on problems of driving safety and fitness to drive and the concerns regarding an assessment to determine fitness to drive in accordance with § 12, Annex 6 of the driving licence regulations.