[Strategies of Intravitreal Injections with Anti-VEGF: "Pro re Nata versus Treat and Extend"]. / Injektionsstrategien bei der Anwendung intravitrealer VEGF-Inhibitoren: "Pro Re Nata versus Treat and Extend".

The goal of this report is to provide a review on different strategies for the use of pro re nata (PRN) and treat and extend (T&E) regimens with intravitreal anti-VEGF agents (bevacizumab, ranibizumab or aflibercept) in patients with retinal diseases such as neovascular AMD, diabetic macular oedema and macular oedema due to retinal vein occlusion. The main focus is to present the effectiveness and visual outcomes of both PRN and T&E regimens in the main pivotal trials and studies based on currently available evidence. We also discuss the advantages and disadvantages of both regimens, as well as monitoring and treatment of the disease, including treatment intervals and injection frequency. Currently there is increasing interest in establishing a regimen which offers the best visual outcome with lower injection frequency, and with reduced treatment burden by individualising treatment intervals and minimising the number of clinic visits and costs. Studies have shown that the PRN regimens in a clinical setting are insufficient in assuring the best visual outcome. The PRN regime requires frequent clinic visits to monitor disease status and intravitreal treatment if needed in a reactive approach. Individualised T&E regimens can improve visual outcome and require fewer injections than those administered in a monthly regimen and fewer monitoring visits than those in a PRN regimen.

[Explosives-based vole traps-A novel injury pattern in the eye region]. / Sprengstoffbasierte Wühlmausfallen ­ ein neuartiges Verletzungsmuster im Augenbereich.

BACKGROUND: A novel method for trapping voles is the use of pistol-like explosive tools loaded with bolt-action ammunition. When triggered the vole is killed by the very high gas pressure created. Accidental releases can result in facial and/or eye injuries. The aim of this work was to describe the injury pattern in the patient and to experimentally verify whether there is a risk of penetrating eye injuries. METHODS: Two emergency patients presented to our eye clinic with eye injuries after unintentional triggering of the explosive trap. Based on the new pattern of injury noted, experiments were performed on enucleated porcine eyes to determine the possible severity. For this purpose, a vole trap was clamped in a holder and loaded with a Cal. 9â€¯× 17 mm cartridge in each case. In front of the muzzle opening, 3 pig eyes each were fixed on Styrofoam at a distance of 20, 40, 60 and 80 cm. The foreign body indentations in the cornea were visualized and measured by spectral domain optical coherence tomography (SD-OCT). The pig eyes were then dissected and searched for foreign bodies using microscopy. The SD-OCT images of an injured patient were also included for human comparison. RESULTS: On patient examination, in addition to the usual fine gunshot marks on the face and conjunctiva/eye area, wax-like, larger and heavier particles of approximately 0.1-0.2 mm in size were found, which originated from the cartridge end cap. Removal of these foreign bodies, some of which were injected more deeply into the cornea, conjunctiva, and tenon, is much more difficult and extensive than in usual blast trauma. There was no evidence of intraocular foreign bodies in either patient. Likewise, no intraocular foreign bodies could be detected experimentally in any pig eyeball (n = 12). Remnants of the wax-like cartridge end were found deeply penetrating into the corneal stroma. The maximum penetration depth measured against the total corneal thickness was 46% at 20 cm device distance and decreased with greater distance to the vole trap (penetration depth at 40 cm at 37%, at 60 cm at 28% and at 80 cm at 19%). For comparisons on the human eye, a penetration depth of 54% was measured at a distance of about 40 cm. In pig eyes the number of foreign bodies per cm2 decreased with increasing distance from the vole trap (mean: n = 174 foreign bodies, FB, at 20 cm distance, n = 46 FB at 40 cm, n = 23 FB at 60 cm, and n = 9 FB at 80 cm). The largest penetrating foreign bodies measured a mean of 383 ± 43 µm with a maximum of 451 µm. CONCLUSION: New vole traps with gas-powered mechanisms result in larger deeply penetrating wax-like foreign bodies in the cornea, conjunctiva, and tenon of the eye, which are difficult to remove and only surgically possible. Despite the significant explosion during triggering, there was no evidence of penetrating ocular injury from the foreign bodies either in the patient or experimentally in the pig eyes. Safety goggles should be worn when handling the traps to avoid penetration of foreign bodies into the eye.

[Testing for visual deficits by the police among road users in Germany]. / Überprüfung visueller Defizite durch die Polizei bei Verkehrsteilnehmern in Deutschland.

BACKGROUND: The Professional Association of Ophthalmologists (BVA) estimates that at least 100,000s of traffic accidents with 10,000s of injuries and fatalities are caused by known and unknown visual disorders on German roads every year. Until now, however, the police have not had the opportunity to check for potential visual disorders on the spot in cases of conspicuous driving. In a pilot project of the police with the Eye Hospital of the Hannover Medical School (MHH), the aim was for the first time to extend the existing tests of the police by adapted "car-side" vision tests. MATERIAL AND METHOD: On-site evaluation of eye motility, pupil size and light reaction of car drivers as well as an orienting visual acuity test and an orienting confrontation visual field was performed. The practical performance of all examination modalities was previously coordinated and trained. RESULTS: The scope and type of individual examinations for estimating visual ability of car drivers were described and standardized. In addition to the visual characteristics, more familiar neurological tests, such as walking along a straight line were also recorded. The combined test evaluation results in an objective basis for the official decision of an immediate temporary withdrawal of the driving license, if necessary, and the initiation of further measures, such as an ophthalmological examination. With these innovations, the Lower Saxony police have revised their training concept for checking driving ability and issued it for implementation at the beginning of 2022, including the vision tests recommended by ophthalmologists. In the meantime, around 150 officers have been trained in Lower Saxony and are now authorized to carry out qualified driving ability tests. In this respect, a large number of corresponding traffic examinations have already been carried out and the continued driving of road users with significant visual deficits has been prevented. CONCLUSION: In this pilot project, the aim was for the first time to expand the common testing procedures of the traffic police for the detection of drivers who are dangerous to traffic, in addition to screening for alcohol, drugs and neurological deficits, to include specific tests for the detection of visual deficits. The corresponding training of police officers has been carried out across the board in Lower Saxony and Hamburg, and the measures are currently being applied as needed during traffic controls. In the future, the tested characteristics will be evaluated in a weighted score and will provide an objective basis for the police to decide whether to stop the driver in cases of deficits.

[Spectrum of firework injuries at a university eye clinic after the COVID-19 lockdown]. / Spektrum von Feuerwerksverletzungen an einer Universitäts-Augenklinik nach dem COVID-19-Lockdown.

BACKGROUND: The handling of fireworks regularly leads to a variety of injuries affecting the periocular region. Due to the COVID-19 lockdown and a sales ban on consumer fireworks for the private sector the number of injuries massively decreased; however, a considerable increase was registered again at the last New Year festivities. The aim of this work was to present the extent and spectrum of such injuries in a maximum care center. METHODS: As part of the nationwide survey of firework-associated eye injuries in emergency care eye clinics and hospitals, data from the MHH Eye Hospital in Hannover were compiled over the period of 3 days (30.12.2022-01.01.2023) and evaluated with respect to gender, age, severity, injury pattern, type of fireworks and treatment. RESULTS: Of a total of n = 25 injured patients, n = 19 (76%) were male. Most patients presented on New Year's Day (n = 14, New Year's Eve: n = 9; 30.12.2022: n = 2), with the majority of cases presenting with mild injuries with irritation and erosion of the ocular surface (n = 15; 60%). Of the patients four sustained moderate to severe injuries with bulbar contusion, hyphema, and sometimes iris base tears (16%). Of the patients six suffered severe, mainly open, eye injuries (24%), two of which required primary evisceration. Ignition of fireworks batteries revealed the highest risk of serious injury, affecting mainly males 31-40 years of age. Children up to 12 years of age generally sustained only minor injuries, although there were exceptions as there were among adolescents. The person who caused the fireworks injury was affected in about 52% of the cases; in 48% the victim of the accident was a bystander. In cases of complex injuries, under certain conditions only surgical exploratory diagnostics could lead to the correct diagnosis and best possible care. CONCLUSION: The extent of firework injuries is manifold and the consequences including blindness are considerable. The burden on physicians on duty on New Year's Eve and New Year's Day was enormous, as with the permission of private fireworks a large number of patients had to be cared for via the emergency room, some of whom required complex surgical care. To prevent serious eye injuries, targeted education about the risks of private fireworks and possibilities to increase safety should be intensified.

[Economics of operating room use at a university eye hospital]. / Wirtschaftlichkeit der Operationssaalnutzung an einer Universitäts-Augenklinik.

BACKGROUND: In ophthalmologic surgery, there are usually short operation times and thus many changes between the individual operations, which are not subject to remuneration. As in maximum care hospitals consecutive different operations with different durations are often performed, emergency operations have to be inserted and further training of colleagues is practiced, it is particularly important to generate the shortest possible transfer times in order to have both sufficient operation time and to be able to treat as many cases as possible. The aim of this work is to evaluate the efficiency of the surgical performance of a university eye hospital. MATERIAL AND METHOD: The surgeries performed in 2021 at the MHH Eye Clinic were evaluated with respect to the spectrum, number, surgery duration, transfer times and process times. In terms of personnel, each operating room was staffed with one assistant anesthesiologist, one nurse anesthetist, two operating room nurses, one surgeon, and 20% senior anesthesiologist supervision. Based on a theoretical concept, which provides an increased staffing ratio while maintaining the same infrastructure, it was calculated how many more surgeries could be performed if the transfer time was halved and whether the additional financial expense could be compensated. RESULTS: With a total of n = 2712 surgeries performed during regular duty hours (244 working days) in 2 operating rooms (average daily n = 11.1; weekly n = 53.6 and monthly n = 237.1), the average surgery duration was 37 min and the transition time 43 min. This means that the operating rooms were used for surgery for 51% of the total operating time. Main procedures were vitrectomy with n = 1350 and cataract surgery with n = 1308. The new personnel concept provided one additional operating room nurse per operating room and one additional anesthesiologist for both operating rooms. The additional costs for this personnel expenditure were calculated at approx. 300,000 € per year. The halving of the transfer time from 43 min to about 21 min through possible overlapping induction and parallel work, which was not possible until now, results in an additional operation time of about 100 min per operating room, so that at least 4 additional operations can be planned and performed. In this way, with stringent implementation and the same spatial structures with stable fixed costs, n = 976 more operations could be performed, which, minus the personnel costs, the additional material costs for surgery and anesthesia of 557,042 € and the inpatient hotel costs of 600,663 €, with an average length of stay of 2.8 days, would result in an additional revenue of about 2.4 times the additional personnel costs at the current flat rate of 3739.40 € and an average case mix index of the MHH Eye Hospital of 0.649 (total revenue: 2,155,449 €; profit margin II: 701,389 €) for the considered surgical patient collective in 2021. CONCLUSION: An increase of the personnel expenditure in the operating room for surgical subjects such as ophthalmology with shorter interventions and many changes is economically worthwhile also for a large hospital in order to enable and optimize overlapping transfers of anesthesia and surgical care. This should therefore also be considered separately, contrary to standardized staffing of the overall hospital, in order to use existing resources with their fixed costs as optimally as possible.

[Adapted and standardised patient management in the treatment of neovascular AMD in the outpatient setting of a university eye hospital]. / Angepasstes und standardisiertes Patientenmanagement bei der Behandlung der neovaskulären AMD im ambulanten Bereich einer Universitäts-Augenklinik.

Visual results in treating neovascular age-related macular degeneration (AMD) using intravitreal injected anti-VEGF (IVT) clearly depend on injection frequency. Regarding to the European approval Ranibizumab has to be used only in cases of recurrent visual loss after the loading phase. In contrast monthly treatment--as also provided in the ANCHOR and MARINA studies--is generally allowed in Switzerland. However, it is commonly tried to reduce the injection frequency because of the particular cost situation in all health systems and of cause also due to the necessary strict monitoring and reinjection regimes, which raise management problems with increasing patient numbers. In this article the special treatment regimes of our University Eye Hospital is presented, in which a reduced injection frequency basically leads to the same increased and stable visual results as in ANCHOR and MARINA; however, needing significantly more injections as generally provided in other countries of Europe. The main focus for achieving this in a large number of patients is placed on re-structuring our outpatient flow for IVT patients with particular emphasis on patient separation and standardisation of treatment steps leading to significantly reduced time consumption per patient. Measurements of timing and patient satisfaction before and after restructuring underline its importance in order to be able to treat more patients at a high quality even in the future. The exceptional importance of spectral domain OCT measurements as the most important criterium for indicating re-treatment is illustrated.

[Regression of idiopathic epiretinal membrane-Case report and consideration of the possible mechanism]. / Regression einer idiopathischen epiretinalen Gliose ­ Kasuistik und Überlegungen zum Mechanismus.

In the presence of a symptomatic epiretinal gliosis, pars plana vitrectomy with membrane peeling to remove the membrane is usually indicated in clinical practice. According to common clinical experience, almost no independent regression of such an epiretinal membrane and thus healing of the pathology alone exists. Therefore, the unusual case of bilateral independent regression of idiopathic epiretinal gliosis and formation of a lamellar macular hole in a 73-year-old male patient is described. Considerations of the possible mechanism are presented based on the existing literature. These include separation of inflammatory versus noninflammatory membranes, possible separation of individual layers depending on the status of the posterior vitreous limiting membrane and also the possible action of proteolytic systems in the posterior vitreous region. Finally, the question arises, whether patients have to be informed about this fact before possible surgery.

[The most serious incident-Experiences of aggression and violence in ophthalmology]. / Der schwerwiegendste Vorfall ­ Erfahrungen von Aggressionen und Gewalt in der Augenheilkunde.

BACKGROUND: Experiences of aggression/violence influence job satisfaction and can have a long-term psychological and physical impact on employees. In the fall of 2018, the Professional Association of Ophthalmologists (BVA) and the German Ophthalmological Society (DOG) conducted a survey on experiences of aggression and violence. The first results were published in 2020. In the survey it was also possible to describe the most serious incident to date using free text fields, among others. METHOD: All 9411 members of the DOG and BVA were given the opportunity to complete a questionnaire online in 2018 regarding aggression and violence in ophthalmology. RESULTS: Overall, 253 of 1508 (16.8%) ophthalmologists participating in the survey reported their most serious incident, 46.8% of which were classified as moderate and 34.3% were related to verbal violence such as insults and threats. The most serious incident was experienced by 171 (67.6%) physicians in a practice setting, 71% were specialists at the time of the incident and 74.3% of the incidents occurred during regular working hours. The main causes were intercultural conflicts, long waiting times, problems with the allocation of appointments, excessive expectations, differences in treatment and basic aggressiveness. The offenders were male in 86.3% of cases, 15.8% of the incidents were reported to the police and 21 (8.3%) physicians issued a practice reprimand or house ban. DISCUSSION: The description of the most serious incidents illustrates situations that are sometimes hard to imagine and also which incidents were considered serious. There are large subjective variations in the assessment of the incidents. Protective measures in practices and clinics are essential.

[Performance and cost calculation for a university ophthalmological outpatient clinic]. / Leistungs- und Kostenkalkulation für eine universitäre, augenheilkundliche Hochschulambulanz.

BACKGROUND: Outpatient procedures at a university hospital are generally considered to be unprofitable. In the present publication we evaluate the turnover and costs of the university eye outpatient department of the Hannover Medical School (MHH) in terms of a cost unit accounting as well as providing a summary of the workload. MATERIAL AND METHOD: Given the data of the hospital information system (IS-H/i.s.h.med from SAP) and a proprietary software (TimeElement), all patient contacts in the year 2019 were evaluated. The latter software is applied in a standardized manner to record the patient flow of our outpatient service in real time electronically. The total costs consist of personnel, material and room costs including infrastructure of the MHH and are compared to the flat-rate revenues according to the university outpatient contract (HSA) as well as further revenues from internal referral services, self-pay patients, outpatient surgery and cooperation contracts for intravitreal injections (IVOM). RESULTS: With an average full-time equivalent (FTE) headcount of 10.63 assistant physicians, 3.6 specialist physicians, and 21 nonphysicians (plus 4 Federal Volunteer Service, BUFDI) in our policlinic, we have determined €â€¯2,927,022 in personnel costs, including overheads, for the entire year. Including infrastructure (€â€¯524,942), material and equipment costs with overheads and internal cost allocation of €â€¯258.657, the total costs in 2019 resulted in €â€¯3,710,621. In contrast, the total income in 2019 was €â€¯3,524,737 generated through the abovementioned patient segments, resulting in a deficit of €â€¯-185,884 (5%). Our data provide evidence that regular outpatient revenues are insufficient and are mainly balanced by outpatient surgery, IVOMs and self-pay patients. In total, there were 19,453 patient contacts during regular office hours (with 17,305 billable cases). At n = 9943, the majority of the contacts were HSA visits; however, only 82% of the cases could effectively be charged due to multiple visits per quarter. The median total patient attendance was 3.21 h (mean 3.38 h). On average, 78 patient contacts were counted per working day. The analysis with TimeElement unveiled a median of n = 2 physician contacts per patient (mean n = 1.91). The median duration per interaction with a physician was 17.98 min (mean 23.23 min). For diagnostics, we counted a median of n = 2 interactions per patient (mean n = 2.31), with an entire interaction lasting a median of 18.30 min (mean 22.60 min). In total n = 37,363 individual diagnostic procedures were recorded in 2019, with SD-OCT being the primary procedure at n = 10,888. CONCLUSION: The cost/turnover calculation showed a marginal financial loss through our ophthalmological outpatient department. Thus, the costs of a university eye outpatient department in Lower Saxony do not seem to be sufficiently covered by direct outpatient revenues. Maintaining quarterly flat rates for all cases of the outpatient department would require a fee of about €â€¯214 in our setting to remain cost neutral. Currently, the lower flat rates in the HSA area are compensated by other areas. Obviously, the high content-related workload in our setting requires a high personnel expenditure with a considerable personnel cost contribution of nearly 80%.

[Influence of COVID-19 shutdown on the workload of a university eye clinic]. / Einfluss des COVID-19-Shutdowns auf die Arbeitsleistung einer Universitäts-Augenpoliklinik.

BACKGROUND: The outbreak of the novel coronavirus disease 2019 (COVID-19) has led to a significant reduction in the number of patients treated in elective medicine in hospitals in spring 2020. Up until now, there are no corresponding data for university policlinics. MATERIAL AND METHODS: With the help of the data of the clinic's electronic medical record system (IS-H/i.s.h.med from SAP, Cerner Corporation, North Kansas City, MO, United States of America and SAP SE, Walldorf, Germany) and the time recording and management software TimeElement (Hannover Medical School, Hannover, Germany), which was codeveloped at our clinic, all patient contacts of the COVID-19 shutdown were evaluated over a period of approximately 7 weeks from 18 March 2020 to 8 May 2020 and compared with the same period in 2019. In addition, quarterly revenues for the first and second quarters of 2019 and 2020 were put into perspective via SAP. RESULTS: During the COVID-19 period the total number of patient contacts was reduced by 59.5% compared to the previous year. The number of lockdown period cases decreased by 74.8% compared to the same period in 2019. In particular, the university outpatient/self-paying sector recorded the largest number of lost patient contacts with a reduction to 17.2% of the 2019 baseline. The reduced patient contacts and case numbers resulted in a significant financial loss of at least €â€¯218,000. Via TimeElement there was a 69.4% decrease in all special diagnostic services, with visual field examinations in particular also reduced by 75.3%. Optical coherence tomography (OCT) measurements recorded a decrease of 60.3%. Patient tracking revealed a reduction of average patient attendance times by approximately 23% (COVID 19: 145.8 ± 88.8 min versus 189.6 ± 97.2 min in 2019). DISCUSSION: The COVID-19 shutdown caused the work performance of our policlinic to drop to only about 40% of patient contacts and that of functional diagnostic examinations to only about 30%, compared to the performance in 2019; however, the reduction in the number of patients also led to a significant reduction in the time patients were present at the clinic compared to the regular workload. The associated financial losses are considerable and obviously not compensated by legally regulated compensation payments as in the inpatient sector.

[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.

[Cost unit accounting of strabismus surgery at a university eye hospital]. / Kostenträgerrechnungen von strabologischen Operationen an einer Universitäts-Augenklinik.

BACKGROUND: Strabismus surgery is frequently carried out in university centers. The aim of this work was to calculate the costs of strabismus surgery at a university hospital and to assess the remuneration of costs for outpatient procedures. MATERIAL AND METHODS: Of all strabismus surgeries at the Hanover Medical School in the years 2018 and 2019, relevant surgical data, such as patient age, number of muscles operated on, incision to suture time, attendance time of the surgeons and anesthetists as well as the nursing staff, were evaluated based on the clinics own information system. During this process, the costs for personnel, material, room rental charges and overheads were computed applying cost unit accounting. RESULTS: A total of 302 operations (inpatient proportion 92.1%) were carried out in most cases with the patient under general anesthesia. The mean patient age was 31 years (median 26 years), with 33 patients being children under 6 years of age. On average 1.84 muscles were treated per intervention. The mean incision to suture time was 51.5 min, mean anesthesia time was 85 min, the attendance time of surgical as well as anesthesia nursing staff each accounted for 104 min, the additional time in the postanesthesia care unit added 66 min. Average personnel costs originating from the overall process amounted to 642.14 €, with the addition of 109.23 € for material and medication (surgery and anesthesia) and costs for cleaning and room rental (including overheads) of 178.71 €. Therefore, the overall costs of an average strabismus surgery in our collective added up to 930.08 € (minimum 491.01 €, maximum 1729.29 €). Cost accounting of subgroups yielded substantially higher costs for anesthesia in children as well as for higher numbers of muscles operated on due to different treatment duration (37 min for 1 muscle to 72 min for 3 muscles) and anesthesia time, especially in children <6 years of age (on average 22 min longer than adults and children >5 years; the differences being 11 min for 1 muscle, 25 min for 2 muscles and 30 min for 3 or more muscles). The pure costs of a strabismus surgery at this clinic seem on average to exceed the revenues for strabismus surgery in the outpatient sector calculated by the German uniform evaluation benchmark (EBM) by about a factor of 2. CONCLUSION: It could be shown that the purely economically calculated costs for strabismus surgery at a university clinic are significantly higher than the revenues achieved in the outpatient sector according to paragraph 115b, section 1, of the Social Security Act V (SGB V). Under these circumstances, such operations cannot be performed in a cost-effective manner.

[Experiences of aggression and violence against ophthalmologists]. / Erfahrungen von Aggression und Gewalt gegen Augenärztinnen und Augenärzte.

BACKGROUND: The media have reported an increased willingness of patients and relatives to use violence against medical personnel. So far a few studies have been carried out on this topic and the data situation is correspondingly weak. Ophthalmologists in particular have close contact with patients at the slit lamp and are often alone with patients. METHODS: A questionnaire was developed based on the perception of prevalence of aggression scale (POPAS) questionnaire and the survey on aggression and violence among general practitioners. In autumn 2018, all members of the German Ophthalmological Society (DOG) and the Professional Association of Ophthalmologists (BVA) received an invitation by e­mail to complete the questionnaire online. RESULTS: Of the 9411 ophthalmologists contacted a total of 1508 (age 49 ± 12 years) took part in the survey (16%). Of the respondents 806 (53.7%) were female and 1139 (75.5%) participants worked in practices. A total of 1264 (83.3%) ophthalmologists had experienced aggression/violence in their work, 986 (65%) respondents had already experienced verbal assaults without threats, 363 (24.1%) doctors reported experiences with threats of physical violence and 30 (2%) participants had received medical treatment for severe physical violence. Sexual intimidation/harassment was affirmed by 322 (21.4%) of respondents, of whom 243 (75.5%) were female and 533 (47.9%) doctors felt that aggressive/violent behavior had increased in the last 5 years. CONCLUSION: The high number of participants indicates the high relevance of the topic. The survey produced astonishing results, which should lead to further discussion and action to improve the safety of employees.

[Prioritisation in the German health care system--an issue in ophthalmology?]. / Priorisierung im Deutschen Gesundheitswesen--ein Thema in der Augenheilkunde?

At the 111th German Medical Assembly in May 2008 in Ulm, Germany, a public debate on rationing of health care performances was started. Since the money in the German health care system is not enough to provide every diagnostic or therapy for every patient as a coverage of the compulsory medical insurances, a lot of specific health care performances have been rationed during the last years not to be covered by the regular medical insurance any more, such as, e. g., PSA measurements in urology or IOP measurements in ophthalmology. In contrast to the health care system in Scandinavia, where rationing of health care performances is publicly documented by the government, no similar public statements exist in Germany. Due to this, it is left to physicians to explain to their patients the "hidden" rationing of public health care performances, which also leads to an increase in individual health care performances (IGeL in Germany) to be paid for privately by the patient. It is undoubtedly true that not all medically possible performances need to be paid for by the health insurance; however, an official determination of these "out of pocket" health care performances is necessary. Therefore, it was the aim herein to work out possible "stop" criteria--according to the Scandinavian system--for common eye diseases and consecutive therapies, which need not be paid for or only be paid after a delay by the health insurances.

Long-term evaluation of anatomic and functional results after complicated retinal detachment treated with pars plana vitrectomy and heavy silicone oil tamponade.

BACKGROUND: Heavier than water tamponades offer the possibility to support the inferior part of the fundus after retinal detachment. The aim of this study was to evaluate the anatomic and functional outcome of complicated retinal detachment treated with vitreous surgery and heavy silicone oil (HSO) tamponade. Surgery was performed in eyes with rhegmatogenous retinal detachment (RD) predominantly in the lower hemisphere or with penetrating injury (either as primary intervention or after development of proliferative vitreoretinopathy [PVR]). MATERIALS AND METHODS: Sixty-one eyes of 61 patients with RD - mostly complicated by PVR - and a minimum follow-up of 12 months were included in this study. Vitreoretinal surgery with HSO (Oxane HD) tamponade was performed in all patients. In 52 patients, heavy silicone oil was used in the management of complicated RD. 9 patients had surgery for complicated RD after penetrating eye injury.The mean follow-up period was 30.3 +/- 10.2 months. RESULTS: The overall final anatomic success rate was 79 %. In 39 % of the cases the retina remained attached during the entire follow-up period. CONCLUSIONS: The anatomic success rate after surgery with HSO (Oxane HD) was relatively low; however, only complex cases bearing a higher risk of retinal re-detachment received HSO in this study. Oxane HD does not appear to have major advantages compared to conventional silicone oil or other new-generation heavy silicone oils in these cases.

[Bruch's membrane opening minimum rim width : Correlation and diagnostic accuracy in comparison to peripapillary retinal nerve fiber layer thickness]. / Die auf der Bruchschen Membranöffnung basierende Minimale Randsaumweite : Korrelation und diagnostische Genauigkeit im Vergleich zur peripapillären retinalen Nervenfaserschichtdicke.

BACKGROUND: Glaucoma is one of the main causes of blindness in the Western hemisphere. Because the disease often painlessly progresses it remains unnoticed until major optic nerve head damage occurs in many cases. That is why new, more sensitive diagnostic methods are needed. Bruch's membrane opening minimum rim width (BMO-MRW), measured with the new glaucoma module premium edition (GMPE) was recently introduced as a more accurate tool to detect glaucomatous changes. The purpose of this study was to assess the correlation of SPECTRALIS® spectral domain optical coherence tomography (SD-OCT) and the GMPE anatomic positioning module (APS module) for retinal nerve fiber layer thickness (RNFLT) measurements. The second aim was to assess the diagnostic accuracy of BMO-MRW. METHODS: Prospective study of 41 eyes (41 patients) with glaucoma and 26 eyes from 26 healthy controls. Scans were obtained using SPECTRALIS® SD-OCT and RNFLT was measured with both modules and compared using Spearman's rank test. The BMO-MRW was assessed by GMPE. Sensitivity, specificity and area under receiver operating characteristics curves (AUROC) of each sector of the optic nerve were calculated and compared using the method of Delong et al. RESULTS: We found a positive correlation (0.694-0.955, p < 0.0001) between RNFLT measurements by standard SD-OCT and all diameters of RNFLT of APS module within all sectors. The AUROC of RNFLT in standard SD-OCT was 0.693 for the inferior nasal sector (NI) and BMO-MRW was 0.85 in NI. The difference in AUROC was statistically significant (p = 0.0049). No other sector showed statistically significant differences. CONCLUSION: The RNFLT measurements of both modules showed a positive correlation and appear to be comparable. The BMO-MRW in one sector (NI) showed a significantly higher accuracy of measurement than standard RNFLT. All other sectors showed a comparable accuracy of measurement.

[Cost calculations for treating penetrating eye injuries within the DRG C01Z at a university eye hospital]. / Kostenkalkulation für die Behandlung von offenen Augenverletzungen in der DRG C01Z an einer Universitäts-Augenklinik.

BACKGROUND: Since 2004, inpatient health care for penetrating eye injuries in Germany had been paid according to the calculated DRG C01Z. Because the extent of treatment mainly derives from the extent of eye damage, this DRG economically summarises very heterogeneous cases. It was the aim to check the cost recovery for the surgical treatment of penetrating eye injuries at a university eye hospital. MATERIAL AND METHODS: Performance data for the DRG C01Z were collected for the years 2005 and 2006 using the E1 sheets according to section sign21 KHEntG. Costs for single operations were calculated from fixed and variable costs for the operating theatre and the ward, including costs for personnel and supplies. RESULTS: In the 2-year period, out of 4,721 inpatient procedures, 180 perforating eye injuries were surgically treated. In 80 cases, a pure corneal/scleral suture (plus cataract surgery, n=10; mean operating time 67.81 min) was performed. In the other 100 cases, a pars plana vitrectomy (ppV) with adjuvant measures (mean operating time 124.69 min) was needed. Each operation had fixed surgical costs of EUR 130.60; variable costs, including personnel and supplies, varied between EUR 570 for corneal/scleral suture (+/-EUR 250 for combined cataract surgery (n=10) and EUR 1230 (mean) for a ppV. Cost-effective additional adjuncts such as cerclage, perfluorocarbon, gas, silicone oil, or cataract surgery led to extra costs of between EUR 51 and EUR 250 per adjunct (mean EUR 182). At least two of these adjuncts were used in 50% of ppVs, and at least one was used in 90% of ppVs. Hospitalisation costs were about EUR 2184 (EUR 273 per day), with a mean stay of 8 days. The overall costs of an operation for penetrating eye injuries differed significantly in terms of the procedure (corneal/scleral suture: EUR 2662, mean length of stay 7.06 days; ppV: EUR 3712, mean length of stay 8.62 days). Additional costs for multiple surgeries, as occurred in 11.1% of all cases, were not compensated by the DRG system. CONCLUSION: In consideration of a relative DRG weight of 1,177 and a base rate of EUR 2723.79 in Bavaria for 2005 and 2006, perforating eye injuries were compensated within the C01Z DRG at EUR 3205,96. Thus, for ppVs no costs are recovered, whereas "pure suture" procedures are overweighted. Due to this inhomogeneity, a split in the C01Z DRG is necessary.

[Hospital quality management in Germany]. / Qualitätsmanagement im Krankenhaus.

Hospital quality management (QM) is a legal obligation in Germany. This article reviews the regulations of quality control, the basic principles of QM, specific quality techniques, the process of QM implementation in the hospital and the possibilities of external QM certifications. Due to the increasing and effective privatisation of hospitals in Germany, careful attention to specially designed QM systems for private hospitals seems to be reasonable.

[Cost recovery for the treatment of retinal and vitreal diseases by pars plana vitrectomy under the German DRG system]. / Kosteneffizienz von netzhaut- und glaskörperchirurgischen Eingriffen mittels ppV unter DRG-Bedingungen.

BACKGROUND: Since 2004 inpatient health care in Germany is paid according to calculated DRGs. Only a few university hospitals participated in distinct cost calculations of clinical treatment. It was the aim of this study to check the cost recovery at a University Eye Hospital for the surgical treatment of retinal and vitreal diseases by pars plana vitrectomy (ppV), which are included in DRGs C03Z and C17Z. MATERIAL AND METHODS: The performance data for both DRGs were collected for the years 2005 and 2006 using the E1 sheets according to section 21 KHEntG. The mean duration of all procedures was collected by data from the internal controlling. Costs for single operations were calculated from fixed and variable costs for the operation theatre and the ward including costs for personnel and material. RESULTS: In the 2-year period of 4,721 inpatient procedures 1,307 ppVs were performed. Each ppV had fixed surgical costs of 130.60 EUR; personnel costs varied between 575 EUR (C03Z; including cataract surgery; mean OP duration: 85 min) and 510 EUR (C17Z; no cataract surgery; mean OP duration: 73 min) at a proportion between general anaesthesia and local anaesthesia of 80/20. For a pure ppV material costs were 255 EUR. Additional adjuncts such as an encircling band, perfluorcarbon, ICG, tPA, gas and silicon oil or cataract surgery led to extra costs between 51 EUR and 250 EUR per adjunct und were used in 56% (C03Z) and 74.5% (C17Z) of all procedures. Costs for hospitalisation were about 1765 EUR at a mean residence time of 6.5 days. Thus, the overall costs of a pure basic ppV amounted to 2975 EUR (C03Z) and 2661 EUR (C17Z). In consideration of the current relative DRG weights of 1.08 and 0.957 and a current base rate of 2787.19 EUR in Bavaria, cost recovery is only given for basic ppV but not for complex ppVs having higher material and personnel costs. Additionally, the costs for multiple surgeries as occur in 5.9% of cases are not compensated by the DRG system. CONCLUSION: The reimbursement for inpatient ppVs in a University environment is not covered for complex procedures requiring more cost-effective material and personnel time. To consider an adequate cost recovery for these procedures a DRG split for both DRGs (C03Z and C17Z) in basic ppVs and complex ppVs is required. We recommend this proposal for the InEK.

[Software-based visualization of patient flow at a university eye clinic]. / Elektronische Visualisierung des ambulanten Patientenflows in einer Universitäts-Augenklinik.

OBJECTIVE: This article presents a method for visualization and navigation of patient flow in outpatient eye clinics with a high level of complexity. MATERIAL AND METHODS: A network-based software solution was developed targeting long-term process optimization by structural analysis and temporal coordination of process navigation. RESULTS: Each examination unit receives a separate waiting list of patients in which the patient flow for every patient is recorded in a timeline. Time periods and points in time can be executed by mouse clicks and the desired diagnostic procedure can be entered. Recent progress in any of these diagnostic requests, as well as a variety of information on patient progress are collated and drawn into the corresponding timeline which can be viewed by any of the personnel involved. The software called TimeElement has been successfully tested in the practical implemenation for several months. As an example the patient flow regarding time stamps of defined events for intravitreous injections on 250 patients was recorded and an average attendance time of 169.71 min was found, whereby the time was also automatically recorded for each individual stage. CONCLUSION: Recording of patient flow data is a fundamental component of patient flow management, waiting time reduction, patient flow navigation with time and coordination in particular regarding timeline-based visualization for each individual patient. Long-term changes in process management can be planned and evaluated by comparing patient flow data. As using the software itself causes structural changes within the organization, a questionnaire is being planned for appraisal by the personnel involved.