[Jury prize of the Austrian National Prize 2018 : 12 years European Foundation for Quality Management (EFQM) at the University Eye Clinic Graz]. / Jurypreis des Österreichischen Staatspreises 2018 : Zwölf Jahre EFQM (European Foundation for Quality Management) an der Universitäts-Augenklinik Graz.

BACKGROUND: The European Foundation for Quality Management (EFQM) approach has been successfully implemented in healthcare but reports about EFQM awards at university clinics are lacking so far. Can a non-profit organization, such as a university eye department successfully compete with profit companies from industry for the National Prize of the Federal Ministry for Innovation and Business in Austria? MATERIAL AND METHODS: Following successful committed to excellence (C2E) assessments in 2008 and 2010, a 70-page corporate report was compiled strictly according to the EFQM logic (latest version 2013), consisting of basic concepts, criteria matrix and results/approach/deployment/assessment and refinement (RADAR) logic, which formed the basis for an 1­day assessment in 2018. Special emphasis was laid on the development and presentation of the strategy by means of the X­matrix (according to Hoshin-Kanri) between the University Eye Department and its shareholders, the Styrian Hospital Association (KAGes) owned by the Federal State of Styria and the Medical University financed by the Austrian State Federal Ministry. RESULTS: The total points score in the recognized for excellence (R4E) assessment 2018 was 500-550 points, which prompted the jury to award a jury prize of the Austrian National Prize (focus: participative leadership). Potential for improvement, which needs to be worked on in the near future was the alignment of core processes with the main performance indicators of the University Eye Department, which arises from its mission consisting of patient care, research, teaching, training and public relations activities. The development of the strategy with the shareholders has developed from a potential to a strength compared to the R4E assessment from 2017. CONCLUSION: Feedback from the assessor team after the site visit is the greatest added value for a university eye department and/or business enterprise. Improvement measures can be effectively derived following the RADAR logic and lead to a higher quality standard/score and improved performance.

[Successful implementation of the EFQM management model at the Department of Ophthalmology in Graz]. / Erfolgreiche Umsetzung des EFQM-Management-Modells an der Universitätsaugenklinik Graz.

BACKGROUND AND OBJECTIVE: In the context of legal requirements and scarcer resources, the implementation of a quality management (QM) model will provide a competitive advantage or a site warranty for a hospital. For 3 years, the Department of Ophthalmology in Graz has been working with the EFQM model and has now accomplished the first level quality award, namely "Committed to Excellence (C2E)". The project work towards achieving this C2E-award is described below. STUDY DESIGN AND METHODS: EFQM stands for European Foundation for Quality Management, an organization that was founded in 1989 by the EU, together with 14 leading enterprises. In the EFQM model, the maturity of an organization in terms of quality is determined through the achievement of a number of quality awards. The C2E award is the first of these awards. At the beginning of our work for the C2E level, the strengths and weaknesses of the Department of Ophthalmology were determined by means of an EFQM questionnaire. Three improvement measures with the highest impact on the performance of the clinic were identified by the questionnaire: 1. The hospitalization of a cataract patient. 2. The lack of information between the various professional parties. 3. The lack of knowledge within the professional groups of the objectives and strategy of the Department of Ophthalmology. RESULTS: These areas requiring improvement were targeted, addressed and improved in a 6-months project work, structured by the EFQM model. The project work as a whole, the results obtained and the corresponding written documentation were evaluated positively in a 1-day assessment by Quality Austria. DISCUSSION: The EFQM model is a challenging quality management model. After the necessary training of project members or under the supervision of experienced quality managers, the EFQM model may be successfully applied to patient care, teaching and research in a department of ophthalmology.

[Safety and efficacy of interferon alfa-2b in the adjuvant treatment of uveal melanoma]. / Verträglichkeit und Wirksamkeit einer adjuvanten Interferon-alfa-2b-Behandlung beim Aderhautmelanom.

PURPOSE: In this manuscript, the safety and efficacy of adjuvant interferon alfa 2b treatment of uveal melanoma is described. PATIENTS AND METHODS: A total of 39 patients (23 male and 16 female, mean age 56.5 years, range 35-78 years) with uveal melanoma were treated with interferon alfa 2b, 3 million units three times a week subcutaneously for 1 year after therapy of the primary tumor. In all patients age, gender, primary melanoma data, therapeutic interventions, treatment side effects and outcome were documented. RESULTS: Of the 39 patients, 31 (80%) finished the treatment as scheduled after 1 year. In 18 patients (46%) the initial dose had to be reduced due to leucopenia, thrombopenia, cardiac symptoms, elevated of liver function or vertigo (WHO grade I-III). In eight patients, therapy had to be withdrawn because of serious side effects (five patients) and the appearance of metastases (three patients). Neither a univariate approach nor a multivariate approach could show a protective effect of interferon treatment on survival. CONCLUSIONS: Adjuvant treatment of uveal melanoma with interferon alfa should be abandoned until the question of dose and administration for cutaneous melanoma is solved.

[Transpupillary thermotherapy (TTT) for uveal melanomas. Long term results of a single TTT with an adapter for a conventional infrared laser]. / Transpupillare Thermotherapie (TTT) von Aderhautmelanomen. Langzeitergebnisse einer alleinigen TTT mit einem Adapter für einen konventionellen Infrarotlaser.

BACKGROUND: An increasing number of orbital recurrences after TTT have been reported; the aim of our paper was to present our long-term results after a maximum follow-up of 8 years and 2 months. PATIENTS AND METHOD: Among 18 eyes, 10 tumors were classified as small, and 8 as medium sized (with a maximum prominence of 5.6 mm): 5 melanomas had a juxtapapillary location, 6 a macular (or juxtamacular) location, and 7 were located in the midperiphery of the fundus. RESULTS: After a median follow-up of 7 years in seven tumors a complete regression (scar formation) could be achieved, and in six a partial regression (with a maximum residual prominence of 2.9 mm) could be seen. In three patients a recurrence was treated either by another TTT or a Ruthenium-106 plaque; in another two recurrences, enucleation had to be performed. In none of the cases has an orbital recurrence occurred so far. CONCLUSION: To prevent recurrences, adequate technique and appropriate selection of patients are mandatory in our opinion (no tumors higher than 3 mm). The higher the tumor prominence, the greater the chance of recurrences. Amelanotic melanomas and macular melanomas seem to respond poorly to thermotherapy.

Calculated tumour volume as a prognostic parameter for survival in choroidal melanomas.

PURPOSE: Tumour diameter, tumour height, and tumour volume are considered important prognostic indicators of survival in choroidal melanomas. In this study, we investigated the prognostic impact on survival of the easily calculated volume estimate based on the assumption of a half-rotation ellipsoid. METHODS: The largest tumour diameter and tumour height were measured by ultrasound A- and B-scan in 93 patients with choroidal melanoma. Tumour volume was calculated by the half volume of a rotation ellipsoid formula, rotated around the y-axis, and compared to tumour diameter and tumour height. All parameters were correlated to the clinical outcome of the patients. RESULTS: At the time of diagnosis, the mean diameter was 10.4 mm (range 4.1-18.9 mm), and the mean height was 5.7 mm (range 1.74-14.9 mm). The range of the calculated tumour volume was between 11 and 628 mm(3) (mean volume 190 mm(3)). Among all patients, distant metastases occurred in 10 patients (10.8%). In a univariate approach using Mantel-Haenszel log-rank test, the calculated tumour volume at the time of diagnosis was the best prognostic indicator of survival followed by tumour diameter and tumour height (P=0.028). When tumour volume, horizontal and vertical tumour diameter, age, sex, and primary tumour therapy were considered in a multivariate approach using Cox proportional Hazard model, only tumour volume turned out as a significant prognostic parameter (P=0.001). CONCLUSIONS: Calculated tumour volume is a better prognostic indicator of survival of patients with choroidal melanomas than the largest tumour diameter and tumour height, and might be established in daily routine.

[Dose-volume histogram regression analysis of uveal melanomas after single fraction gamma knife radiosurgery]. / Dosis-Volumen-Histogramm-Regressionsanalyse von Aderhautmelanomen nach einzeitiger Leksell-Gamma-Knife-Radiochirurgie.

BACKGROUND: To evaluate tumor regression and sequelae in 30 uveal melanomas treated with Gamma Knife radiosurgery between 1992 and 1995 at the Gamma Knife center in Graz. PATIENTS: A total of 30 uveal and ciliary body melanomas were treated with a single fraction of the Gamma Knife. The mean marginal dose was 52.1 Gy, (median 50 Gy). Of the tumors, 15 were large (higher than 8 mm), 14 were medium sized (3-8 mm) and one was a small melanoma (<3 mm). Among them were 6 juxtapapillary, 10 (juxta-) maculary melanomas, 5 tumors located in the midperiphery and 9 ciliary body melanomas. METHOD: Dose-volume histogram analysis. RESULTS: After a maximum follow up of 9 years and 7 months, 8 tumors regressed into a scar, 17 tumors into a residual prominence between 50% and 80% of the initial tumor height, 3 tumors showed no change and in 2 patients recurrence was obvious. Sequelae were classified as mild (in 3 patients), moderate (3), severe (5) and very severe (19). CONCLUSIONS: Significant factors for the development of severe sequelae were the tumor volume and the marginal dose, the mean dose proved to be more important than the marginal dose and the irradiated volume more important than the selective critical dose.

[Guidelines for surgery in the treatment of rhegmatogenous detachments (buckle, pneumatic retinopexy, endosurgery)]. / Richtlinien zur Indikationsstellung bei netzhautchirurgischen Massnahmen (einfache Buckelchirurgie, pneumatische Retinopexie, Endotamponadechirurgie).

In view of diverging opinions for retinal detachment surgery (pneumatic retinopexy or buckling procedure with or without drainage versus primary vitrectomy without external buckling) pneumatic retinopexy, orbital balloon, buckling procedures (sponge, encircling band) are discussed with a short historical background and a brief description of current technology. Pros and cons of the individual technique are discussed on the basis of monographs and articles. From the repertoire of a retinal surgeon typical case examples are presented, different operation methods discussed, advantages and disadvantages of each individual technique emphasized. A goal of the work is to provide a practicable manual for the less experienced surgeon and the expert, who experiences an increasing trend to vitrectomy techniques instead of the conventional buckling procedures.

Ocular melanoma: epidemiology, clinical presentation and relationship with dysplastic nevi.

PURPOSE: Ocular melanoma is a rare entity compared to cutaneous malignant melanoma. We examined the frequency of the tumor in a defined geographic region, its clinical presentation and its relationship with dysplastic nevi in 136 patients. METHODS: 136 patients (64 men and 72 women; mean age 61.7 years, range 20-92 years) with ocular melanoma were treated at the University Hospital of Graz between June 1996 and December 2001. 129 had primary uveal melanoma in one eye (117 choroidal melanomas, 11 melanomas of the ciliary body and 1 of the iris), 2 patients had uveal melanoma in both eyes, 4 patients had conjunctival melanoma and 1 patient had a melanoma of the lacrimal sac. Epidemiology, history, potential risk factors, clinical presentation and relationship with dysplastic (= atypical) nevi were documented. RESULTS: 48 patients (35.3%) showed more than five dysplastic nevi, compared to only 1.2% in the general population (chi(2) test: p < 0.001). 5 (3.7%) had additional cutaneous melanoma and 7 (5.1%) had a family history of melanoma. The lifelong risk for the occurrence of an additional primary cutaneous melanoma was 2.9%, which is significantly higher than the usual estimate of 1% for the general population. CONCLUSIONS: Patients with primary ocular melanoma have an increased risk to develop cutaneous melanoma and should therefore be examined regularly by dermatologists.

[Diplopia after encircling procedure for retinal detachment]. / Bleibende Doppelbilder nach Cerclageoperationen bei Amotio retinae.

PURPOSE: Our aim was to evaluate the frequency, duration and therapy of diplopia in primary position caused by motility disorders after retinal detachments treated only with encircling bands. METHODS: A retrospective review is made of 264 consecutive patients. RESULTS: At 6 months after surgery,18 (7%) out of the 264 patients had motility disorders with diplopia in primary position. In 55%, we found an esotropia and vertical deviation. For the treatment of diplopia, eight patients had prisms foils, five of whom are scheduled for surgery, six patients wear prism glasses and three patients did not return for follow up after their sight had been corrected with prisms. An operation for strabism was necessary in three cases, mainly because of hypertrophic scarring (adhesion syndrome), rather than suturing material or muscular decompensation. One patient needed eye occlusion for untreatable diplopia. The average change of refraction after the encircling procedure was -2.0 D. CONCLUSIONS: We recommend avoiding unnecessary preparation of the muscles when placing the encircling band (without destruction of the Tenon or periorbital tissue), motility exercises after the operation and full refractive correction for sensory compensation of deviations as early as possible. In addition, antiphlogistic drugs should be used to avoid scarring and treatment with prism lenses. Removal of the encircling band does not seem to improve the motility as the disorder is mainly caused by hypertrophic scarring, neither does mitomycin C or the application of viscoelastic substances.

Transpupillary thermotherapy for choroidal metastases.

INTRODUCTION: We report on a case with bilateral choroidal metastases derived from a renal cell carcinoma 13 years after nephrectomy. The treatment modality is discussed. METHODS: A male patient (58 years of age) presented with asymptomatic bilateral choroidal metastases deriving from renal cell carcinoma. The right kidney had been removed because of renal cell carcinoma 13 years before the appearance of the choroidal metastases. He had full visual acuity (20/20) and normal intraocular pressure in both eyes. Fundus examination showed a small tumor in the peripheral choroidea of his right eye and an intermediate-sized solid tumor in the periphery of his left eye. RESULTS: The tumor of the right eye was treated by TTT and the tumor of the left eye by (106)Ru plaque radiotherapy. The tumors showed total regression into flat chorioretinal atrophies in both eyes and no tumor could be found 13 moths after treatment maintaining full visual acuity (20/20). CONCLUSION: Asymptomatic ocular metastases can develop even many years after removal of the primary tumor. TTT and (106)Ru brachytherapy are useful treatment modalities in cases of small and intermediate-sized choroidal metastases.

[Malignant melanoma of the ciliary body. A diagnostic problem]. / Das maligne Melanom des Ziliarkörpers. Ein diagnostisches Problem.

BACKGROUND: Ciliary body melanoma is often diagnosed too late and therefore has a poor prognosis. The circular infiltration of the iridocorneal angle by malignant cells can lead to secondary glaucoma, often misdiagnosed as pigmentary glaucoma. MATERIAL AND METHODS: In a 40-year-old patient the diagnosis "atypical pigmentary glaucoma" was made due to elevated intraocular pressure and pigmentation of the iridocorneal angle; no changes were present in the iris. In a second case pronounced pigmentation of the chamber angle and secondary glaucoma led to the clinical diagnosis of a ring melanoma and resulted in enucleation of the globe. RESULTS: In the first case, increasing pigmentation of the chamber angle over 4 weeks led to the presumed diagnosis of a ring melanoma. Histopathological evaluation confirmed the diagnosis of a ring melanoma of the ciliary body. In the second case histology revealed retinal detachment with intraocular bleeding without intraocular melanoma. The pigmentation in the lower part of the chamber angle was due to hemosiderosis. CONCLUSION: Diagnosis of ciliary body melanomas may be difficult in some cases due to its similarity to other eye diseases. The differential diagnosis of malignant melanoma of the ciliary body should be considered in cases of unilateral pigmentary glaucoma.

Morphologic characteristics of disciform scarring after radiation treatment for age-related macular degeneration.

OBJECTIVE: To investigate the influence of radiation therapy on the development of disciform lesions in patients with age-related macular degeneration (AMD). DESIGN: A prospective, nonrandomized, comparative trial (patient self-controlled). PARTICIPANTS: Forty eyes with exudative AMD involving the central fovea in 40 consecutive patients were enrolled in this study. INTERVENTION: Radiation was administered to the posterior pole with an 8-mV photon beam from a linear accelerator. A dose of 14.4 Gy, 1.8 Gy per day, five fractions per week was delivered through a single port. MAIN OUTCOME MEASURES: The visual acuity and the morphologic characteristics, demonstrated by fundus photography, fluorescein, and indocyanine green angiography, were investigated before treatment and every 3 months after treatment over a period of 24 months. In 10 patients with bilateral disease the disciform lesions were compared. RESULTS: Twenty five patients could be followed regularly over the period of 24 months. The disciform lesions occurring after radiation were classified in three types. Type I (10 patients) was characterized by being smaller than 2 DD in size, with little fibrotic tissue underneath the retina, but pronounced retinal pigment epithelial changes. Type II (seven patients) showed extensive growth of the choroidal neovascularization (CNV) extending to and beyond the arcades with angiographically active loops in the peripheral parts. Eight patients had type III lesions develop characterized by a size greater than 2 DD but fewer than 6 DD and by a different amount of fibrotic tissue, hemorrhage, and lipid. Type I scarring was significantly associated with occult CNV without pigment epithelial detachments, whereas type II scarring was associated with classic CNV at the initial presentation (P<0.05). CONCLUSIONS: Although no severe side effects have been reported after radiation therapy for AMD, a subgroup of patients may experience extensive growth of CNV after radiation, causing greater functional damage than occurs spontaneously.

Idiopathic sclerotic inflammation of the orbit with left optic nerve compression in a patient with multifocal fibrosclerosis.

We present the MR imaging findings in a 43-year-old male patient with bilateral idiopathic sclerosing inflammation of the orbit. Bilateral enhancing retrobulbar masses, with concentric compression of the retrobulbar segment of the left optic nerve, were seen. MR imaging proved to be the only means to distinguish between the different intraorbital structures and to determine the exact site of optic nerve compression. To our knowledge, this is the first documented case of MR imaging findings of this entity.

Gamma knife treatment of subfoveal, classic neovascularization in age-related macular degeneration: a pilot study.

OBJECT: Age-related macular degeneration (AMD) is the leading cause of severe vision loss in people older than age 65 years in the western world. The visual acuity loss usually results from the ingrowth of new vessels from the choroid capillaries, so called choroidal neovascularization (CNV). The aim of this pilot study was to investigate the effect of a single-fraction gamma knife radiosurgery (GKS) on visual acuity and the growth pattern of CNV in patients with AMD. METHODS: Ten patients with a mean age of 75 years and with a subfoveal, classic CNV due to AMD were enrolled in this study. All patients were treated with GKS in one fraction with a prescription dose of 10 Gy. The treatment target was the CNV located in the macula. Computerized tomography scans of the globe were obtained. After a follow up of 1 year visual acuity was stable in six patients and decreased in four. The size of the CNV could be stabilized in four patients, and in six an enlargement of these neovascular complexes was shown. No side effects, such as cataract formation, development of radiation-induced retinopathy, or optic neuropathy, have been observed so far. CONCLUSIONS: Gamma knife radiosurgery seemed to have a beneficial effect on visual acuity in patients with AMD, but it failed to control growth of CNV in six patients. A longer follow up, a larger study population, and a randomized and controlled study are necessary for a final conclusion.

Gamma knife radiosurgery for uveal melanomas: an 8-year experience.

OBJECT: The authors report their experience using gamma knife radiosurgery (GKS) to treat uveal melanomas. METHODS: Between 1992 and 1998, 60 patients were treated with GKS at a prescription dose between 45 Gy and 80 Gy. The mean diameter of the tumor base was 12.2 mm (range 3-22 mm). The mean height of the tumor prominence was 6.7 mm (range 3-12 mm). The eye was immobilized. The follow-up period ranged from 16 to 94 months. Tumor regression was achieved in 56 (93%) of 60 patients. There were four recurrences followed by enucleation. The severe side effect of neovascular glaucoma developed in 21 (35%) patients in a high-dose group with larger tumors and in proximity to the ciliary body. A reduction in the prescription dose to 40 Gy or less and excluding treatment to tumors near the ciliary body decreased the rate of glaucoma without affecting the rate of tumor control. CONCLUSIONS: Gamma knife radiosurgery at a prescription dose of 45 Gy or more can achieve tumor regression in 85% of the uveal melanomas treated. Neovascular glaucoma can develop in patients when using this dose in tumors near the ciliary body. It is advised that such tumors be avoided and that the prescription dose be reduced to 40 Gy.

Chondroplast: A new material for eyelid reconstruction.

After tumor excision both lamellae of the eyelid require reconstruction in order to achieve good functional and cosmetic results. The tarsus is replaced either by autologous or heterologous material. We used Chondroplast as a tarsal replacement in 25 patients who had undergone extensive tumor excision. Chondroplast is a beta-irradiated bovine cartilage. A 1-mm-thick lamella is fixed to the rest of the tarsal plate or the canthal tendon and positioned in a preformed pocket or the conjunctiva and a thin layer of orbicularis muscle and skin. All implants took well. Postoperative results, lid closure and cosmetic appearance were excellent. No complications such as infection or loss of the implant occurred. The advantages of Chondroplast are: its availability in large pieces, no need for harvesting procedures and good biocompatibility.

The role of UV-radiation in the development of conjunctival malignant melanoma.

PURPOSE: To investigate the possible role of UV-radiation in the development of conjunctival malignant melanoma. N-ras mutations are frequently found in cutaneous melanomas of sun-exposed body areas. UV-radiation is thought to induce mutations in the N-ras gene, that convert these genes into active oncogenes. The presence of N-ras mutations has been considered an indicator for UV-exposure in the development of melanomas on sun-exposed body sides. METHODS: We analyzed six paraffin-embedded conjunctival melanomas for mutations of the N-ras gene. Codons 12, 13 and 61 were amplified using polymerase chain reaction and sequenced. RESULTS: We could not detect point mutations of the N-ras gene in our samples. CONCLUSION: Since we could not find deviations from the wild type sequence in the N-ras gene, our study does not support UV-exposure as being causative in the development of conjunctival melanoma.

Echographic findings in uveal melanomas treated with the Leksell gamma knife.

BACKGROUND/AIMS: Between June 1992 and July 1995, 29 uveal melanomas were treated radiosurgically with the Leksell gamma unit at the University of Graz. The aim of this retrospective study was to examine the pattern of regression and the extent and time period of the decrease in tumour size. METHODS: The Leksell gamma knife, model B, was used. Patients were divided into three groups according to marginal dose: group 1: eight patients with a marginal dose > 50 Gy, group 2: 15 patients with a marginal dose = 50 Gy, and group 3: six patients with a marginal dose = 45 Gy. For the retrospective study two groups were examined: group A, tumours < 5 mm and group B, tumours > or = 5 mm. RESULTS: No significant correlation was found between tumour regression and the marginal dose. Tumour shrinkage depends on the pretreatment height. In the group of eight patients with an initial tumour prominence of less than 5 mm, no prominence was found after therapy. In the group of patients with an original tumour prominence of 5 mm and more, only two tumours formed a flat scar while a residual prominence was found in 18 patients. Increase in reflectivity combined with a decrease in size appears to be a good criterion for the effectiveness of the treatment. In five patients with tumours showing low reflectivity, over a longer period of time metastases were found. An enucleation was performed in two patients because of uncertain tumour regression and in one patient as a result of an increase in tumour size. CONCLUSION: The pattern of echographic reflectivity and decrease in size is similar to brachytherapy and is one of the most important diagnostic variables for evaluation of tumour regression. An increase in reflectivity as well as a decrease in tumour size in the first 6-8 months can be considered a therapeutic success.