[Demographic change : challenges to ophthalmological patient-centered care]. / Demografischer Wandel : Herausforderungen für die ophthalmologische Versorgung.

BACKGROUND: Demographic change not only affects patients with ophthalmological diseases but also ophthalmologists. OBJECTIVES: The aim of this article is to evaluate the consequences of an aging society on health care provision. How can these challenges be overcome? MATERIAL AND METHODS: Evaluation of publications from the German Federal Statistical Office about the current and projected population, analysis of own studies about health care provision, utilization, and delivery as well as the presentation and discussion of regulatory and organizational conditions. RESULTS: There is a continuous increase in chronic and age-related diseases. At the same time the prevalence of multimorbidity and the number of patients dependent on long-term care is rising, leading to an increase in the demand for ophthalmological care. Regarding health care providers we observed a cutback in qualified ophthalmological personnel, especially for remote areas thus causing difficulties in providing adequate eye care to the population. CONCLUSION: To deliver health care to a growing number of patients with a decreasing number of medical professionals is the major challenge of demographic change. This will have an enormous impact on ophthalmological health care in terms of maintaining high quality health services covering a nationwide area.

[Mason's lacing cord. Potential danger of severe open ocular injuries]. / Maurerschnüre. Potenzielle Gefahr für schwere offene Augenverletzungen.

BACKGROUND: Introduction of new working equipment or the modification of established working routines could induce new trauma mechanisms. In all of theses cases ophthalmologists are not only responsible for ocular treatment they also have to act as assessors. This might include legal aspects, e.g. to validate the circumstances of an accident. METHODS: We present a new trauma mechanism caused by a mason's lacing cord which was fixed with nails. In addition to two case studies we collected experimental data (maximum tension and maximum elongation of various mason's lacing cords) about the triggering event using standard test conditions. RESULTS: A tensile force of 96.2 N was needed to achieve maximum elongation of mason's lacing cords. With a cord length of 5 m, an elongation of 0.09 m was enough to cause penetrating injuries (for 10 m cord length the critical elongation was 0.13 m). Under these conditions a nail could be accelerated to a velocity of 18 m/s. This may lead to open eyeball injuries with severe visual loss. CONCLUSIONS: Nails fixed to elastic mason's lacing cords are potential risk factors for occupational ocular injuries and severe loss of vision. Caution labels should be attached to the work equipment and proper eye protection should be used to prevent severe occupational ocular injuries.

[Health economical aspects of telemedical glaucoma monitoring]. / Gesundheitsökonomische Aspekte des telematischen Glaukom-Monitorings.

BACKGROUND: Telemedical home monitoring of glaucoma patients is not covered by health insurance in Germany. Various clinical studies have indicated that 24 h monitoring of intraocular and blood pressure of glaucoma patients allows a better evaluation of the individual disease condition. If the necessary parameters can be collected with telemedical home monitoring it will be possible to reduce the number of 24 h intraocular pressure profiles which necessitate hospital admission. Therefore inpatient 24 h profiles have been chosen as a health economical allocation base with a presentable economical value for the comparative examination. Assuming an at least identical or even higher clinical outcome of the telemedical glaucoma home monitoring inpatient 24 h profiles were chosen as a health economical allocation base to compare and contrast these methods. METHODS: All procedures of the inpatient 24 h profiles at the ophthalmic clinic of Greifswald were measured using the stopwatch method. In a 1 day test run all activities of the medical staff were identified and documented in a list and afterwards measurements were carried out over 7 days with several stopwatches to allow the documentation of parallel activities. To determine the consumption of resources in telemedical home monitoring the self-documentation of all employees involved in the research project TT-MV were evaluated. Expert interviews helped to determine the economically relevant data about the applied medical technology, e.g. measuring devices, server and electronic health records. RESULTS: The number and complexity of the subprocesses of the inpatient 24 h intraocular pressure profiles were significantly higher compared to telemedical home monitoring. The total costs of the inpatient 24 h profiles were 571.21 € per patient including 291.21 € for medical care and 280 € for accommodation. In contrast the total costs of telemedical home monitoring were 288.72 € per patient. A direct cost comparison shows that telemedical home monitoring resulted in lower costs compared to hospital admission of glaucoma patients. CONCLUSION: Telemedical home monitoring of glaucoma patients is not only effective but also cost-efficient. As modern health care systems have to consider cost efficiency, a randomized, controlled longitudinal clinical study of both methods would be required.

[Documentation of ophthalmological findings in contact lens wearers: software-based symbol library of the Efron grading scale]. / Ophthalmologische Befunddokumentation bei Kontaktlinsenträgern: Softwarebasierte Symbolbibliothek nach Efron-Standard.

BACKGROUND: To prevent complications through the use of contact lenses the efforts spent on documentation will have to be increased to meet the demands of quality management. How can ophthalmologists benefit from the use of software-based graphical documentation? METHODS: To make a standardized documentation of contact lens complications possible a software module with a graphically intuitive visualization scheme of the Efron grading scale was developed. The Efron grading scale defines 16 different classes of findings scaled to 5 grades. RESULTS: The software module shows a schematic view of the eye which allows an easy sectoral assignment of all 16 Efron findings. The designated sector can simply be marked with a mouse click. A subsequently appearing context menu offers all 16 Efron findings together with the corresponding 5 grades. Finally the chosen Efron grade is graphically visualized in the corresponding sector. CONCLUSION: The software module supplies a feasible way for high quality documentation in the clinical routine with illustrative visualization. The practical application of software tools to assist clinical documentation can help to meet the challenges of quality management in contact lens utilization.

[Binocular status of dyslexics--are there differences to a healthy comparison group?]. / Binokularsehen bei Legasthenikern - Gibt es Unterschiede zu einer gesunden Vergleichsgruppe?

BACKGROUND: Despite numerous studies dealing with the question of a possible relation of visual problems and dyslexia, which is negated by most ophthalmologists, some opticians still favour the treatment of dyslexia by correction of the "Winkelfehlsichtigkeit" following MCH. Our aim was by also including the Pola test to check the usefulness of this treatment. PATIENTS AND METHODS: In a 2-year prospective study we examined the 4th grade elementary school students in our city who had dyslexia as an assured diagnosis (n = 21). The results were compared to those of an age-matched group without pathological findings regarding their reading and spelling ability (n = 21). Examinations included visual acuity, eye position by cover test, Maddox cylinder and Pola test for near distance, binocular vision (Bagolini and Worth test, Lang test I and II, Titmus test, amplitude of fusion), amplitude of accommodation, refraction in cycloplegia and organic status. RESULTS: A significant difference was found between the two groups regarding the amplitude of divergence in near (p = 0.009) and far distance (p = 0.019) which were both smaller for the dyslexia group, as well as the binocular near visual acuity (p = 0.04). Using the SAS procedure STEPDISC we discriminated the normal and dyslexia group by amplitude of divergence, near visual acuity and alternating near prism cover test with a sensitivity of 81 % and a specifity of 75 %. The results of the Pola test did not show any significant difference between the groups. CONCLUSIONS: No differences were found between the groups regarding the eye position. Therefore a treatment of dyslexia using prisms does not appear reasonable. However because of the group sizes the significance of the results is limited.

[Technical options and prospects for telemedical devices in ophthalmology]. / Technische Möglichkeiten und Perspektiven des Einsatzes telemedizinischer Geräte in der Augenheilkunde.

Home monitoring will soon be established as an innovative way to provide telemedical care in ophthalmology. At present there are no fundamental technical restrictions for telemedical enhancements in ophthalmology, however a wider application range and depth could lead to harmonized and simplified device and interface development. This may help to initiate new concepts in ophthalmological home monitoring.

[Possibilities and limitations of telemedical home monitoring in ophthalmology]. / Möglichkeiten und Grenzen des telemedizinischen Homemonitorings in der Augenheilkunde.

For medical professionals, home monitoring represents an innovative health service for remote patient care: The patient may remain in his or her domestic environment and continue normal activities. The physician can also, through technical and organizational integration, provide medical attendance from his or her usual working environment. All in all, in the near future home monitoring can help provide sufficient health services while also enabling medical resources to be used more effectively. The patient may benefit from individually optimized treatment and active integration into medical care. The better we manage the technical, organizational, medical, legal, and economic challenges of telemedicine, the better we can minimize the limitations of telemedical home monitoring. Other existing subjective concerns will be eliminated only if telemedical concepts are adapted to the specific needs of affected patients and physicians.

[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.

[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.

[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.

[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.

Dynamic pressure measurement of cartridge operated vole captive bolt devices.

INTRODUCTION: Vole captive bolt devices are powder actuated spring guns that are used as a pest control mean. After having triggered the explosion of the blank cartridge by touching a metal ring around the muzzle, the vole is killed by the massive propulsion of the gas jet. Improper use and recklessness while handling these devices may cause severe injuries with the hand of the operator at particular risk. Currently, there are no experimental investigations on the ballistic background of these devices. METHODS: An experimental test set-up was designed for measurement of the firing pressure and the dynamic force of the gas jet of a vole captive bolt device. Therefore, a vole captive bolt device was prepared with a pressure take-off channel and a piezoelectric transducer for measurement of the firing pressure. For measurement of the dynamic impact force of the gas jet an annular quartz force sensor was installed on a test bench. Each three simultaneous measurements of the cartridges' firing pressure and the dynamic force of the blast wave were taken at various distances between muzzle and load washer. RESULTS: The maximum gas pressure in the explosion chamber was up to 1100 bar. The shot development over time showed a typical gas pressure curve. Flow velocity of the gas jet was up to 2000 m/s. The maximum impact force of the gas jet at the target showed a strong inverse ratio to the muzzle's distance and was up to 11,500 N for the contact shot distance. Energy density of the gas jet for the close contact shot was far beyond the energy density required for skin penetration. CONCLUSION: The unique design features (short tube between cartridge mouth and muzzle and narrow diameter of the muzzle) of these gadgets are responsible for the high firing pressure, velocity and force of the gas jet. These findings explain the trauma mechanics of the extensive tissue damage observed in accidental shots of these devices.

[Computer-based graphic documentation of retinal findings]. / Computergestützte Erstellung grafischer Netzhautbefunde. Grafisch-intuitive Software zur Qualitätsverbesserung der Befunddokumentation bei Veränderungen am Augenhintergrund.

AIM: To develop a software package that improves the standardized clinical documentation of retinal findings. In the clinical routine, retinal findings are usually documented with sketchy freehand drawings and supplementary handwritten remarks. Documentation features of common ophthalmologic software products include only simple sketching functions, which are limited to a change in location, size, or color of graphic primitives (e.g., ovals, rectangles, lines, textboxes). As a result, a feasible creation of standardized graphic documentation in retinal imaging is almost impossible. METHODS: We developed a Java-based software tool that features quick and intuitive generation of fundus schemes, which can be printed as a findings sheet or digitally archived. Particularly for clinical ophthalmologists, we created a set of standardized symbols that can be digitally rendered for graphic documentation. All symbols were integrated into a graphics library and separated in specific categories: preoperative, postoperative, angiomas and tumors, and retinopathy of prematurity. The user can simply choose the required symbol from the library and place it onto the retina scheme using drag-and-drop functionality. RESULTS: The practicability of existing features for graphic documentation of retinal findings is not sufficient because freehand drawings are too time-consuming and also share the risk of false interpretation due to individual handwriting. In contrast to freehand sketching, our software tool not only allows faster graphic creation but also improves medical documentation using a standardized symbol library, which is also specifically categorized. CONCLUSIONS: Graphic symbols for retinal documentation have found universal acceptance by ophthalmologists for a long time, but their practical use is still not efficient in clinical routine. This report shows how the appropriate use of software technology can contribute to documentation quality and clinical practice.