["Flipped classroom"-A future concept for student teaching in ophthalmology?] / "Flipped classroom" ­ Ein Zukunftskonzept für die studentische Lehre in der Augenheilkunde?

BACKGROUND: "Flipped classroom" is a didactic teaching concept in which learning contents are prepared by self-study with arranged tools before the classroom session. The concept offers the advantage of a uniform knowledge base for the students at the beginning of the course and also the advantage of a greater theoretical knowledge, which creates more opportunities for practical exercises, application and consolidation in the subsequent joint teaching units. This study describes the establishment and application of such a model in student teaching in ophthalmology and analyzes the student's evaluation. METHODOLOGY: For the winter term 2018/2019, a new teaching module was designed and established in a cooperation between the department of ophthalmology and the Institute for Education and Study Affairs (IfAS) at the medical faculty of the University of Münster. A uniform training of the lecturers as well as a preparation of the students for the restructuring took place. After the course the evaluation of the students was recorded and evaluated using a standardized online evaluation. RESULTS: Between the winter semester 2018/2019 and the winter semester 2019/2020, an average of 112.3 ± 4.0 students were taught with the "flipped classroom" model. Of these 93.7% were able to give an assessment. In the previous semesters with the old teaching concept (summer semester 2015 to summer semester 2018), the average number of students was 115.4 ± 15.1 with an assessment rate of 93.3%. The new teaching concept achieved on average a better assessment than the old module. CONCLUSION: With a "flipped classroom" space and flexibility can be generated for a more individual course preparation and at the same time a higher practical part. Further studies are needed to analyze whether this also enables a sustainable transfer of knowledge.

[Choroidal neovascularisation in a patient with choroidal osteoma visualized by OCT angiography]. / OCT-angiographische Darstellung einer choroidalen Neovaskularisation infolge eines Aderhautosteoms.

We present the case of a 38-year-old Asian patient who reported vision loss of her left eye since 4 weeks. The funduscopy showed a choroidal tumor in the papillomacular bundle, which could be identified as a choroidal osteoma with secondary choroidal neovascularization (CNV). OCT angiography (OCT-A) detected abnormal flow in the choriocapillaris; the osteoma showed no flow in the OCT angiogram of the choroid level. Therefore, OCT-A can be a helpful adjuvant for diagnosis of CNV secondary to choroidal osteoma.

Long-Term Outcomes of External Dacryocystorhinostomy in the Age of Transcanalicular Microendoscopic Techniques.

Purpose. This study aimed to evaluate long-term results of external dacryocystorhinostomy (DCR) at a tertiary eye care center specializing in lacrimal duct surgery in Germany. Methods. The medical records of 1010 patients with acquired nasolacrimal duct obstruction (NLDO), who had undergone lacrimal duct surgery at a tertiary eye care center, were reviewed. Only adult patients who had undergone external DCR were included. The evaluation included the following parameters: age, gender, duration of symptoms, patient satisfaction, previous dacryocystitis, complication rates, and surgical outcome. Results. 154 eyes of 146 patients (14.5%) could be included in the study. The average age was 64.1 ± 29.7 years. 66.4% of patients were females and 33.6% were males. Acute or chronic dacryocystitis was found in 81 patients (55.5%). Overall, 82.8% of patients had full resolution of symptoms. The success rate of external DCR for patients with previous episodes of dacryocystitis was 82.7% compared to 83.4% for patients without dacryocystitis in their medical history. Conclusion. In cases in which transcanalicular microendoscopic techniques are contraindicated (e.g., after dacryocystitis) or in complex cases where microendoscopic procedures have failed (revision surgery), external DCR is still the surgical treatment of choice with very good postoperative success.

[Traumatic Lacrimal Duct Stenosis: Demographics and Success Rate of Surgical Procedures for Secondary Treatment]. / Traumatische Tränenwegsstenosen: Epidemiologie und Erfolgsraten nach sekundärer operativer Intervention.

BACKGROUND: Traumatic lacrimal duct stenosis can be the result of sharp trauma of the eyelid, indirect trauma or surgery in the nasoorbital region, as well as burns, chemotherapy and radiation of the facial region. The aim of the study is to present the demographics, patient satisfaction, and course of different surgical procedures for secondary treatment of traumatic lacrimal duct stenosis. METHODS: We retrospectively reviewed the medical records of 50 patients who required surgery for traumatic lacrimal duct stenosis from 2009 to 2011 at the University Eye Hospital in Muenster. The evaluation included the following criteria: age, sex, duration of symptoms, complication rate and the rate of recurrence. We systematically evaluated the medical data and asked the patients about the recent symptoms via telephone questionnaire. RESULTS: 60 eyes of 50 patients were included (18 women; 32 men; age: 51.8 ± 17.1 years); 34 eyes (56.7 %) had already had operations of the lacrimal system. The success rate was 58.1 %. The mean postoperative follow-up was 52.3 ± 10.7 months. In 11 cases (18.3 %), a dakryocystorhinostomy (DCR) was necessary. CONCLUSION: Traumatic lacrimal stenosis is more common in men, and has a poorer prognosis than lacrimal duct stenosis from other causes.

[Microsurgical Treatment of Canalicular Stenosis: Long-Term Follow-Up]. / Verlauf von Kanalikulusstenosen nach mikroskopischer Kanalikuluschirurgie.

PURPOSE: Studies about the indication and the functional prognosis of microsurgical treatment of canalicular stenosis (CR) are rare. In this study we determined the cause, recurrence and success rates of CR and compared our results with the results in the literature. METHODS: We retrospectively reviewed the medical records of 22 patients who required a microsurgical treatment of canalicular stenosis (CR) from 2009 to 2011. We systematically evaluated the medical data and asked the patients about the recent symptoms via telephone questionnaire. RESULTS: 22 patients were included (73 % women; 27 % men; age: 52.8 ± 19.9 years), 12 (55 %) patients had already had operations. The mean postoperative follow-up was 45 ± 9.2 months. The patients were followed for a minimum of 30 months. The success rate was 58 %. CONCLUSION: In some cases like long localised canalicular stenosis and especially after traumatic lacerations of the lacrimal canaliculi, a microsurgical treatment of canalicular stenosis is required. The aim of this procedure is to restore the lacrimal mucosa continuity so that a spontaneous lacrimal drainage is possible. The success rate of CR in our study was 58 %.

[Botulinum toxin injections for senile entropium]. / Botulinumtoxin-Injektionen bei senilem Entropium.

Involutive changes in the collagen and muscular structures of the lower lid in ageing may lead to the formation of senile entropium. Treatment of this condition may be achieved using botulinum toxin injections to the dislocated orbicularis muscle. These injections lead to cessation of the symptoms for a mean of 3.8 months. Repeat injections are possible. Botulinum toxin injections are a viable option for patients who are not amenable to surgical correction of the entropium.

[Defect covering of a perforated corneal ulcer with bovine pericardium transplant]. / Defektdeckung eines perforierten Hornhautulkus mit einem bovinen Perikardtransplantat.

An 89-year-old patient presented in an emergency situation with a perforated corneal ulcer of neurotrophic genesis. An operative treatment with a Tutopatch® was performed. In the course of treatment a reorganization of the Tutopatch® into corneal tissue resulted and a subsequent satisfactory defect covering with maintenance of visual acuity. Tutopatch® represents a good alternative for covering perforated corneal ulcers.

[Fasanella-Servat procedure for the surgical treatment of acquired ptosis of the upper eyelid]. / Das Fasanella-Servat-Verfahren zur Therapie der erworbenen Ptosis.

PURPOSE: The oculoplastic surgeon may choose between several surgical procedures to treat ptosis of the eyelid. One such potential therapeutic option is the Fasanella-Servat procedure. The purpose of our study was to evaluate the postoperative outcome of the Fasanella-Servat procedure in patients with ptosis of the eyelid with regard to objective and subjective criteria. METHODS: The postoperative success of 20 patients (23 eyelids), 11 female and 9 male, with acquired ptosis of the upper eyelid who underwent the Fasanella-Servat procedure between 1995 and 2004 in an eye tertiary care centre, was evaluated. With regard to the type of ptosis, the pre- and postoperative opening of the eyelid, the levator function, and the symmetry between both eyes were analysed statistically. The patients' subjective satisfaction with the functional and cosmetic postoperative outcome was evaluated by means of a nominal questionnaire (scale 1 - 5). The intraoperatively removed tissue was analysed histopathologically for accessory lacrimal glands or levator muscle. RESULTS: The mean preoperative opening of the eyelid was 7.1 mm (min. 4 mm, max. 10 mm) with a mean levator function of 12.6 mm. Postoperatively, the opening of the eyelid improved significantly to 9.3 mm (min. 7 mm; max. 14 mm), while the levator function remained stable. The preoperative asymmetry between both eyes was significantly decreased. 90 % of the patients were satisfied with the cosmetic and functional results. There were no early and late postoperative complications. No side effects were recorded following treatment. The intraoperatively removed tissue showed no evidence of tissue of accessory lacrimal gland or levator muscle. CONCLUSIONS: The Fasanella-Servat procedure remains an effective procedure in treating mild ptosis with few complications and good cosmetic and functional results.

[Microbiological analysis in contact lens-associated keratits]. / Bakterielles Spektrum der kontaktlinsenassoziierten Keratitis.

INTRODUCTION: More than 125 million (2 %) people worldwide wear contact lenses (CL). 0.011 - 0.2 % of the wearers develop keratitis per year. The aim of this study was to explore and analyse the spectrum of germs in different microbiological analysis techniques to optimize the strategy of antiobiotic therapy. PATIENTS AND METHODS: A retrospective study about 65 eyes with CL induced keratitis or corneal ulceration who were treated in our hospital between 2005 - 2010. We analysed and compared the development of best-corrected visual acuity (BCVA) under single and combined antibiotic therapy and microbiological analysis of conjunctiva (CS) and CL and CL-container swabs (CLS). RESULTS: Of the patients 96.9 % were soft contact lenses wearers. 48.8 % had microbiological findings in the CS, 81.3 % in CLS. 19.6 % (n = 9) coagulase-negative Stapyhlococcus and 17.3 (n = 8) Pseudomonas species were found. Different spectra of germs in CS and CLS were found. Gram-positive bacteria in CS (54.5 %) were dominant, whereas Gram-negative bacteria were dominant in CLS. No significant difference of mean BCVA changes between single (0.09 ± 0.2) and double (0.14 ± 0.29) topical antibiotic therapy (p = 0.16) were seen, but significant differences between the groups of "gentamicin & ofloxacin" (0.2 ± 0.2) and "moxifloxacin & tobramycin" (0.1 ± 0.43) (p < 0.05) were found. No significant differences of BCVA change between patients with positive (0.12 ± 0.23) and negative (0.20 ± 0.37) microbiological results of conjunctival swabs were observed (p = 0.5). CONCLUSIONS: A strong association between keratitis among wearers of soft lenses and typical spectra of germs was found. Different microbiological findings in different swabs, a lack of findings in around 51.2 % of CS combined with the comparable clinical outcomes between sterile and "microbial" disease means the findings from CS are less important. No differences in development of BCVA between single and double antibiotical therapy were found. There was a better outcome of BCVA with ofloxacin with gentamicin compared to newer generation agents. To improve current treatment strategies in future we recommend increasing the microbiological analysis of CL and CL containers.

[Concomitant cellular reactions in optic nerve siderosis existing for 30 years]. / Zelluläre Begleitreaktionen bei seit 30 Jahren bestehender Siderosis N. optici.

Metal foreign bodies located in the optic nerve are a rare clinical picture and sooner or later often associated with vision loss. We report on a patient who had a foreign body in the optic nerve for 30 years. Histochemical analysis of the optic nerve after the requisite enucleation with complete functional loss of the eye revealed amazing results. Even 30 years after entry of the foreign body into the optic nerve neuronal structures with organized axons surrounded by cytoblasts, glial cells, and immunocompetent cells still remoined. These findings hold out hope and may serve as the starting point for regenerative medicine to potentially restore neuronal function.

[Comparison of the aesthetic outcome and complication rate of reconstructive surgical procedures of the eyelid after basalioma excision]. / Vergleich rekonstruktiver Operationsverfahren des Lides. Ästhetische Ergebnisse und Komplikationsrate nach Basaliomexzision.

BACKGROUND: The therapy of choice of the basalcellcarcinoma is the surgical removal often combined with soft-tissue reconstruction. Aim of this study was to evaluate the subjective aesthetic outcome and the complication rate in consequence of the chosen surgical procedure. METHOD: 57 patients formerly treated by surgery enclosing free grafts, Hughes flaps, interpolated flaps or primary wound closures were included. The patients were examined to evaluate possible surgery derived complications. Furthermore the aesthetic outcome was assessed by a questionnaire. RESULTS: After an interpolated flap nearly 30% of the patients were without any complications and after a Hughes flap 21.4%. In contrast 43.8% of the patients after primary wound closure showed any complications and even 57% of the patients treated with a free graft. Concerning the aesthetic outcome 92.3% of the patients undergoing an interpolated flap were subjective satisfied or even very satisfied with their aesthetic outcome. CONCLUSION: Regarding the complication rate the free graft and the primary wound closure seem to be superior. On the contrary the interpolated flap demonstrated a considerable better estimated aesthetic outcome.

[Definition of the success of the surgical treatment of palpebral tumours with respect to quality of life]. / Definition des Operationserfolgs von Lidtumoren im Hinblick auf Lebensqualität.

BACKGROUND: The NEI-VFQ-25 (National Eye Institute Visual Function Questionnaire) was extended by several questions taking account of aesthetic and cosmetic aspects in addition to the mere visual function aspects. This amended questionnaire, named NEI-VQF +, was used to evaluate the perceived overall success of various surgical - including reconstructive - measures taken in the case of palpebral tumours. MATERIALS AND METHODS: The NEI-VFQ + was presented to a group of 73 patients (average age 71 years) after surgical treatment of malignant palpebral tumours (basal cell carcinoma, squamous cell carcinoma, melanoma). The surgical treatment included different types of surgical techniques for eyelid resection and reconstruction performed between 2005 and 2008. The questions were asked after at least three and at most 56 months of post-operative observation. They covered the perceived success of the surgical treatment with respect to general quality of life, in particular concerning personal problems relating to behavioural as well as social changes caused by functional or aesthetic deficiencies resulting from the treatment. RESULTS: The ratings given by the vast majority of patients, when linked to particular treatment regimes, reflect the subjectively superior importance of the aesthetic outcome in comparison to probable health risks, such as, e. g., rate of relapse or metastasis. CONCLUSIONS: The overall success of a particular surgical intervention to treat a malignant palpebral tumour depends not only on the expected minimisation of future health problems, including decreased visual function, but appears to depend strongly on the personal expectations of individual patients with respect to the aesthetic outcome. Therefore in the case of a malignant palpebral tumour, it should be envisaged to plan a treatment strategy not only on the basis of the objective needs and limitations as seen by the surgeon, but also involving the patient's concern with all his/her expectations and fears in order to build up more mutual trust and to get a result that is satisfactory for the surgeon as well as for the patient.

[Treatment of wrinkles with botulinum toxin]. / Faltenbehandlung durch Botulinumtoxin.

The use of botulinum toxin A for the treatment of wrinkles is increasing. Botulinum toxin A inhibits exocytosis of acetylcholine from 3 to 12 months, depending on the target tissue. Low-dose botulinum toxin A is used to smooth hyperkinetic facial lines. This is especially successful in the upper facial parts, since the target muscles (procerus, corrugator supracilii, frontalis, orbicularis oculi) all directly overlie the osseous structures of the face. This is not the case for the lower facial parts, and more side effects are encountered when treating, for example, wrinkles around the mouth. Contraindications to the use of botulinum toxin A are diseases affecting neuromuscular signal transduction, allergic reactions to components of the solution, therapy with aminoglycosides or acetylsalicylic acid prior to treatment, infections in the planned treatment area, and pregnancy and lactation. Alternative and complementary treatments include erbium-YAG or CO2 laser, as well as augmentation and surgical plastic procedures.

[Botulinum toxin injection for production of ptosis]. / Botulinumtoxin-Injektionen zur Erzeugung einer Ptosis.

Selective muscles can be paralysed or weakened for a limited time period using botulinum toxin type A. The upper eyelid muscles can be a target, leading to a temporary protective ptosis. In this report we discuss indications for this application, describe how to perform the injection, and present results. The procedure is safe and effective.

[The treatment of a primary acquired melanosis of the conjunctiva with atypia by low dose of Mitomycin C 0.02 % - case report with follow up of 2 years]. / Behandlung einer primär erworbenen konjunktivalen Melanosis mit Atypien mittels niedrig dosiertem Mitomycin C 0,02 % - eine Kasuistik mit Nachbeobachtungszeit von 2 Jahren.

BACKGROUND: About 70 % of the melanomas of the conjunctiva develop from an primary acquired melanosis (PAM) with atypia. This is the reason why excision, radiation, cryotherapy or a combination of them are proposed for therapy. But, if the acquired melanosis is very large, serious complications will be found with that treatment. PATIENT AND METHOD: A 65-year-old woman has shown a large melanosis of the conjunctiva of her left eye. Biopsies, taken from different sites of the conjunctiva, have confirmed the diagnosis of an acquired melanosis of the conjunctiva with atypia. This has been the reason for our Mitomycin C 0.02 % therapy for one week. It has been repeated once again after half a year. RESULTS: Atypia of the cells was shown in the upper cell layer of the conjunctiva after the first therapy. But after the second therapy no atypia of the cells was present within two years after the last treatment, examining several biopses. CONCLUSION: Looking for an effective treatment without complications, a new therapy with Mitomycin C has been introduced in the last years. As it is not yet clearly known how to use Mitomycin to have maximal effectiveness with minimal complications, the reports about doses and frequency are differing a lot in the literature and are more often considerably lying over the introduced effective dose of our case. If Mitomycin is used in that low dosage and in that special application as shown, it could be a very efficient therapy with less complications.