Training in cataract surgery in Spain: analysis of the results of a survey of the European Board of Ophthalmology in a Spanish cohort.

INTRODUCTION: A survey conducted by the European Board of Ophthalmology (EBO) revealed significant differences in the surgical training of the ophthalmology residents in Europe, including a disparity between the sexes and a variation in the experience on cataract surgery (CC) between them. This study is about the Spanish sub-cohort of the survey, and its objective is to present and analyse the peculiarities of ophthalmology training in Spain within the European context, as well as discussing ways to harmonise and improve that training throughout the EU. METHODS: We analyse data of the Spanish participants in the EBO exams, defining subgroups by the Autonomous Communities existing in Spain. RESULTS: 93 of 135 requested participants (68.9%) responded. A 60.2% passed the EBO exam between 2021 and 2022, being mostly women (65.59%) aged 31 years old on average. The 91.4% were right-handed, coming from 13 of the 17 Spanish autonomous communities, although mostly from the Community of Valencia, Madrid and Catalonia. Respectively, 16.1%, 3.2% and 8.7% of the respondents said they have completed 10 or more training sessions on animal eyes, synthetic eyes and through the virtual reality simulator. This training was correlated with greater self-confidence in the management of a posterior capsular tear during surgery (p .025). All respondents manifested to have already performed stages of the CC. The average number of operations reported was 181.6 with regional disparities. A significant difference is observed between the sexes against women (-28.3%, p 0.03). DISCUSSION: Ophthalmologists in Spain, much more than other European countries, have greater opportunities for surgical training, with surgical procedures during the residency, that nearly triples those made by the others. Spanish women refer, like their European colleagues, to be in disadvantage in learning opportunities about cataract surgery. The Simulation Based Medical Education (SBME) allows to respond to the training deficit and complements the training on the patient. Although we demonstrate a significant correlation between the number of procedures carried out and self-confidence to operate simple cases, the SBME would be a complementary tool in self-confidence in front of a complication like capsular rupture. CONCLUSION: Spain massively adopts the model named by us "surgery for all", despite the underrepresentation of women in this area, emphasising a need for cultural change that the SBME could facilitate.

[Real-life results of anti-VEGF treatment in fellow eyes with nAMD]. / Real-life-Ergebnisse der Anti-VEGF-Therapie bei nAMD der Partneraugen.

PURPOSE: Neovascular age-related macular degeneration (nAMD) often affects both eyes. This study compared real-life outcomes of the first affected eye (1st eye) and the last affected eye (2nd eye) after anti-vascular endothelial growth factor (anti-VEGF) treatment. MATERIAL AND METHODS: For this retrospective monocenter study 3217 eyes from 2793 patients with nAMD were identified, who received at least 3 anti-VEGF injections between 2006 and 2014 at the University Eye Hospital of Munich. Included in the study were patients with bilateral nAMD when the 1st and 2nd eyes were not previously treated and there was a strict adherence with continuous follow-up for at least 5 years. Corrected visual acuity, number of intravitreal injections and visits as well as central macular thickness were compared. RESULTS: A total of 72 eyes of 36 patients were included in this analysis. Before anti-VEGF therapy, the group of 2nd eyes showed significantly better mean visual acuity than the 1st eyes (p < 0.001). This difference in visual acuity between 1st and 2nd eyes was noted at all time points throughout the follow-up period (p < 0.05). The mean number of cumulative injections was higher in the group of 2nd eyes (p = 0.04) with a comparable number of visits between both groups. In more than half of all patients the 2nd eye became affected by nAMD within 12 months following treatment initiation of the 1st eye and the majority (83%) followed within 3 years. CONCLUSION: In unilateral nAMD, regular monitoring of the fellow eye is essential to avoid severe bilateral vision loss. Early diagnosis with rapid initiation of treatment can preserve visual acuity and quality of life.

[Proliferative vitreoretinopathy (PVR) minimal: same, same but different. Characteristics and surgical treatment of PVR-associated macular pucker]. / Proliferative Vitreoretinopathie (PVR) minimal: "Same same, but different". Besonderheiten und chirurgische Therapie des PVR-assoziierten Makula-Puckers.

BACKGROUND: Epiretinal membrane formation resulting in a macular pucker is among the typical complications associated with proliferative vitreoretinopathy (PVR) in retinal detachment and has a major impact on the functional outcome after surgical treatment. METHODS: A literature search was carried out in PubMed. RESULTS: Approaches to the surgical treatment of PVR-associated macular pucker include complete membrane removal within the vascular arcades aimed at relieving retinal traction at the posterior pole and peeling of the internal limiting membrane (ILM). As a further option it has been suggested that primary ILM peeling in rhegmatogenous retinal detachment repair may reduce or even prevent postoperative epiretinal membrane formation. In addition, correct timing of surgery is a factor that may contribute to successful treatment. DISCUSSION: Due to the particularly strong adhesion and the frequent occurrence of concurrent retinal detachment, the surgical approach to PVR-associated macular pucker is particularly challenging. As with idiopathic epiretinal membranes, surgical removal has the potential to improve functional outcomes; however, visual improvement depends largely on whether the macula was involved in the original retinal detachment.

[Proliferative vitreoretinopathy process-To heal or not to heal]. / Proliferative Vitreoretinopathie-Prozess ­ "To heal or not to heal".

BACKGROUND: Proliferative vitreoretinopathy (PVR) is still an unsolved problem after half a century of research. METHODS: This article provides a review of mechanisms leading to PVR in the context of wound healing research. RESULTS: Wound healing is a physiological repair process that occurs in a similar way in all organs and may end in scar formation. The development of PVR is based on this wound healing mechanism. The localization and structures involved lead to specific characteristics and consequences. Up to now the pharmacotherapeutic strategies were not sufficiently effective. The growing understanding of the mechanisms of scar-free fetal wound healing, could however lead to a solution of the PVR problem. CONCLUSION: The PVR is a physiological process with a pathological result. The complex steps involved in vitreoretinal wound healing are well understood. There is currently no therapeutic approach neither in ophthalmology nor in other medical disciplines that is able to restore the original function and structure of the involved tissue or organ but there is hope that this can succeed in the future.

[Proliferative vitreoretinopathy (PVR) surgery: Scar Wars : Five steps to successful treatment of PVR detachment]. / Proliferative Vitreoretinopathie(PVR)-Chirurgie: "Scar Wars" : Fünf Schritte zur erfolgreichen Therapie der PVR-Amotio.

BACKGROUND: After initially successful surgery of retinal detachment, proliferative vitreoretinopathy (PVR) is the most common cause of renewed retinal detachment. With an incidence of 5-20% it represents a frequent surgical challenge based on a pronounced epiretinal, subretinal and intraretinal scar formation. MATERIAL AND METHODS: The five most important steps leading to a successful repair of a PVR retinal detachment are described. RESULTS: 1. The basic prerequisite is the complete removal of the vitreous body in order to remove the substrate for proliferation of pathological cells. 2. Furthermore, the complete removal of all tractional PVR membranes is necessary. Subretinal PVR membranes that show no traction can be left in place. 3. The professional care of the macular is still important. As approximately 12% of all patients who undergo surgery for retinal detachment develop an epiretinal gliosis/macular pucker, peeling of the internal limiting membrane (ILM) is obligatory in cases of PVR. 4. Particularly in PVR detachment the mentioned surgical procedure is facilitated by the selection of suitable modern instruments, including wide-angle optics, such as the binocular indirect ophthalmomicroscope (BIOM), chandelier lights, perfluorocarbons (PFCL) and silicone oil. 5. Last but not least, the credo as much as necessary, as little as possible is of essential importance, as PVR eyes have usually been previously operated on and any further surgical intervention leads to subsequent inflammation and a persisting stimulation of the PVR reaction and further damage. CONCLUSION: Following a few decisive rules and tips is a prerequisite for a successful reattachment in cases of PVR retinal detachment.

Comparing refractive outcomes of a standard industry toric IOL calculator using anterior corneal astigmatism and total corneal refractive power.

PURPOSE: To evaluate refractive outcomes for a standard industry calculator using anterior corneal astigmatism or total corneal refractive power. METHODS: This prospective interventional study evaluated the refractive outcomes of 56 eyes using a standard industry calculator (Zeiss ZCalc) and a digital IOL alignment software. After A-constant optimisation the ZCalc was recalculated with two different keratometry values using appropriate refractive indices: anterior corneal astigmatism (ACA) by IOLMaster 700 and total corneal refractive power (TCRP) by Pentacam. The Barrett toric calculator was used as a reference. RESULTS: Undercorrection of 0.04 ± 0.42 D after 1 week and 0.13 ± 0.48 D after 3 months was achieved for the spherical equivalent by using a standard industry calculator. IOL misalignment was 2.8° ± 3.4° using a digital alignment system. For the ZCalc, the mean absolute error could be reduced from 0.19 ± 0.40 D using ACA to 0.04 ± 0.48 D when considering total corneal refractive power (p = 0.06). The Barrett calculator delivered better refractive outcomes than using a standard industry calculator with ACA measurements only (- 0.06 ± 0.43 D; p < 0.01). CONCLUSION: Reliable and accurate refractive outcomes in toric IOL calculation were achieved by using the ZCalc calculator. The prediction error for a widely used standard industry toric IOL calculator could be reduced by using measured total corneal refractive power.

[Intense pulsed light (IPL) as a therapeutic option for Meibomian gland dysfunction]. / Pulslichttherapie ("intense pulsed light") als Therapieoption bei der Behandlung der Meibom-Drüsen-Dysfunktion.

Meibomian gland dysfunction (MGD) is a common cause of dry eye disease. Intense pulsed light (IPL) treatment is a new and approved therapeutic option for MGD. The treatment consists of 2-4 sessions where light impulses are applied to the lower lid and temporal lid margin. The IPL technique is a safe form of treatment when the required safety precautions are followed. Current studies document an improvement of patients' subjective symptoms and objectively measured clinical parameters.

[Corneal dystrophies in optical coherence tomography]. / Hornhautdystrophien in der optischen Kohärenztomographie.

BACKGROUND: Corneal optical coherence tomography (anterior segment OCT, AS-OCT) is described in the current IC3D classification of corneal dystrophies to be a method for improvement of clinical diagnostics and treatment. OBJECTIVE: In this case series AS-OCT images of corneal dystrophies were analyzed with respect to morphological changes. MATERIAL AND METHODS: This was a retrospective imaging and morphological case series with 38 eyes. For image acquisition the corneal module of the high-resolution spectral-domain OCT Zeiss Cirrus HD-5000 platform (Oberkochen, Germany) was employed. The following corneal dystrophies were analyzed: epithelial basement membrane dystrophy, Meesmann corneal dystrophy, Reis-Bücklers corneal dystrophy, granular corneal dystrophy type 1, granular corneal dystrophy type 2 and macular corneal dystrophy. RESULTS: The AS-OCT images showed the typical changes of the dystrophies through hyperreflectivity and hyporeflectivity in the individual corneal layers. The findings in the AS-OCT images correlated well with the histological descriptions in the literature and provided additional information to the slit lamp examination, especially with respect to the exact location of the alterations. CONCLUSION: Corneal AS-OCT imaging seems to be a helpful tool for determination of morphological changes in patients with corneal dystrophies and can facilitate both the diagnostics and surgical treatment decisions.

Modern Corneal Eye-Banking Using a Software-Based IT Management Solution.

BACKGROUND: Increasing government legislation and regulations in manufacturing have led to additional documentation regarding the pharmaceutical product requirements of corneal grafts in the European Union. The aim of this project was to develop a software within a hospital information system (HIS) to support the documentation process, to improve the management of the patient waiting list and to increase informational flow between the clinic and eye bank. MATERIALS AND METHODS: After an analysis of the current documentation process, a new workflow and software were implemented in our electronic health record (EHR) system. RESULTS: The software takes over most of the documentation and reduces the time required for record keeping. It guarantees real-time tracing of all steps during human corneal tissue processing from the start of production until allocation during surgery and includes follow-up within the HIS. Moreover, listing of the patient for surgery as well as waiting list management takes place in the same system. CONCLUSION: The new software for corneal eye banking supports the whole process chain by taking over both most of the required documentation and the management of the transplant waiting list. It may provide a standardized IT-based solution for German eye banks working within the same HIS.

Comparison of Two Toric IOL Calculation Methods.

PURPOSE: To compare two calculators for toric intraocular lens (IOL) calculation and to evaluate the prediction of refractive outcome. METHODS: Sixty-four eyes of forty-five patients underwent cataract surgery followed by implantation of a toric intraocular lens (Zeiss Torbi 709 M) calculated by a standard industry calculator using front keratometry values. Prediction error, median absolute error, and refractive astigmatism error were evaluated for the standard calculator. The predicted postoperative refraction and toric lens power values were evaluated and compared after postoperative recalculation using the Barrett calculator. RESULTS: We observed a significant undercorrection in the spherical equivalent (0.19 D) by using a standard calculator (p ≤ 0.05). According to the Baylor nomogram and the refractive influence of posterior corneal astigmatism (PCA), undercorrection of the cylinder was lower for patients with WTR astigmatism, because of the tendency of overcorrection. An advantage of less residual postoperative SE, sphere, and cylinder for the Barrett calculator was observed when retrospectively comparing the calculated predicted postoperative refraction between calculators (p ≤ 0.01). CONCLUSION: Consideration of only corneal front keratometric values for toric lens calculation may lead to postoperative undercorrection of astigmatism. The prediction of postoperative refractive outcome can be improved by using appropriate methods of adjustment in order to take PCA into account.

[Newly occurring loss of visual acuity in choroidal osteoma]. / Neu aufgetretene Visusminderung bei choroidalem Osteom.

PURPOSE: Approach to loss of visual acuity in a patient with a choroidal osteoma (CO) which had been stable for seven years. METHODS: Fluorescence angiography confirmed a choroidal neovascularization (CNV) as the cause of the loss of visual acuity. Treatment with intravitreal (IVT) injection of ranibizumab. RESULTS: Increase of visual acuity and decrease of edema after IVT injection. CONCLUSION: Monitoring is necessary even for primarily benign CO in order to detect secondary complications causing loss of visual acuity, e. g. secondary CNV. Anti-VEGF IVT represents an approved treatment option.

[Lamellar macular holes with hyporeflective epiretinal proliferation : OCT diagnostics and clinical course]. / Makulaschichtforamen mit hyporeflektivem epiretinalem Gewebe : OCT-Diagnostik und klinischer Verlauf.

BACKGROUND: High-resolution spectral domain optical coherence tomography (SD-OCT) is the standard examination for assessment of lamellar macular holes (LMH). According to the current SD-OCT classification of LMHs, they are characterized by (1) an irregular foveal contour, (2) a defect in the inner fovea, and (3) a separation of inner retinal layers from outer retinal layers of the fovea leading to an intraretinal splitting with loss of retinal tissue. OBJECTIVE: The article aims to give an overview on the current knowledge of retinal imaging in LMH diagnostics and clinical course of disease. MATERIALS AND METHODS: This review is based on current literature and analyses of data from different case series from the Department of Ophthalmology, Ludwig-Maximilian University Munich, Germany. RESULTS: In eyes with LMH, a homogenous atypical, hyporeflective epiretinal tissue has been described in addition to conventional tractional epiretinal membranes (ERM). By SD-OCT, this named lamellar hole-associated epiretinal proliferation (LHEP) does not show common signs of traction and is characterized as a thick homogenous layer of moderately reflective material. LHEP has been demonstrated to be related to the occurrence of photoreceptor layer defects, enlargement of LMH diameter and poor visual acuity. CONCLUSION: The correlation of SD-OCT and en-face OCT can help to identify LMH subgroups and morphology progression early on. FAF enables detection of structural changes at a subclinical stage without visual deterioration. With regard to a high variability of intraretinal changes in LMHs and epimacular fibro-cellular proliferation, the current classification of LMH should be discussed and re-evaluated.

[Histopathological correlation of epiretinal tissue in lamellar macular holes and macular pseudoholes]. / Histopathologische Korrelation epiretinalen Gewebes bei Schichtforamen und Pseudoforamen der Makula.

BACKGROUND: Using high-resolution spectral domain optical coherence tomography (SD-OCT), morphologically different types of epiretinal tissue can be distinguished in lamellar macular holes (LMH) and macular pseudoholes (MPH). OBJECTIVE: This article presents the results of histopathological characterization and differentiation of epiretinal tissue in eyes with LMH and MPH, which are classified based on a morphological differentiation in SD-OCT. MATERIAL AND METHODS: This review is based on the currently available literature and own data analyses. Using SD-OCT, a differentiation into hyporeflective epiretinal tissue and contractile epiretinal membranes (ERM) was performed. For fluorescence and transmission electron microscopic analyses, epiretinal tissue harvested by pars plana vitrectomy and peeling of epiretinal tissue was processed. RESULTS: By SD-OCT hyporeflective tissue appears as a thick homogeneous layer of hypodense material located directly on the surface of the inner retina and has no visible signs of traction. Using immunocytochemistry, hyalocytes and glial cells showing no contractile activity are dominant; however, in contractile ERM in MPH, anti-alpha SMA-positive myofibroblasts are predominantly found representing the contractile element. CONCLUSION: The results of ultrastructual investigations demonstrate that morphological cell components of hyporeflective epiretinal tissue from LMH have less contractile properties than cells of contractile ERM. It can therefore be assumed that there are differences in the pathogenesis of epiretinal cell proliferation in LMH. Histopathological investigations support the hypothesis that hyporeflective epiretinal tissue represents modified material from the outer layer of the vitreous body.

[Descemet Membrane Endothelial Keratoplasty]. / Descemet-Membran-Endothelkeratoplastik (DMEK).

Descemet membrane endothelial keratoplasty (DMEK) is the gold standard for the treatment of corneal endothelial disease, first and foremost Fuchs' endothelial dystrophy. Superior visual rehabilitation as well as lower and decreasing complication rates can be obtained with DMEK than with Descemet stripping automated endothelial keratoplasty (DSAEK) - still the most commonly performed type of posterior lamellar keratoplasty. Recent advancements in the DMEK method include the establishment of a standardised and reproducible surgical "no touch" technique and the emerging role of eye banks, which are able to prepare convenient pre-cut DMEK grafts. These developments pave the way for increasing numbers of corneal surgeons to add DMEK to their armamentarium, despite the more challenging nature of this procedure. However, a review of the current literature shows that this fascinating technique still offers certain challenges, which need to be further addressed. For example, graft detachment remains the most commonly encountered complication after DMEK. A plethora of prospective-randomised studies is required to further endorse the evident superiority of DMEK over alternative types of lamellar keratoplasty and to help propagate the practice of this fascinating technique.

[Incidence of retinal vein occlusion during the football World Cup in 2014 : A database analysis]. / Inzidenz von Zentralvenen- und Venenastverschlüssen während der Fußballweltmeisterschaft 2014 : Eine Datenbankanalyse.

BACKGROUND: The association between cardiovascular events, such as acute coronary syndrome and emotional triggers, such as football world cups is well-known. Significant differences could sometimes be identified depending on the country of origin and design of the study. From an ophthalmological perspective the correlation between pre-existing cardiovascular diseases and retinal angiopathy is well-known. This study investigated whether the incidence of retinal vein occlusion (RVO) at a German university eye clinic increased during and 4 weeks after the 2014 football World Cup. METHODS: From the electronic files of almost 290,000 patients contained in the Smart Eye database, those with RVO during and 4 weeks after the 2014 football World Cup (from 12 June to 13 August 2014) and during the same time period in 2013 could be identified. Demographic data, visual acuity, intraocular pressure (IOP) and laboratory parameters were extracted and compared, when available. RESULTS: From 10 male (average age 68 years) and 8 female (average age 62 years) a total of 9 central RVO (CRVO), 8 branch RVO (BRVO) and 1 hemi-CRVO were identified in 2013 with a visual acuity ranging from 0.05 to 0.9 (average 0.39) and an IOP from 12 mmHg to 25 mmHg (average 16 mmHg). In 2014 a total of 26 patients (11 male average age 67 years and 15 female average age 76 years) were identified, an increase of 69 % (15 CRVO, 6 BRVO and 5 hemi-CRVO). The visual acuity ranged from 0.05 to 1.0 (average 0.63) and the IOP from 8 mmHg to 24 mmHg (average 15 mmHg). CONCLUSION: Due to the high comparability of the patient collectives an increase of RVO during and 4 weeks after the 2014 football World Cup could be identified, compared to the same period in 2013. It can be assumed that emotional strain caused by a World Cup is a risk factor. Data from other centers have to be assessed in order to be able to make a more general statement.

[Smart eye data : Development of a foundation for medical research using Smart Data applications]. / "Smart eye data" : Entwicklung eines Fundaments für medizinische Forschung mittels Smart-Data-Applikationen.

BACKGROUND: Smart Data means intelligent data accumulation and the evaluation of large data sets. This is particularly important in ophthalmology as more and more data are being created. Increasing knowledge and personalized therapies are expected by combining clinical data from electronic health records (EHR) with measurement data. OBJECTIVE: In this study we investigated the possibilities to consolidate data from measurement devices and clinical data in a data warehouse (DW). MATERIAL AND METHODS: An EHR was adjusted to the needs of ophthalmology and the contents of referral letters were extracted. The data were imported into a DW overnight. Measuring devices were connected to the EHR by an HL7 standard interface and the use of a picture archiving and communications system (PACS). Data were exported from the review software using a self-developed software. For data analysis the software was modified to the specific requirements of ophthalmology. RESULTS: In the EHR 12 graphical user interfaces were created and the data from 32,234 referral letters were extracted. A total of 23 diagnostic devices could be linked to the PACS and 85,114 optical coherence tomography (OCT) scans, 19,098 measurements from IOLMaster as well as 5,425 pentacam examinations were imported into the DW including over 300,000 patients. Data discovery software was modified providing filtering methods. CONCLUSION: By building a DW a foundation for clinical and epidemiological studies could be implemented. In the future, decision support systems and strategies for personalized therapies can be based on such a database.

[Anatomic Success of Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment during the Changeover from 20 to 23 Gauge - A Study on 313 Consecutive Cases]. / Anatomischer Erfolg der Pars-plana-Vitrektomie bei rhegmatogener Netzhautablösung im Rahmen der Umstellung von 20 auf 23 Gauge - eine Studie an 313 konsekutiven Fällen.

BACKGROUND: The aim of this investigation was to evaluate the effect on the anatomic surgical success with the changeover from 20 Gauge (G) (n = 206) to 23 G (n = 107) pars plana vitrectomy (PPV) in rhegmatogenous retinal detachment. METHODS: 313 consecutive patients were retrolective-prospectively analysed. Several parameters including lens status, number of retinal breaks, extent of retinal detachment, proliferative vitreoretinopathy (PVR) and refractive error were examined. Primary success rate was defined as anatomic success after a minimum follow-up of 6 months. The secondary success rate was determined as anatomic success after one further operation if necessary. Moreover recurring retinal detachment after initial success was registered. In additional to the analysis over all patients, cases were grouped according to the severity of the preoperative baseline situation. RESULTS: Primary success rate was 87.4 % for 20 G PPV and 87.9 % for 23 G PPV, secondary success rate was 95.6 % for 20 G PPV and 94.4 % for 23 G PPV. 13.9 % (20 G) and 7.4 % (23 G) of patients with initially reattached retina after one surgery developed recurrent retinal detachment in the follow-up and were successfully treated in 17/25 and 7/7 cases. With 20 G PPV a primary success rate of 85 % was obtained in phakic eyes and 89.6 % in pseudophakic eyes, respectively. However, primary success rate with 23 G PPV was 90.4 % for phakic eyes and 85.5 % for pseudophakic eyes. For simple, medium and severe cases, the primary success rate decreased from 97.1 to 92.4 and 74.2 % in 20 G PPV, whereas no obvious tendency appeared for 23 G PPV (93.9, 83.7, 88 %). In 20 G PPV surgery the lens status had no influence on the primary success rate (p > 0.05), for medium and severe cases in 23 G PPV better results were obtained in phakic eyes (88.5 and 93.3 %) compared to pseudophakic eyes (78.3 and 80 %, n. s.). CONCLUSION: 20 G PPV as well as 23 G PPV are good surgical techniques in rhegmatogenous retinal detachment. Overall the miniaturisation of surgical instruments seems to be without any disadvantage for the surgical success.