Glaucoma Treatment in German Hospitals in 2019. / Glaukombehandlung in deutschen Krankenhäusern 2019.

BACKGROUND: Surgical procedures in ophthalmology are subject to fluctuations in their application and are dependent on new developments, availability, and success rates. In the field of glaucoma surgery in particular, numerous new procedures have been introduced over the last few years. So far, hardly any analyses have been done on the current application of these newer procedures. In this paper, we present the extent to which different glaucoma surgery procedures were used in German hospitals in 2019. METHODS: The quality reports of German hospitals from 2019 were evaluated regarding all glaucoma-specific procedure codes. In particular, laser procedures, "classic" glaucoma procedures, and "modern" procedures such as MIGS (minimally invasive glaucoma surgery) are compared below. RESULTS: In 2019, 49,031 glaucoma procedures were performed in German hospitals. Numerically, cyclodestructive procedures were used most frequently. MIGS accounted for approximately 10% of procedures according to the available data. Among filtering procedures, about 40% were implant-assisted. DISCUSSION AND CONCLUSION: On the one hand, the data analyzed show a mixed expansion of the spectrum with newer procedures such as the MIGS and implants; on the other hand, classic procedures such as cyclodestruction are still used. It can be assumed that further shifts in surgical methods will be seen in the coming years.

Long-Term Outcomes of Excimer Laser-Assisted Penetrating Keratoplasty Using a Commercially Available Laser System - A Retrospective Case Series.

BACKGROUND: Favorable functional outcomes have been reported after excimer laser-assisted penetrating keratoplasty (EXL PKP). But this technique has not been widely adopted, and there are reports on EXL PKP from only a very limited number of institutions. Some of these results refer to operations carried out with laser systems that are not commercially available. In this retrospective case series, we report the long-term outcome of EXL PKP using the Schwind Amaris 500E laser system. MATERIAL AND METHODS: This retrospective consecutive case series included 30 eyes of 29 patients who had undergone EXL PKP between 2010 and 2013. Primary outcome measures were topographic astigmatism and visual acuity. Secondary outcome measures were the rates of graft rejection and graft failure, and the rate of grafts with an endothelial cell density below 500 cells/mm2. Survival analyses were carried out for the following endpoints: visual acuity, rate of graft rejection, and rate of grafts with endothelial cell densities higher than 500 cells/mm2. RESULTS: The median interquartile range (IQR) duration of follow-up was 45 (36) months. The indications for PKP were keratoconus (n = 21), corneal scarring (n = 6), Fuchs endothelial dystrophy (n = 1), and corneal dystrophy other than Fuchs endothelial dystrophy (n = 2). The median (IQR) topographic astigmatism at the end of the follow-up period was 5.3 (2.9) D. Forty-five months after surgery, 73% of all eyes had a visual acuity better than 0.3 LogMAR. The rate of graft rejection after 45 months of follow-up was 32%. All eyes maintained endothelial cell densities higher than 500 cells/mm2. There was no graft failure. CONCLUSIONS: EXL PKP is a safe and effective surgical procedure. No general conclusions can be drawn on the refractive outcome of EXL PKP. Potential advantages, such as a higher degree of graft-host congruity, that could possibly improve the refractive outcome should be weighed against the higher costs of EXL PKP.

The Eye Van - An Evaluation of the Quality of Care of Visually Impaired People in the Rural Areas of South Baden. / Die Versorgung Sehbehinderter im ländlichen Raum Südbadens ­ das Projekt "Augen-Bus".

BACKGROUND: Especially in rural areas, access of visually impaired people to ophthalmic care and counselling can be limited. The Eye Van is a project supported by the Ministry for Rural Affairs and Consumer Protection Baden-Württemberg which offers visually impaired people an on-the-spot ophthalmological examination and counselling on low-vision aids and social support services. The aim of this project was to evaluate the quality of care provided to visually impaired people in the rural areas of South Baden. MATERIALS AND METHODS: Between 2016 and 2019, 45 villages in South Baden participated in this project. The visits were advertised in the local press. Appointments were assigned and participant eligibility was assessed over the telephone by the local Federation of the Blind and Partially Sighted in South Baden. During the on-site visits, a medical history was obtained from participants, who then received a comprehensive ophthalmological examination and counselling on low-vision aids and social support services. Interviews were conducted in order to determine the expectations of the participants and to assess their quality of life. A second interview, focused on the measures that had been implemented and changes in the participants' quality of life, was carried out three months later. RESULTS: In total, 264 participants were examined. Of these, 101 participants fulfilled the criteria of moderate/severe visual impairment or blindness defined by the WHO (World Health Organization). The mean age of the visually impaired participants was 85 years. The median decimal visual acuity was 0.08. The median length of time since the participants' last ophthalmological examination was one year. Among the visually impaired participants, 13% did not have any low-vision aids. Their use was recommended to 62% of the visually impaired participants. The main expectation of participants was counselling on low-vision aids and support services. Among all the participants, 42 did one interview and 28 did two interviews. In the second interview, 72% of the participants claimed to have implemented the recommendations. There was no statistically significant change in their quality of life. CONCLUSION: The access of visually impaired people to ophthalmic care does not seem to be limited in the rural areas of South Baden. Nevertheless, there was a high demand for counselling on low-vision aids and social support services.

[Keratoplasty in Germany: Systematic Analysis of the Quality Reports of German Hospitals between 2006 and 2017]. / Die Keratoplastik in Deutschland: systematische Auswertung der Krankenhausqualitätsberichte der Jahre 2006 bis 2017.

BACKGROUND: Keratoplasty is considered the most frequently performed type of transplantation in humans. Traditionally, penetrating keratoplasty has been the most common procedure. However, over the last 15 years, the importance of posterior lamellar keratoplasty has increased for the treatment of Fuchs endothelial dystrophy and bullous keratopathy. In Germany, based on national surveys, it was suggested that there was a trend towards lamellar keratoplasty. OBJECTIVE: The main objective of this study was to determine whether the proportion of lamellar keratoplasties carried out in Germany between 2006 and 2017 had increased. Furthermore, the number of keratoplasties carried out as HLA-matched (HLA: human leukocyte antigen) keratoplasties should be calculated. MATERIALS AND METHODS: The numbers of all keratoplasties carried out as lamellar/penetrating and HLA-matched keratoplasties was extracted from the hospital quality reports published between 2006 and 2017. Descriptive statistical analysis was carried out in R (www.r-project.org). RESULTS: Between 2006 and 2017, 43,021 keratoplasties were carried out in Germany. The number of keratoplasties increased from 2,849 (2006) to 8,231 (2017). The number of penetrating keratoplasties remained stable. The proportion of lamellar keratoplasties increased from 6.5% (2006) to 61.4% (2017). The proportion of HLA-matched keratoplasties was below 20% and declined between 2010 and 2017 (2010: 19.7%; 2017: 9.8%). DISCUSSION: In Germany, posterior lamellar keratoplasty has become increasingly important. Since 2014, the number of lamellar keratoplasties has exceeded the number of penetrating keratoplasties. However, the number of penetrating keratoplasties remained stable between 2006 and 2017 and still plays an important role in the management of patients with predominantly stromal or corneal defects affecting all layers. The decreasing number of HLA-matched keratoplasties is most likely due to the lack of clear evidence of a significant reduction in the rejection rates in cases of normal risk keratoplasty.

[Scleral Buckling Surgery in Germany for Rhegmatogenous Retinal Detachment: A Spirit of the Past or Current Practice?] / Eindellende Operationen zur Behandlung der rhegmatogenen Amotio in Deutschland: ein Geist der Vergangenheit oder gelebte Praxis?

BACKGROUND AND OBJECTIVES: Scleral buckling and pars-plana vitrectomy are therapeutic options for the treatment of rhegmatogenous retinal detachment. Comparative studies still support the value of scleral buckling in phakic eyes. Nevertheless, the number of sceral buckling procedures may be continuously decreasing over time. The study aims to analyse the incidence of scleral buckling procedures for the treatment of patients with retinal detachment in Germany over time. MATERIAL AND METHODS: The numbers of scleral buckling procedures (OPS 5-152) and rhegmatogenous retinal detachment (ICD H33.0) in Germany are analysed on the basis of data from the quality reports published by the Federal Joint Committee and secondary analyses of the DRG-based billing system (DRG-Statistik) of the Federal Statistical Office between 2006 and 2017. RESULTS: Based on the quality reports, numbers of scleral buckling procedures performed between 2006 and 2017 dropped by 49% from 8841 to 4510. During this period of time, the number of rhegmatogenous retinal detachments, identified by the ICD code H33.0, rose by 102% from 11 507 to 23 314. A decrease in scleral buckling procedures of 42% between 2006 and 2017 was also observed in the DRG Statistics. Regional and age-dependent subgroup analyses suggests that there are both regional and age-dependent differences in the practice of scleral buckling. CONCLUSIONS: Our analysis clearly illustrates that scleral buckling procedures are now less commonly performed in Germany than in 2006. However, the total of ~ 4500 billed procedures in 2017 in Germany shows that scleral buckling is still an important and current therapeutic option in the treatment of retinal detachment.

[Automated Cell Counting Using "Deep Learning" in Donor Corneas from Organ Culture Achieves High Precision and Accuracy]. / Automatisierte Zellzählung in Spenderhornhäuten aus Organkultur mittels "Deep Learning" erreicht hohe Präzision und Genauigkeit.

BACKGROUND: Human corneal grafts from organ culture need to have more than 2000 endothelial cells/mm2 to be suitable for transplantation. Measurement of the endothelial cell density is complicated by invisible cell borders in phase contrast microscopy, as well as by limited areas for counting due to folds in the Descemet membrane of the swollen corneal grafts. To date, no automated counting method for measuring the endothelial cell density exists. The neuronal network U-Net has already proven itself in automated segmentation of specular microscopy images of human corneal endothelium. The aim of this study was the application of the U-Net in the quality control of human corneal grafts. MATERIAL AND METHODS: Training of the U-Net was performed using 100 manually tagged endothelial cell images of corneal grafts from the Lions eye bank in Baden-Württemberg. Another 100 images were obtained for testing the precision of measurements of the U-Net. These were adjudged manually by a) an experienced investigator and b) a less experienced ophthalmologist. The endothelial cells in identical images were then counted automatically by the trained U-Net. Comparison with the manually counted results was drawn by Pearson correlation. RESULTS: The correlation coefficient between the U-Net and the experienced investigator as gold standard was 0.9. The correlation coefficient between the less experienced ophthalmologist and the gold standard was only 0.81. Both correlations were statistically highly significant (p < 0.0001). DISCUSSION: The strong correlation between the U-Net and the gold standard points out that, given medical approval, effective assistance for eye banks is possible in quality control by automated counting. This could improve objectivity and efficiency of work flow.

[Unsupervised Linkage between ICD- and Alpha-ID Codes and Real-World Diagnoses from Medical Reports by Means of the "word2vec" Method]. / Automatisierte Zuordnung von ICD- und Alpha-ID-Codes zu "Real-World"-Arztbriefdiagnosen durch die "word2vec"-Methode.

BACKGROUND: Transformation into a standardised code system such as ICD-10 or Alpha-ID is required before medical reports can be scientifically analysed. This is due to the use of different terminologies and the frequent use of synonyms. The so-called "word vector embedding" seems to be suitable for the generation of the required thesaurus, because synonymous diagnoses can be identified independently of the spelling - after suitable training of the underlying neural network. METHODS: All letters from a total of 50,000 patients were extracted anonymously. Diagnoses consisting of several words were merged into single words by means of phrase recognition and the "word2vec" model was trained on the text corpus of 352 megabytes. A total of 3742 diagnoses and ophthalmological interventions were extracted semi-automatically. The ophthalmological ICD and Alpha-ID codes were downloaded together with the official descriptions from the DIMDI website and the ophthalmological diagnoses/interventions were automatically linked with the nearest ICD- and Alpha-ID codes in the "word2vec" model. RESULTS: The "word2vec" model assigned 90% of the doctor's letter diagnoses correctly to appropriate ICD-10 codes. At the finer level of Alpha-ID, the rate of correct assignments was only 76%. The interventions were assigned to the correct indication in 92% of cases. Rare diseases, unusual designations and code degeneration in the official DIMDI file were identified as sources of error for incorrect or missing allocations. DISCUSSION: A diagnostic thesaurus can be generated with the "word2vec" method from a corpus of anonymised medical reports and the official Alpha-ID file from the DIMDI website. This thesaurus could be used for automatic extraction of diagnoses from doctor's letters in the future, given appropriate manual revision.

[The Role of Hospitals in the Treatment of Patients with Cataract in Germany: Systematic Analysis of the Quality Reports of German Hospitals for the Years 2006 to 2016]. / Die Bedeutung der Krankenhäuser für die Versorgung von Patienten mit Katarakt in Deutschland: Systematische Auswertung der Krankenhausqualitätsberichte der Jahre 2006 bis 2016.

BACKGROUND: Cataract is one of the most prevalent eye diseases in Germany. According to the German Ophthalmological Society, its prevalence will increase significantly in the coming years. It has been suggested that most cataract operations are carried out in an outpatient setting. However, there still seems to be a need for inpatient cataract surgery. OBJECTIVE: The main objective of this study was to determine the total number of cataract operations carried out in German hospitals over the last 12 years and to investigate whether the proportion of cataract operations carried out as outpatient procedures has increased in recent years. MATERIAL AND METHODS: The numbers of cataract operations carried out as outpatient and inpatient procedures were extracted from the quality reports published by the Federal Joint Committee between 2006 and 2016. The total number, the number of cataract operations per 1000 residents (inpatient and outpatient procedures) and the proportion of complex cataract operations carried out as inpatient procedures were calculated. The descriptive statistical analysis was carried out in R (www.r-project.org). RESULTS: Between 2006 and 2016, 1,884,506 cataract operations were carried out in German hospitals. There was an increase in the total number of cataract operations (2006: 223,070; 2016: 279,331). The proportion of outpatient procedures increased between 2006 (44%) and 2010 (48.9%) and remained stable between 2010 and 2016 (2016: 48.5%). Between 2006 and 2016, the proportion of complex cataract operations carried out as inpatient procedures ranged from 56 to 86%. DISCUSSION: A stable and significant proportion of cataract operations in Germany is still carried out in hospitals. The total number of cataract operations has increased. After increasing between 2006 and 2010, the proportion of cataract operations carried out as outpatient procedures remained stable. This sustained demand may be triggered by a group of patients who, due to medical and/or social reasons, require treatment under inpatient conditions.

Medical Management of Children With Congenital/Infantile Cataract Associated With Microphthalmia, Microcornea, or Persistent Fetal Vasculature.

PURPOSE: To report the surgical outcomes of children with cataract associated with microphthalmia, microcornea, or persistent fetal vasculature (MMP) and children with isolated cataract. METHODS: The study included 111 children (cataract associated with MMP: n = 25) who underwent cataract surgery at younger than 16 years. Exclusion criteria were duration of follow-up less than 5 years, intraindividual differences in age at surgery, eye disorders other than MMP, secondary cataract, and syndromal diseases. Main outcome measures were proportion of eyes with glaucoma and best corrected visual acuity (BCVA). Both groups were dichotomized by age at surgery (early intervention group: ≤ 48 days). Descriptive analysis was performed throughout. RESULTS: Median age at surgery was 3.9 months for cataract associated with MMP and 23.3 months for isolated cataract. The median (interquartile range [IQR]) duration of follow-up was 95.9 months (range: 76.0 to 154.5 months). In children with bilateral cataract associated with MMP, the proportion of eyes with final BCVA worse than 0.3 logMAR was similar regardless of age at surgery (early intervention: 80%, later intervention: 78%). In bilateral isolated cataract, the proportions were 56% and 33%, respectively. Children with cataract associated with MMP had a high prevalence of glaucoma (28%). Glaucoma prevalence was lower in the later intervention group. CONCLUSIONS: In the presence of MMP, early cataract surgery is associated with a high risk of post-lensectomy glaucoma, but does not offer the benefit of better visual outcomes. [J Pediatr Ophthalmol Strabismus. 2019;56(1):43-49.].

Dynamic Changes in Schlemm Canal and Iridocorneal Angle Morphology During Accommodation in Children With Healthy Eyes: A Cross-Sectional Cohort Study.

Purpose: The purpose of this study was to explore changes in Schlemm canal (SC), trabecular meshwork (TM), and iridocorneal angle (ICA) morphology during accommodative effort in children and young adults. Methods: We acquired anterior segment optical coherence tomography images (AS-OCT) of the ICA and ciliary muscle (CM) of both eyes of 50 children age 4 to 16 years with healthy eyes, at two levels of accommodation: 2.5 and 15 diopters (D). Semiautomated nasal ICA measurements were as follows: angle opening distance at 500/750 µm (AOD-500, -750), trabecular iris space area at 500/750 µm (TISA-500, -750), and trabecular iris angle at 500/750 µm (TIA-500, -750). Manual measurements were as follows: anteroposterior and radial SC diameter (SC-APD, SC-RD), cross-sectional area of SC (SC-CSA) and TM height (TMH), TM length (TML), and TM density (TMD). CM width was measured at 1, 2, and 3 mm from the scleral spur (CM-1, CM-2, CM-3). For each parameter, a three-level random-effects model was fitted to estimate differences between the two levels of accommodation. Results: With accommodative effort, SC diameters and CSA increase significantly, as do TM length and iridocorneal angle parameters. With increasing age, SC dimensions reduce. Angle parameters are smaller in eyes with greater spherical equivalent (hypermetropia). Conclusions: AS-OCT can be used to visualize dynamic morphologic changes in outflow structures with physiologic accommodation. The increase in SC dimensions with accommodative effort may contribute to the regulation of IOP in children.

Detecting optic nerve head swelling on ultrasound and optical coherence tomography in children and young people: an observational study.

BACKGROUND: Following high-profile cases, referrals for evaluation of 'suspicious optic discs' to eye clinics in the UK have sharply increased, asking ophthalmologists to reliably distinguish between true and pseudopapilloedema. Optic nerve sheath dilatation (ONSD) on ocular ultrasound (US) is considered a reliable sign of true papilloedema, but this test is not widely available. Recently, anterior bowing of Bruch's membrane (BM) and increased retinal nerve fibre layer thickness on optical coherence tomography (OCT) have emerged as indicators of intracranial hypertension, and OCT is widely available. We aimed to evaluate safety and efficacy of the diagnostic workup in our service, with particular emphasis of diagnostic reliability of US and OCT. METHODS: Retrospective service evaluation/cohort study of children and young people younger than 16 years investigated for 'suspicious discs' over a 7-month period in 2016 at a single eye care provider in London, UK. 61 children and young people underwent clinical assessment, US scan and OCT. RESULTS: Of 61 cases, 3 had intracranial pathology. At presentation, only one had ONSD on US and anterior bowing of BM on OCT. Increased nerve fibre layer thickness in at least one of three relevant sectors was observed in two cases. All three cases of intracranial pathology, however, had significant points in their presenting or medical history. CONCLUSION: Ophthalmologists and optometrists must not rely on funduscopy and ocular imaging when assessing a child for possible intracranial disease; history and basic neurological assessment are critical in the diagnostic workup.

Medical Management of Blepharokeratoconjunctivitis in Children: A Delphi Consensus.

PURPOSE: To describe a pragmatic approach to the medical management of blepharokeratoconjunctivitis in children, based on published evidence and clinical experience. METHODS: The authors used the Delphi consensus method to explore the preferred management patterns of four senior clinicians at one institution to reach agreement on indications and dosage schedules for commonly used treatments. Four iterations were created, with electronic questionnaires distributed via an online survey platform. Initial questions were based on recent systematic reviews and clinical experience. After each round, a facilitator summarized the responses and fed these back to the expert participants, together with an invitation to complete the next round of questions. RESULTS: Typical and specific eyelid, corneal, and conjunctival disease features influenced management decisions, and treatments were targeted toward specific findings in these tissues rather than to overall disease severity. Active keratitis was considered the main indication for high potency steroids, systemic antibiotics, and possibly systemic immunomodulators. Other indications for systemic antibiotics were chronic active blepharitis and recurrent troublesome chalazia. Oral antibiotics were used for their anti-inflammatory and antimicrobial properties. There was little agreement on the role of dietary modification, topical lubricants, and preference for oral or topical antibiotics. CONCLUSIONS: Detailed clinical assessment of eyelids and ocular surface allows targeted treatment. Research is needed to clarify disease mechanisms and to optimize treatment strategies. [J Pediatr Ophthalmol Strabismus. 2017;54(3):156-162.].